COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX00036846 
 
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 C^^U^ O/rrT^y^^^"^ 
 
 I 
 
ABDOMINAL TUMOURS 
 
DIAGNOSIS 
 
 AND 
 
 SUEGICAL TREATMENT 
 
 OF 
 
 ABDOMINAL TUMOURS 
 
 By sir SPENCEE WELLS, Bart. 
 
 LATE PRESIDENT OP THE ROYAL COLLEGE OF SURGEONS OF ENGLAND 
 
 PHILADELPHIA 
 
 P. BLAKISTON, SON, AND GO. 
 
 1012 WALNUT STREET 
 
 1885 
 
4 3 -D-65)^9- 
 
 
PEEFACE 
 
 The book which I have now written is in many respects a new work, though 
 it may be called a fourth edition of the first published in 1865. Twenty 
 years have entirely changed the boundaries of the subject. Before 1860, 
 ovariotomy sometimes succeeded, as often failed, and was very generally 
 discredited. My first book was a record of cases, showing how difficulties 
 were overcome, how principles were gradually brought into view, how rules 
 of practice were established, and what results might be obtained. It silenced 
 objections, and encouraged others to follow in the same course. My second 
 book, in 1872, was no longer a plea for ovariotomy. An experience of 500 
 cases, which then seemed large, made me feel that, though I was still a 
 learner, there was something I could usefully teach, and had no right to 
 withhold. According to the views then held, I went iato the diagnosis of 
 ovarian disease and into the details of ovariotomy. There is evidence enough 
 that my example and teaching were not unfruitful. Ten years more brought 
 into the field many co-labourers who tilled the ground I had partially 
 cleared, and no one is more ready than I am to acknowledge the value of 
 what they have done, and to rejoice over the relief they have given to a 
 multitude of sufferers. My own experience had more than doubled, some 
 of my views had changed, in some respects my practice was modified, and I 
 had information acquired from others to add to my own observations. The 
 subject had expanded. Uterine pathology and surgery had been grafted 
 upon that of the ovary, and my third book, in 1882, included both. Since 
 that time the 'domain of abdominal surgery' has not only spread over every 
 abdominal organ, but has been taken possession of with equal zeal by the 
 profession throughout the civilised world. The proof of this, so far as I am 
 concerned, is that in less than two years a new edition of my last book is 
 called for. I have adopted a new form, and issue it at a price which puts 
 the information it contains at the command of every student. Suppression 
 and condensation have enabled me to bring this work into smaller compass, 
 and have also enabled me to make considerable additions on various conditions 
 which call for the performance of abdominal section. Details which were 
 interesting when novelties have been omitted. My time has been too fully 
 taken up as a practical surgeon for me to do much as a pathological explorer. 
 Eesearches in ovarian pathology have been too limited and the facts collected 
 
Yl PREFACE 
 
 too fe'w, for any but the most empirical conclusions. Tliere are laws of 
 disorder, degeneration, and decay as well as laws of evolution, development, 
 and function. It must be by reasoning on the facts gathered together, by 
 a survey of all the coiTesponding structures and diseases through the whole 
 series of organic life, that we shall arrive at some solution of the problems 
 of ovarian pathology. Fortunate it is for humanity that the art of relief is 
 somewhat independent of scientific generalisations. Some observers main- 
 tain that ovarian disease is an affair of race — that it is much more common 
 in Great Britain and Germany than in France or Spain. If it be so, there 
 is a special call upon British pathologists to do as much in the way of study- 
 ing causes and prevention as British surgeons have done by way of cure ; 
 and I would repeat the hope which I expressed in 1882, in the preface to 
 the third edition, ' that the pathological industry of those who are not 
 ovei-whelmed with the routine of mere clinical labour will bring us to such 
 an understanding of the origin, causes, and nature of these diseases as will 
 give us the means of arresting their development and progress, and will 
 shield us from the reproach of being able only to offer the ultimate 
 resource of relief by excision.' 
 
 In condensing I have expunged nothing of practical value, and perhaps 
 have made some points more clear than they were. The additions are large, 
 and naturally arise out of the gl•o^vth of the subject. Never a mere bvario- 
 tomist, I have followed, and sometimes led. the advance of abdominal surgery, 
 and this new edition or new book now includes the operative treatment of 
 various kinds of tumours — splenic, renal, hepatic, and others — hardly noticed 
 in my earlier books. 
 
 But there is one fact which stands out with ominous significance in all 
 these records. Whatever may be our diagnostic accuracy and our operative 
 skill, our success in the treatment of these diseases is fatally restricted by 
 the influence of septicsemia. We have already reached as great an amount 
 of success in the results of ovariotomy as can reasonably be hoped for, and 
 shall in like manner approach such success in the results of the extii-pation 
 of other organs. But until we find some more certain protection for our 
 patients against the ravages of septic£Emia than any antiseptic precautions 
 hitherto taken secure, abdominal surgery, though not without just claim to 
 the credit of liaving done good ser\"ice to humanity, must still be looked 
 upon as a branch of our science and art which, still imperfect, calls for 
 continued search for truth, and for constant efforts to improve methods of 
 practice, from every surgical student. 
 
 Uppeb (Jrosvexoe Street, London : 
 April ] 885. 
 
CONTENTS 
 
 PAET I 
 
 OVAJRIA^^ AXB ALLIED TUJIOmS 
 
 CIIAPTETl PACE 
 
 I, Classification of Otariax axd Allied Tc:.iocrs — Diagxosis of Adhesions — The 
 
 Pedicle — Kotation of the Pedicle ......... 1 
 
 II. Differentiae Diagnosis of Otabian Tumours 10 
 
 III. Palliative and Minor Scegicae Treatment of Otarian Toiours . . .37 
 
 IV. The Eise and Progress of Otaeiotomt . 46 
 
 V. The Conditions affecting the Operation of Otariotomy 67 
 
 YI. Preparation of a Patient for Ovariotomy ; Duties of the Xurse ; Desceiftion 
 
 OF necessary Instruments ........... 73 
 
 VII. The Operation of Ovariotomy — Division of the AsDoanNAL "W'ael ; Situation 
 and Length of the Incision ; Separation of the Cyst ; Emptying and Ee- 
 moval; Treatment of the Pedicle; Sponging of the Peeitontxm; Closure 
 of the "Wound ; Dressing and Bandage ........ 80 
 
 VIII. Accidents during Ovariotomy 97 
 
 IX. On the Eemoval of both Ovaries at ont: Operation . . . . .100 
 
 X. On Ovaeiotojiy peefoemed Twice on the same Patient 102 
 
 XL On the Treatment of Patients after Ovariotomy . . . . . .106 
 
 XII. 0vaeiot03it during Pregnancy . . . . 115 
 
 XIII. On Incomplete Ovariotomy and Exploratory Incisions 121 
 
 XIV. Oophorectomy — or Battey's Opeeation 125 
 
 XV. Eesults of Ovariotomy. Subsequent History of Patients who Eecover . . 130 
 
 PART II 
 UTERIXE AXD OTHER AEROJIIXAL TUMOURS 
 
 I. Uterine Tumours 134 
 
 II. On Partial Amputation and Complete Excision of the L^terus . . .171 
 
 III. Extirpation of the Spleen . 182 
 
 IV. Operative Suegery of the Ividntey — Xepheoraphy ; Tapping and Drainage ; 
 
 Nepheotomy; Xepheolithotomy ; Nephrectomy . . . . . . .190 
 
 V. Liver and Gall-Bladder — Abscess anto Hydatids ; Distent)ed Gall-Bladder ; 
 
 Gall-Stones ; Cholecystotomy and Ckouecystectomy ...... 201 
 
 VI. 3Iesenteeic, Omental and Pancreatic Cysts — Undescended Testicle . . . 204 
 VII. The Stomach and Intestint:s — Gastrostomy ant) Gastrotomy ; Dilatation of 
 Pyloric and Cardiac Orifices ; Pyloeectomy ; Obstructed Intestine ; En- 
 terotomy and Colotomy ; Artificial Ants : Eesection of Intestine ; Operative 
 Treatment of Peritonitis 207 
 
DIAGNOSIS AND SUKQICAL TREATMENT 
 
 OF 
 
 ABDOMINAL TUMOURS 
 
 PART I. 
 
 OVAR/AN AND ALLIED TUMOURS— THE fB DIAGNOSIS 
 AND SURGICAL. TREATMENT 
 
 CHAPTER I 
 
 CLASSIFICATION OF OVAPJAX AND ALLIED TUMOURS — THEIR DIAGNOSIS— DIAGNOSIS OF 
 ADHESIONS — THE PEDICLE ROTATION OF THE PEDICLE 
 
 Abdominal and pelvic tumours con- 
 nected with the female organs of gene- 
 ration may be classified in the following 
 manner : 
 
 OVARIAN TUMOURS 
 
 Simple and multilocular cysts — of 
 follicular origin. 
 
 Proliferous cysts — of epithelial origin. 
 
 Sarcomatous tumours — of connective- 
 tissue origin. 
 
 Fibrous tumours — of fibre-cell origin. 
 
 Hypertrophy — excess of growth of 
 some or all of the tissues. 
 
 Malignant tumours — -degeneration of 
 one or all of the tissues. 
 
 EXTRA-OVARIAN TUMOURS 
 
 Cysts of parovarium — of epithelial or 
 tubular origin. 
 
 Cysts of broad ligament — origin, con- 
 nective-tissue cells or ova. 
 
 Cysts of Fallopian tubes — origin, ova, 
 epithelium tissues ; by occlusion. 
 
 Cysts of subperitoneal tissues — con- 
 nective-tissue cells. 
 
 Cysts developed from aberrant ova — 
 of ovarian follicular origin. 
 
 The ovary is no exception to the uni- 
 versal law of development. It begins 
 Avith a cell. The combined progeny of 
 the primitive cell is as diverse, and 
 
 subject to as many deviations from natural 
 growth and action, as any other cell struc- 
 ture. Each series of cells may go wrong 
 separately ; a few series of cells may go 
 wrong together and entrain the rest, or 
 the whole may go wrong at the same 
 time. It is easy to understand how, by 
 continued development, from a diseased 
 reproductive cell we may have a simple 
 or multilocular cyst ; from endothelium, a 
 papilloma ; from a group of connective 
 tissue cells, a sarcoma ; from fibre cells, 
 a fibroma ; and with partial or general 
 degeneration of the tissues, some form of 
 malignant tumour. In the same way, we 
 ti'ace the origin of extra-ovarian cysts 
 and tumours to the histological elements 
 of the tissues in which they appear, the 
 structural characteristics depending upon 
 the nature of the cell point of departure. 
 
 MODES OF EXAMINATION OF THE OVARIES 
 
 Absence of the ovaries, from their 
 imperfect development or atrophy, may 
 occasionally be inferred from some 
 physical peculiarities or pliysiological 
 aberrations ; and the presence of an 
 accessory ovary, now and then observed, 
 may probably account for the recurrence 
 of menstruation in spite of disease, or after 
 the removal of two by ovariotomy. 
 
 The manipulation in the examination 
 
OVARIAN AND ALLIED TUMOURS 
 
 of the congenital or accidental displace- 
 ments of the ovaries requires skill and 
 care. The ovaries may generally he felt 
 in their normal position on either side of 
 the uterus, a little below the brim of the 
 pelvis, between one finger passed upwards 
 in the vagina and another pressed down- 
 wards from the abdominal wall. It is 
 only in cases of firm vagina, or very tense 
 or thick abdominal wall, that the ovaries 
 cannot be made out. 
 
 In order that this examination may be 
 done effectually, the patient should be 
 made to lie on her back, with the shoul- 
 ders and knees raised so as to relax the 
 belly, and both bladder and rectum must 
 be empty. It is only by combined in- 
 ternal and external examinations that a 
 normal ovary, or one only slightly enlarged, 
 can be detected. External examination 
 alone is fruitless. . By vaginal examina- 
 tion alone a resisting body may perhaps 
 be felt through the upper part of the 
 vault of the vagina : its mobility may be 
 recognised, but nothing more. Some- 
 times the ovaries are so easily displaced 
 that t'ley elude internal examination 
 alone. Yet two fingers brought together, 
 one from without and one from within, 
 may fix and feel the ovary between them. 
 It is well first to find the fundus uteri and 
 to steady it by one or two fingers, and 
 then by the combined examination an 
 ovary is found near the uterus, on one 
 side of it. The finger can be passed 
 around it, and it may be pushed from 
 before backwards, and less easily towards 
 and away from the side of the uterus. 
 It has a firm elastic feel, glides easily 
 under the fingers, and unevenness of the 
 surface may often be detected. 
 
 A small hard mass of fteces in the 
 bowel, a swollen pelvic gland, a cyst in 
 the broad ligament, a dilatation of the 
 Fallopian tube, or a small pedunculate 
 outgrowth from the titerus might give 
 a similar impression to the examining 
 fingers, but after some practice this will 
 not be mistaken for the characteristic 
 feel of the ovar3\ 
 
 The right ovary is most easily reached 
 l)y one or two fingers of the right liand 
 in the vagina, the left hand being on the 
 abdomen ; the left ovary by the left hand 
 being used for the vagina, and the right 
 rfbr the outside. 
 
 Examination by the rectum is in some 
 cases more, in others less, useful than by 
 the viigina. Occasionally, when the rec- 
 
 tum is large and the vagina tense, one or 
 both ovaries may be distinctly felt by the 
 rectum and not by the vagina. In some 
 cases, when the ovaries can be readily 
 felt by the vagina they cannot be touched 
 by the rectum. Even in the case where 
 the ovary is abnormally situated in 
 Douglas's space it may be palpable 
 through the posterior wall of the vagina, 
 and the fingers of the hand compressing 
 the abdomen meet a finger in the vagina 
 much more readily than one in the rec- 
 tum. Examination both by rectum and. 
 vagina is necessary when an ovary, not 
 enlarged, is supposed to be in Douglas's 
 space, for Schultze has known a gland 
 behind the rectum to be felt through the 
 vagina and mistaken for an ovary. 
 
 It must be remembered in judging of 
 the size of an ovary, that if small, and 
 felt through a thick abdominal wall, it 
 will appear to be larger than it is, and 
 that ovaries of the same size felt through 
 walls of different thickness may appear to 
 be of different sizes. A little practice 
 will be sufficient to teach what allowance 
 should be made in face of this source of 
 possible error. 
 
 A healthy ovary is generally insensible 
 to moderate pressure. But touch may 
 give pain when there is no reason to sus- 
 pect inflammation or any other departure 
 from a state of health. The diagnosis 
 can only be made out when the swollen 
 and painful ovary is felt as a circum- 
 scribed lump. 
 
 Schultze says he has observed that 
 the displacement of the ovary during in- 
 flammation may rather be into Douglas's 
 space than to the front of the uterus, and 
 that on regaining its usual volume and 
 sensibility it has returned to its natural 
 position. In other cases after recovery it 
 remains fixed ; and once an ovary which 
 had been adherent to the uterus after in- 
 flammation was months before it became 
 again movable. 
 
 The displacements of the ovary recog- 
 nised by this mode of double examination 
 are all witliin tlie limits of the abdominal 
 cavity ; but the whole gland will some- 
 times find its way through the weak points 
 of tlie parietes, and we have to deal with 
 it as a form of hernia, either inguinal, 
 crural, ischiatic, umbilical, ventral, or 
 vaginal. Pott's case was one of simple 
 hernia and abscission ; but an ovarian 
 cyst has formed outside the inguinal ring, 
 and been the subject of an extra-mural 
 
DIAGJ^OSIS 
 
 ovariotomy by a Spanish surgeon. An 
 instance of this kind has not come under 
 my notice, but I do not see that it can 
 offer any difficuhies to the operator. 
 
 DIAGNOSIS OF THE DIFFERENT KINDS OF 
 OVAKIAN TUMOUnS AND THEIR ADHESIONS 
 
 Many of the signs and symptoms of 
 the tumours classified in this chapter are 
 common to the whole group. Tliere are 
 degrees of hardness and mobility ; there 
 are shades of force and sharpness in fluc- 
 tuation ; there are eccentricities of form 
 and variations in relative position which 
 in different cases alter the areas of reson- 
 ance and dulness. But the physical signs, 
 though often sufficient for diagnosis, are 
 sometimes far from conclusive till we come 
 to test the contents. With thgm Ave ob- 
 tain additional evidence, and are able to 
 declare in certain cases li-om what sort of 
 cyst they are drawn. The symptoms of 
 the tubercular and malignant tumours are 
 a set apart. 
 
 With the cystic enlargements, simple 
 and compound, there are from the first 
 progressive uneasiness running on to dis- 
 tress, pain from nerve pressure and stretch- 
 ing, irritation from local congestion, and 
 other effects purely arising from me- 
 chanical causes. But as the tumour 
 grows bigger and encroaches on the 
 various organs, functions are interfered 
 with and suspended, the lines of innerva- 
 tion are cut or compressed, circulation and 
 absorption are interrupted, nutrition is 
 arrested, and the victim dies atrophied or 
 suffocated. The evidence from mere sym- 
 ptoms is all along more circumstantial 
 than specific, and assists rather in fore- 
 casting the end than in identifying any 
 particular kind of cyst. 
 
 No time of life is exempt from ovarian 
 tumours. They are found in infancy as 
 well as in old age, though it is seldom that 
 the development begins late. When seen 
 in advanced life they are generally ex- 
 amples of longevity of the tumour no less 
 than of the person. The greater part of 
 my patients have come to me between the 
 ages of 25 and 55, and the average age 
 on my list of 1,000 cases of completed ova- 
 riotomy is as near as may be 39. This 
 would seem to show that the condition of 
 the generative function has a great deal 
 to do with the origin of the disease. What 
 Boinet says about childless -women, that 
 ' sur 500 i'emmes atteintcs de kys^tcs de 
 
 I'ovaire, nous en avons trouve 390 qui 
 n'avaient jamais eu d'enfants,' points either 
 to a cause or a consequence, and certainly 
 to some connection between the two 
 facts. 
 
 It has been said that the ovary of tlie 
 right side is more frequently affected than 
 the left. This statement is rather one 
 of impression than of assurance. Both 
 ovaries are often found diseased at the 
 same time in different degrees. With tliis 
 evidence of sequence, and with our know- 
 ledge of the sympathetic morbid action 
 between twin organs, no question can be 
 made as to the rule of practice, as accepted 
 in ophthalmic surgery, to save one by 
 cutting out the other; while it may be as 
 wrong to cut out a sound ovary as a 
 healthy eye. 
 
 A long duration of the disease is ex- 
 ceptional. Race and type yield equallv 
 to the same etiologic influences. M'Dowell 
 soon fell upon cases among negresses as 
 well as whites. My list is multicolor 
 and cosmopolitan, and, if reports may be 
 trusted, ovariotomists are never anywhere 
 in want of subjects. 
 
 The discovery of a tumour in the 
 abdomen is generally made by the patient 
 herself. The question, What is it ? is one 
 for the surgeon. Having satisfied himself 
 that he has an ovarian tumour to deal 
 with, and putting aside the tuberculous 
 and cancerous degenerations which are 
 indicated by the general conditions, to 
 him the points of primary importance are 
 its seat, solidity, and relative freedom. 
 He has to make out, if possible, the basic 
 origin of this tumour, and what sort of 
 pedicle it has, on which side it is attached, 
 and whether it be single or double. It is 
 possible that there may be a cyst of both 
 ovaries. This I saw for the first time in 
 a young lady whom I attended with Dr. 
 Priestley. There was a distinct sulcus 
 between the two cysts near the median line, 
 and it became a question whether this 
 Avas owing to disease on both sides or to 
 the peculiar shape of a cyst on one side. 
 It Avas supposed that the latter opinion 
 was more probably true, because the 
 catamenia Avere regular ; but at the opera- 
 tion tAvo free simple ovarian cysts Avere 
 removed Avithont difficulty. In one case 
 the appearance leading to suspicion of 
 both ovaries being diseased, depended on 
 a deep sulcus in the cyst caused bv the 
 rotation of ihe tumour and the ]iull on 
 the Fallopii n tube. W the resonance of 
 
 B 2 
 
OVARIAN AND ALLIED TUMOURS 
 
 intestine can be traced low down in front 
 between two cysts, the probability of 
 disease on both sides is strong. 
 
 The next questions are, wliether the 
 tumour is cystic or solid, or whether it is 
 free or adherent ; and if adherent, whether 
 the adhesions are of such a character that 
 they may be separated without risk, or 
 so extensive and intimate that separation 
 •would be almost certainly fatal. On their 
 solution depends the decision whether 
 tapping should or should not be recom- 
 mended ; whether drainage should be 
 tried, or whether ovariotomy would be 
 the best practice ; whether this operation 
 could be done with more or less than the 
 average chances of a good result ; or 
 whether the difficulties would be so great 
 that it should not be attempted, even if 
 the patient were herself anxious thereby 
 to escape from her sufferings whatever the 
 risk might be. 
 
 Solid tumours of the ovary are ex- 
 cessively rare. In two of the cases which 
 I have seen, the tumours were surrounded 
 by fluid in the peritoneal cavity, and 
 it was only after removal of this fluid 
 that the size and consistence of the body 
 could be made out. Solid portions of 
 large tumours which fluctuate in other 
 parts are common enough, but general 
 hardness and irregularity of form, with 
 nodular masses cartilaginous or bony to 
 the touch, almost indicate the dermoid 
 character of the growth, especially in a 
 fair and young patient. 
 
 When by internal and external exa- 
 minations the outline of the tumour can 
 be traced smooth and elastic over its 
 whole extent, when the wave of fluctuation 
 is etjually perceptible in all directions and 
 limited by the line ofdulness on percussion, 
 and the want of resonanc? is circumscribed, 
 the inference is pretty clear not only that 
 the tumour is cystic, but that it is prac- 
 tically unilocular. 
 
 This simple cyst, however, may be 
 either ovarian or extra-ovarian. If in a 
 young person it is either flaccid and of 
 long duration, or excessively tense and of 
 recent formation, the inferi^nce is almost 
 equally clear that the cyst is extra-ovarian 
 and the contents limpid. x\s this kind of 
 cyst especially may be not only tempo- 
 rarily emptied, V)ut emptied with some pro- 
 bability tliat the fluid will not collect again, 
 it is interesting to ascertain if pf)ssible 
 whether it is really single, or whether there 
 may be one large cyst with smaller ones 
 
 concealed. Two conditions may be ac- 
 cepted as proof that an extra-ovarian cyst 
 is simple : first, that it has lasted for 
 years with little damage to the health; or 
 second 1}', that it has formed with such 
 rapidity as to be mistaken for ascites. In 
 the first of these two conditions the cyst 
 is generally flaccid, and there is little or 
 no suffering beyond the inconvenience 
 arising from its bulk. In the second, the 
 cyst is tense, and there is the suffering 
 which accompanies undue and sudden 
 abdominal distension. Both are likely ta 
 be mistaken for ascites, but may be dis- 
 tinguished by the signs of the inclosure of 
 the fluid in a cyst, enumerated in the next! 
 chapter. 
 
 With these simple cysts, whether of 
 the ovary or not, the health is fur some 
 time but little affected. The first appear- 
 ance is in much the same spot, the advance 
 is similar, the form of the abdomen and 
 the efiect of change of position are not 
 different. The fluctuation in both is 
 limited, but to the touch the shock is not 
 the same. It is as distinct in the one as 
 in the other, but from the character of the 
 fluid and the thinness of the walls in the 
 broad-ligament cysts, the wave impression 
 under percussion in them is more defined. 
 Scarcely a trace of these tumours can be 
 felt after tapping, so completely do the 
 walls collapse. The fluid itself, in con- 
 trast with that from a true ovarian cyst, 
 is thin, clear, odourless, and any coagulum 
 formed by boiling isredissolved by boiling 
 acetic acid. On this test the practitioner 
 may mostly rely with safety, and found a 
 reasonable hope that further proceedings 
 will t^e unnecessary. 
 
 There are many cysts which, although 
 practically unilocular, have on some part 
 of the Avail o£ the mother cyst, most com- 
 monly near the base, a group or groups of 
 secondary C3's1s, Avhich negative the sup- 
 position that the tumour is extra-ovarian^ 
 and the contents instead of being limpid 
 will in many instances prove to be viscid. 
 Multilocular cysts are sometimes as uni- 
 form in outline as simple cysts, but as a 
 rule their surface is more or less irregular 
 from the unequal development of their 
 component parts; and the projection of 
 the different compartments can be both 
 felt and seen. Thiese projections vary in 
 hardness, and when the resistance of the 
 C3'st wall to pressure i^! considerable, wdien 
 the flucttiation is limited by the divisions 
 between the cavities, and its wave is sloAV 
 
DIAGNOSIS OF ADHESIONS 
 
 and d<iul;Lfu!, the proLaLility is that the 
 cyst wall id thick and the contents colloid. 
 A septum must be very thin which does 
 not intercept the wave of fluctuation, but 
 •in some cases of colloid tumours, where 
 the septa are imperfect, the impulse of 
 the percussed fluid is almost as distinct 
 and instantaneous as in a true unilocular 
 cyst. 
 
 Boinet believes that the coloiu- and 
 •consistence of the contents of multilocular 
 cysts may be predicted before tapping. 
 The progress of the disease, the signs of 
 inflammation more or lei-s acute and re- 
 peated, and the state of the health, Avill be 
 sufficient to indicate if the contents are 
 serous or purulent, and what their colour 
 may probably be. When abdominal pains 
 have been frequent, and the abdomen is 
 tender on pressure, it is probable that, 
 Avhether the cyst is iinilocular or multilo- 
 bular, the contents will be sero-sanguino- 
 lent. When the temperature ranges from 
 100° or 101° in the 'morning to 103° or 
 104° at night, and emaciation is pro- 
 gressive, appetite lost, thirst troublesome, 
 sleep disturbed, nausea or vomiting dis- 
 tressing, and the abdomen tender on 
 pressure,with hurried pulse and respiration, 
 it is probable that one or more of the cysts 
 may contain pus ; and that, when these 
 symptoms are present in an extreme de- 
 gree, or have lasted for a considerable 
 period, the pus has become fetid. Blood 
 may be found in one or more of the cysts, 
 either as an immediate result of twisting 
 of the pedicle, or as a more slow and 
 gradual oozing from degenerative changes. 
 
 When any considerable amount of 
 blood has been poured into the cavity of 
 an ovarian cyst, all the well-known signs 
 ■of internal lja?morrhage are observed. I 
 have twice seen sudden death occur in 
 this way. In one case five pounds of 
 blood and clot were removed from the cyst 
 into which they had been suddenly poured 
 from a large vein. In the second case the 
 blood passed into the peritoneal cavity. 
 Another patient died, but not immediately, 
 of bleeding thiough the Fallopian tube 
 and uterus from a large cyst of the left 
 ovary. 
 
 ADHESIONS 
 
 In the early days of ovariotomy great 
 pains were taken to ascertain whether a 
 tumour was free or adherent, and if ex- 
 tensive adhesions to the abdominal wall 
 were believed to exist, ovariotomy was 
 
 considered to be improper or impracti- 
 cahde. Mr. Walne, in 1S43, began his 
 operations with a small incision just large 
 enough to enable him to ascertain with 
 his finger whether the cyst were free or 
 not. Dr. Frederick Bird published a great 
 number of cases in Avhich he made an 
 exploratory incision, and abandoned the 
 operation as soon as he found that the 
 adhesions were intimate. He was so 
 anxious to ascertain the presence or ab- 
 sence of adhesions that, even before making 
 an exploratory incision, he used to insert 
 needles through different parts of the 
 abdominal walls into the cyst, believing 
 that by Avatching the movements of these 
 needles, as the patient inspired and expired, 
 he could make out whether the cyst shifted 
 its place beneath the abdominal wall or not. 
 Others marked thedeviationsof thecannula 
 after tapping, with the same intention and 
 belief, only to find that all these signs were 
 fallacious. 
 
 Before I had operated on any con- 
 siderable number of cases, I bcgiin to doubt 
 whether adhesions seriously affected the 
 result of the operation, and on analysing 
 the first 500 cases, arrived at certain con- 
 clusions, to be found in the fifth chapter. 
 The experience of the second 500, and 
 of my first 1,000, as a whole, afterwards 
 modified these conclusions, and proves 
 that it is a matter of some interest to know 
 what are the signs by which a free or an 
 adherent cyst may be recognised. To make 
 ^this examination the patient should be 
 placed in a good light, lying on her back, 
 with the shoulders and knees somewhat 
 raised, and the whole abdomen uncovered. 
 By watching the abdominal movements 
 during deep inspiration and full expiration, 
 a free ovarian cyst may be seen, providing 
 the abdominal Avail is not too thick, moving 
 upwards and downwardsAvith every breath. 
 Irregular elevations and depressions on the 
 surface of the cyst make its free mobility 
 perfectly manifest and indubitable; but 
 Avhen the surface is uniform it is only the 
 upper border of the cyst Avhich can be seen 
 to move, and to avoid dece[.tion it may 
 be riecessary to ascertain by percussion 
 how high the outline extends above the 
 umbilicus ; because the transverse colon, 
 following the respiratory movements, may 
 be easily mistaken for a moving cyst. A 
 thick abdominal Avail may obscure the 
 movements of the cyst during inspiration 
 and expiration, but it is quite easy to 
 foUoAV them by the varying position of the 
 
6 
 
 OVARIAN AND ALLIED TUMOURS 
 
 dull sound of the cyst and the clear sound 
 of the colon under percussion. 
 
 The dull sound at the upper boundary 
 of the cyst will often descend from one to 
 two inches during inspiration, and rise 
 during expiration, just as the cyst is seen 
 to move in patients where the abdominal 
 wall is thin. With clos^e adhesions to the 
 abdominal wall no such ireedom of motion 
 can be observed, nor is it possible. The 
 cyst and the abdominal wall nuist move 
 together unless the adhesions arc loose. I 
 have three or four times seen cases where 
 the cyst moved freely beneath the abdomi- 
 nal Avail, but in which very firm adhesions 
 had to be separated, these adhesions con- 
 sisting of flattened cellular bands or cords 
 of fully an inch in length. My belief 
 is that such bands of adhesion have been 
 elongated by the free motion of the cyst, 
 before the lymph forming the connection 
 had been thoroughly organised or hardened. 
 Once aware of this t-ource of fallacy, it is 
 easy to check it by placing the hands Hatly 
 on the abdomen while the patient breathes, 
 when any long bands of adhesion give a 
 sensation of grating or crackling to the 
 liand, Avhich can only be mistaken for the 
 rubbing of recent lymph, or for the pre- 
 sence of omentum in iront of the cyst. With 
 this sensation of crepitus, friction sounds 
 are always audible, and the concurrence 
 Avas formerly supposed to be an evidence 
 of adhesion by lymph recently effused upon 
 the peritoneal surface of the cyst, or upon 
 the peritoneum in apposition with the cyst. 
 But this is an error. So long as the fric- 
 tion can be felt or Jieard, movement must 
 be free. As soon as adhesion takes place 
 friction ceases, and can only be felt again 
 if the lymph which forms the connecting 
 medium becomes so stretched that motion 
 again becomes possible between the cyst 
 and the abdominal wall. It is common 
 for crepitus to be present for a time, and 
 to disappear without any adhesion, the 
 lymph being removed and the surface of 
 the peritoneum again rendered smooth. 
 The crepitus which is produced by the 
 presence of omentum between the cyst 
 and the abdominal wall may be mistaken 
 for tliat caused by recent lympli or old 
 stretched adhesions, but it is not impossible 
 to distinguish them with tolerable certainty. 
 With omentum there is a softer and more 
 doughy feel, and it is seldom present over 
 any paitof a cyst not near some intestine. 
 This is easily recognised by its resonance on 
 percussion and its gurgling luider pressiu-o, 
 
 and there is neither the tenderness nor 
 
 feverishness which accompany the i-ecent 
 effusion of lymph. 
 
 This interesting point in the diagnosis 
 of adhesions presented itself to me some 
 years ago. A tumour, which had not 
 been tapped, was observed to move very 
 freely beneath the abdominal parietes on 
 deep inspiration, and I therefore expected 
 to find it non-adherent. But at the ope- 
 ration on June 13, 18C4, firm adhesions 
 anteriorly and in the right iliac fossa, 
 sufficiently long to admit of the cyst 
 moving freely, and an extensive surface 
 of adherent omentum, were separated by 
 the hand with some difficulty, and a close 
 adhesion to the fundus of the bladder 
 required careful dissection. 
 
 The action of the recti abdominales 
 varies with the different conditions of 
 ovarian tumours, and should be brought 
 into view by directing the recumbent 
 patient to try and sit up without assisting 
 herself by her hands or elbows. This 
 effort puts the recti in strong action, and 
 if a tense ovarian cyst is free from adhe- 
 sion, it falls backwards and to the sides, 
 while the muscles form a projecting 
 ridge in the centre of the abdomen. The 
 same ap^^earance is seen in cases of adhe- 
 rent cyst ordy when it is flaccid or partially 
 empty. 
 
 The umbilicus is not affected by the 
 movements of a free ovarian cyst during 
 respiratory action, or when pushed in 
 various directions. But any movement 
 communicated to a cyst which adheres to 
 the front of the abdominal wall is imme- 
 diately followed by a corresponding move- 
 ment of the naA'el. 
 
 But while slight adhesions to the ab- 
 dominal wall are not much regarded in 
 ovariotomy, adhesions low down in the 
 pelvis are, on the contrary, of great im- 
 portance. The difficulty is to separate 
 them without injury to the rectum or the 
 bladder, or the ureters, or to large blood- 
 vessels or to nerves, and it is not easy to 
 find every bleeding vessel or to stop the 
 loss of blood. When deep seated and 
 very intimate, the dissection necessary is 
 out of the question in the living patient, 
 and gives no small trouble after death. 
 Such a condition may be suspected, espe- 
 cially after tapping, Avhen placing the 
 patient on her elbows and knees, with 
 the pelvis raised and the thorax de- 
 pressed, the lower ])ortion of the tumour 
 can be felt unyielding by the finger 
 
THE PEDICLE 
 
 through the vagina or rectum, and the 
 uterus is either pulled up out of reach, 
 or pressed backwards or forwards or to 
 either side, while its mobility is consi- 
 derably restricted. 
 
 But it is quite possible that the lower 
 portion of an ovarian tumour may be 
 jammed downwards and moulded into the 
 pelvis Avithout becoming attached. Then 
 in the same position some force with 
 the finger will dislodge it and show that 
 it is not bound down by adhesions. I 
 have operated on an ovarian tumour thus 
 simply impacted in Douglas's space with 
 the uterus thrust upwards out of the 
 pelvis. Both ovaries were diseased, and 
 though there were no adhesions, one cyst 
 was prevented from rising by the other. 
 They were successfully removed. It is 
 curious in such cases to hear the rush 
 of air into the hollow Avheu the lower 
 portion of the cyst is pulled away from 
 the sacrum. The air passes down with a 
 gurgling sound, and the tumour is brought 
 away with no more than the ordinary 
 difficulty. 
 
 Adhesions to the liver, stomach, or 
 spleen can never be accurately made out 
 before operation. Sometimes a coil of 
 intestine can be distinctly traced, always 
 remaining attached to the samepart of the 
 cyst wall. Further than this, adhesions to 
 the abdominal viscera can only be ascer- 
 tained after the operation has been com- 
 menced. 
 
 THE PEDICLE 
 
 For the gake of convenience, the 
 attachment of ovarian cysts and tumours 
 to the part from which they spring, 
 whether long, narrow, and cord-like, 
 or short, thick, and broad, may be con- 
 sidered imder the common designation 
 of pedicle. It consists of the Fallopian 
 tube often much elongated, the broad 
 ligament often considerably thickened, 
 the utero- ovarian ligament in some cases 
 bypertrophied into a large fibroid stem, 
 and the round ligament. The round liga- 
 ment may be so convoluted that a double 
 curve of it is included in the pedicle, but 
 it is often quite free. Occasionally the 
 utero-ovarian ligament and the Fallopian 
 tube are not connected by the broad liga- 
 ment; a considerable space may intervene 
 between them, so that they appear as two 
 pedicles to one tumour. -The pedicle con- 
 tains large blood-vessels ; every now and 
 then the veins are so large and distended 
 
 that they resemble the intestines of a 
 rabbit. In all cases of ovarian tumour 
 the arteries are branches from those which 
 supply the ovary itself, and the veins have 
 the tortuous distribution peculiar to the 
 plexuses of this part. Tlie size of these 
 vessels, when adhesions do not materially 
 contribute to the supply of nourishment, 
 is mostly in proportion to the bulk of the 
 tumour ; but oftentimes their volume is 
 inexplicably large, and accounts for the 
 rapid loss of blood when ruptured or 
 divided. Numerous lymphatics, after a 
 devious course and many inosculations 
 passing between the ovary, the tube, and 
 the broad ligament to the lumbar plexus, 
 are also inclosed in the pedicle. Nerves 
 of considerable size accompany the ve'ssels. 
 I have seen a nerve quite as large as the 
 radial in a part of the pedicle left above 
 the clamp. The tissues mixed up with 
 the other components of the pedicle are 
 histologically the same as those of the 
 coats of the tumour — a species of imper- 
 fect connective and fibrous tissues, the 
 chief elements being single white fibres, 
 numerous fusitbrm embryonic fibres, and 
 elliptical round cells or granules, the 
 whole strongly contractile, coherent, 
 and bound together by an envelope of 
 peritoneum. In many cases, especially 
 where the disease assumes the colloid 
 form, the pedicle becomes implicated, is 
 soft in texture, and easily broken through. 
 In others it becomes the seat of numerous 
 proliferous outgrowths or papillary excres- 
 cences. In its ordinary form it is exten- 
 sible, and of variable length and thickness. 
 When elongated, it may form attachments 
 to the surrounding parts, and sometimes 
 is the cause of strangulation of intestine. 
 It is not often that it is seen so long as in 
 Case 603, where it measured more than 
 one foot, and was accompanied through- 
 out by the Fallopian tube. In Case 844 
 it was more than the usual length, and 
 had a band of adhesion stretching across 
 to a coil of intestine. This I ligatured 
 before putting on a clamp to the pedicle. 
 There are also instances of duplicate 
 pedicles. I need only cite two or three 
 cases among my last five hundred. In 
 one case (502) the pedicle was in two 
 divisions v;ith intestine between them. 
 Two distinct pedicles supported the cyst 
 in Case 927, but the tube only was tied. 
 The patient did Avell. In Case 841, I met 
 with the singular complication of four 
 cysts for which there were four pedicles. 
 
OVAIUAX AND ALLIED TUMOURS 
 
 ROTATION OF THE PEDICLE 
 
 A. long pedicle allows free scope to tlie 
 disposition Avhich these tumours have to 
 turn upon themselves, and is then the 
 Bource of important complications. Li 
 1865 Eokitansky published a paper on 
 ' The Strangulation of Ovarian Tumoiirs 
 by Eotation.' The tumour turns upon 
 its axis, and the pedicle is twisted some- 
 times as much as two or three times 
 round. The occurrence is not at all rare. 
 Eokitansky has given the particulars of 
 thirteen cases, eight of which he found in 
 making autopsies after fifty-eight deaths 
 from ovarian disease. The same thing 
 has been observed during my operations 
 in more than twenty cases, and no doubt 
 it has in others escaped notice. In two 
 cases it caused death before operation. 
 
 The direction of this rotation is not 
 at all constant; sometimes being inwards 
 towards the median line, sometimes the 
 reverse, outwards. The tumour may also 
 rotate obliquely, turning over backwards 
 or forwards. In outward rotation the 
 Tallopian tube, if not adlierent to the 
 tumour, becomes spiral round the pedicle ; 
 if adherent, round both tumour and pedi- 
 cle. In inward rotation, the first half 
 turn pushes the tube inwards and back- 
 wards. Should the rotation continue, 
 then the tube forms a spiral round the 
 back of the tumour. Or it may be 
 altogether exempt from participation in 
 the turning. The uterus is pulled in 
 the direction of the rotation, and in one 
 case (lOG) it was so much drawn out of 
 its place that I was led to suppose I should 
 find close adhesions, which, however, 
 did not exist. These movements seem 
 occasionally to take place suddenly and 
 quickly ; but they are gradual in other 
 cases ; may be reversed, and recur. 
 Where the rotation is not complete, the 
 motion may become, as it were, slowly 
 oscillating. The pedicle sometimes gives 
 indications of these changes having taken 
 place repeatedly ; and general symptoms, 
 Buch as sudden accession or increase of 
 pain, change of other sensations from 
 altered relative position of the tumour 
 and viscera, and perhaps some difference 
 in the external contour of the belly, may 
 enable us to conjecture tlie time of com- 
 mencing rotation. 
 
 But if the pedicle has become twisted, 
 and no imwinding of it follovvs, what may 
 be the consequences? The great veins 
 
 are compressed, and blood continues to 
 pour in by the arteries. Congestion, 
 exudation of serum, extravasation of 
 blood into the cysts, and rupture follow 
 in rapid succession ; and, unless timely 
 relief is afforded by ovariotomy, the 
 patient soon sinks. If the rotations are 
 so complete as to strangulate the arteries 
 of the pedicle, gangrene is inevitable. 
 But supposing the revolving of the 
 tumour to be accomplished more tar- 
 dily, nutrition is only impeded, and 
 the more happy result of shrivelling of 
 the w^alls of the tumour, with absorption 
 of the contents, may occur. The remains 
 of such tumours have been found some- 
 times in Douglas's space as a hard, solid, 
 partly cartilaginous substance. Inflam- 
 matory adhe^ions binding down the pedi- 
 cle have also, without twisting, brought 
 about the atrophy of an ovarian tumour. 
 In other instances, the constriction of the 
 vessels by the change of position is so 
 moderate that the tumour itself is not 
 much affected, but it remains stationary, 
 contracts adhesions to some of the viscera, 
 and cannot be replaced. Rokitansky 
 mentions one case in which a strong 
 cord-like band so compressed the sigmoid, 
 flexure of the colon that the slightest 
 change of position rendered it imper- 
 meable. Tlie bowel has also been so 
 entangled, with a long pedicle, during 
 rotation, as to become strangulated. The 
 immediate performance of ovariotomy 
 might be rendered necessary, under such 
 circumstances, for the release of the com- 
 pressed and obstructed intestine. Even 
 after new vascular alliances have been 
 formed between the rotated tumour and 
 the omentum or viscera, the pedicle has 
 by some means, either tension or pressure, 
 been divided. In such a state of ti'ans- 
 plantation, the tumour has drawn its 
 nutriment through the newly formed 
 vessels of the plastic adhesions, and its 
 parasitic existence has not been much 
 less vigorous than before. Several ex- 
 amples of these self-grafted tumours have 
 come imdcr notice among my ovario- 
 tomies. In the operation in Case 110 
 there was no adhesion of the cyst to the 
 abdominal wall, Imt the omentum was 
 strongly attached to the upper part of the 
 cyst, and interlaced with mesentery from 
 below. I tapped several large cysts suc- 
 cessively, got the tumour out, and then 
 found there was no pedicle. It appeared 
 that the tiuiiour derived its vascular 
 
ROTATION OF THE PEDICLE 
 
 siippiy solely from the omental and 
 mesenteric vessels. The fundus of the 
 uterus felt rough, but there v/as no tear 
 nor fracture at the point where the Fal- 
 lopian tube must have separated, nor was 
 there any bleeding ; there was pretty free 
 hajmorrhage from the omental vessels. 
 I cut away some shreds of omentum, and 
 tied at least twelve vessels with very fine 
 silk, cutting off both ends of the ligatures 
 close, and returning the omentum with the 
 tied vessels into the abdomen. The other 
 ovary was found in its natural position, 
 but enlarged and diseased. It too was 
 removed, and the patient was soon fully 
 I'e-established in health, and lived till the 
 year 1878. Another instance (Case 419) 
 was that of a woman thirty-eight years of 
 age, with five children, who for eighteen 
 years, and through all her pregnancies, 
 had carried a dermoid cyst. When two 
 months advanced in pregnancy (May 
 1871) I operated on her without hindrance 
 to the gestation. The tumour being der- 
 moid, its contents would not pass through 
 the trocar, but gushed out from the punc- 
 ture. The cyst was then drawn out, lai'ge 
 shreds of very vascular omentum and a 
 •coil of intestine growing to it. On separat- 
 ing the omentum and intestine, it was 
 found that there was no pedicle. The 
 Jolood supply of the cyst had been kept up 
 by the omental vessels, and some large 
 vessels near the ca^cal a]ipendix, where the 
 intestine appeared thick and contracted. 
 Several vessels and shreds of omentum 
 were tied, and returned with the ligatures 
 cut off short. At the full term of preg- 
 nancy a living child was born, alter a 
 natural labour, in December 1871. The 
 patient was well in 1872, but in 1881 
 suffered from pulmonary disease, which 
 afterwards proved fatal. 
 
 It is very easy to understand that an 
 ovarian tumour of almost any size, pro- 
 vided the pedicle be long and the tumour 
 be free from adhesion, may rotate and form 
 one, two, or more complete twists of the 
 pedicle. I have several times unrolled 
 the pedicle before applying a clamp or 
 ligature, turning round the tumour three 
 or four times before it was set right — 
 although there had been no such stop- 
 page of the supply or return of blood 
 as to have affected in any remarkable 
 degree the nutrition or appearance of the 
 tumour. But in other cases, the veins 
 liaving been compressed while the arterial 
 supply went on, successive hosmorrhages 
 
 have taken place. I have twice known 
 sudden death so caused. I once went with 
 the late Mr. Fowler, of Kennington, to 
 operate upon a lady at Brixton, when 
 we found that she had died unexpectedly 
 two hours before our arrival. The post- 
 mortem examination showed that death 
 was due to a very large extravasation of 
 blood, first into the ovarian cyst and then, 
 after its bursting, into the abdominal 
 cavity, evidently the consequence of a 
 complete twist of the pedicle by the 
 rotation of a non-adherent cyst. In 
 another case I went to the Hospital for 
 Incurables at Putney to see a patient 
 there by the desire of Mr. Cream. She 
 had been found dead that morning by the 
 side of her bed. I opened her abdomen 
 and removed a large free ovarian cyst, 
 which contained more than five pounds of 
 blood-clot, the bleeding in this instance 
 also caused by a long twisted pedicle. 
 These are the only two cases of sudden 
 death I have seen, but I have many times 
 known htemorrhage to a smaller extent 
 lead to attacks of pain, vomiting, and 
 supposed peritonitis ; and more than once 
 such extreme pallor or chloro-ana;mic 
 aspect as gave rise to ungrounded fear of 
 malignant disease. One very remarkable 
 case of this kind was a lady from Moscow, 
 who arrived in London, May 1879, after 
 a journey which was interrupted at Berlin 
 by an attack of severe abdominal pain and 
 vomiting. She was twenty-four years of 
 age, married in January 1873, had her 
 first child in November of that year, 
 aborted in 1875, 1876, and 1877, and 
 gave birth to a second child in October 
 1878. In 1876, before the second abor- 
 tion, she observed a tumour the size of 
 the fist on the left side of the abdomen. 
 Alter the abortion it increased to the size 
 of a child's head, and so remained during 
 the subsequent pregnancies. The last 
 labour was natural, but the abdomen con- 
 tinued to enlarge until she left Moscow 
 for England to consult me. She was de- 
 tained a week in Berlin by^ the symptoms 
 above noticed, attributable, I believe, to 
 a twist of the pedicle, and on reaching 
 London she was suffering from a recur- 
 rence of pain and vomiting. She was 
 extremely weak, and so very white and 
 bloodless that, fearing no time was to 
 be lost, I operated after she had been 
 three days in London ; and found, as I ex- 
 pected, a quantity of blood-clot within a 
 very rotten cyst, and a narrow cord-like 
 
10 
 
 OVARIAN AND ALLIED TUMOURS 
 
 pedicle so tightly twisted as to be almost 
 broken off. There was no fetor. Ex- 
 tensive recent adhesions to omentum and 
 coils of intestine had mainly kept up the 
 supply of blood to the tumour of the leit 
 ovary. The right ovary, being enlarired 
 and cystic, was also removed. The 
 patient recovered without any fever, soon 
 regained her colour, and sent me a 
 coloured photograph portrait to show the 
 difference between her striking pallor 
 before the opeiati(m and her look of 
 blooming health afterv/ards. 
 
 The generality of sessile tumours, 
 extra-ovarian and retro-peritoneal, have 
 no true pedicle, but acquire their supply 
 of blood by numerous vessels entering at 
 all the attached parts. Sonni of the retro- 
 peritoneal, however, in enlarging from 
 
 their base, drive the peritoneum before 
 them. This then makes a band or cord 
 of connection, and may or may not contain 
 a few large vessels, but does not assume 
 the form of a stem as in ovarian cysts. 
 The pi'oportion of cases in which there is 
 a true pedicle — long or short — and those 
 where the connection of the base of the 
 cyst to the surrounding parts is so intimate 
 that separation can only be effected by a 
 sort of enucleation is not very easy to 
 estimate' exactly ; because when the base 
 is small and may be surrounded by a 
 ligature, many would call this a short 
 pedicle. But, speaking roughly, I should 
 say that in my practice I have not met 
 with more than 5 per cent, where true 
 enucleation has been necessary. 
 
 CHAPTER II 
 
 DIFFERENTIAL DIAGNOSIS OF OVAUIAN TUMOUIIS 
 
 "When a woman with enlarged abdomen 
 comes under naedical examination the' 
 three inevitable questions rise up for de- 
 termination : 1st. Has she an ovarian 
 tumour, or is it something else which can 
 give rise to the same symptoms and ap- 
 pearances ? 2nd. If she has an ovarian 
 tumour, of what kind is it, and how can 
 Ave distinguish one kind from another ? 
 and 3rd. Are there any other abdominal 
 conditions and diseases of enlargement co- 
 existing with it and disguising its identity, 
 modifying its progress, or influencing our 
 views as to its treatment ? 
 
 The first point, therefore, which has to 
 be considered in studying a case of abdo- 
 minal swelling is the organ from which it 
 ai'ises. The presumption being on the 
 side of an ovarian tumour from the exist- 
 ence of a certain set of signs and S3'mptoms, 
 the probability of its being simulated by 
 some other disease has to be discussed. 
 And there are many conditions — some 
 morbid, otliers natural — which may give 
 rise to doubt and difKculty in coming to a 
 decision ; though these diagnostic puzzles 
 vary much in force according to their 
 nature and the conditions under which 
 they offer themselves. 
 
 After the following enumeration of the 
 principal states and diseases which jnay 
 
 throw doubt on the diagnosis of an ovarian 
 tumour, or for which it may be mistaken, 
 I shall proceed to the sepaiate considera- 
 tion of the most important. In connection 
 with the peritoneum we have : 
 
 Ascites, 
 
 Encysted dropsy of the peritoneum, 
 Tympanites and phantom tumours, 
 Fibro-plastic tumours of peritoneum, 
 Fatty and other tumours of omen- 
 
 tuni and mesentery. 
 Hydatids, 
 Cancer and tubercle. 
 
 Difficulties in diagnosis caused by 
 uterine enlargements :a-ise from : 
 
 Pregnancy, 
 
 Retained menses and moles. 
 
 Air and fluids in uterus or Fallopian 
 
 tubes. 
 Fibroid tumours. 
 Cancer. 
 
 Another miscellaneous group is this : 
 
 Hypertrophy of the abdominal wall, 
 Enlargements of other viscera, such 
 as the liver, spleen, kidney, and 
 luml)ar and mesenteric glands. 
 Hydatid cysts of the liver, gall- 
 stones, 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 11 
 
 Movable kidney, and cysts and tu- 
 mours of the kidney, 
 
 Fascal accumulations, 
 
 Distended bladder, 
 
 Hajmatocele, 
 
 Pelvic abscess, 
 
 Extra-uterine pregnancy, 
 
 Enchondroma, or encephaloid dis- 
 ease of ilium or vertebra?. 
 
 Many of the evils and discomforts 
 Avhich accompany the progress of a case 
 of ovarian tumour arise, no doubt, from 
 its mere mechanical interference with the 
 organs in the chest, pelvis, and abdomen, 
 displacing and compressing them, impair- 
 ing their nutrition, and disturbing their 
 functions. But the pressure of the gravid 
 
 uterus is as great, or even greater, and a 
 pregnant woman has sometimes to endure 
 real miseries. Still the process is natural, 
 and there are compensations in the shape 
 of local adjustments, and temporary 
 accommodating changes of form and 
 moral influences, -which are wanting to 
 the victim of ovarian disease. Instead 
 of being cheered by the hopes and aspira- 
 tions of maternity, she has to bear the 
 torture of suspense or despair ; her blood 
 is impoverished and her nervous system 
 shattered by imperfect assimilation. After 
 a time, the emaciation always going on, 
 and the weary, ceaseless self-watchings, 
 made inevitable by the incapacity to use 
 healthful exercise or to undertake the 
 
 usual occupations with success, chisel out 
 the features into the peculiar pinched 
 expression which has been described as 
 the fades uteriaa, but which would pro- 
 bably be better named fades ovariana. 
 
 This drawing, an exact copy of a photo- 
 graphic portrait, gives a very correct idea 
 of the peculiar physiognomy. The ema- 
 ciation, the prominent or almost uncovered 
 muscles and bones, the expression of 
 anxiety and suffering, the furrowed fore- 
 head, the sunken eyes, the open sharply- 
 defined nostrils, the long compressed lips, 
 the depressed angles of the mouth, and 
 the deep wrinkles curving round these 
 angles, form together a face Avliich is 
 strikingly characteristic. 
 
 The tumour begins to grow on one 
 side, where it occupies space wanted for 
 the large intestine with its accumulations, 
 and no provision is made, as for the uterus, 
 for its expansion or for the due mainte- 
 nance of its relative position in respect to 
 the viscera. All is irregular and wrong. 
 At first the weight makes it settle down 
 into the pelvis, where it causes irritation 
 of the bladder and rectum. Mounting 
 higher with augmenting bulk, it presses 
 on the large intestine, according to side, 
 and fa;cal matter is impacted. The uterus 
 is displaced, thrust do-wn, or to one or the 
 other side, retroverted or anteverted ; and, 
 
12 
 
 OVARIAX AND ALLIED TUMOURS 
 
 •as the' case advances, is sometimes so 
 dragged up by its attachments to the tu- 
 mour as to be out of reach of the finger 
 in the vagina. Its form is distorted and its 
 functions rendered difficult and painful, 
 though not absolutely impossible ; for, as 
 it has been already seen, tliere are many 
 coincident cases of pregnancy and ovarian 
 disease. The urinary organs seldom 
 escape at any stage of the disease. 
 When the pressure is on the bladder, 
 micturition is either troublesome, impos- 
 sible, or distressingly urgent. With 
 strain upon or pinching of the ureters, 
 there may be stoppage of the flow of urine, 
 or suspension of its secretion, or poisonous 
 ireflux into the system. Even the kidneys 
 anay be flattened and almost annihilated. 
 The vital organs in the chest suffer in 
 cnany ways, and the chest symptoms of 
 
 oppressed action are often among the 
 most tormenting. (Edema, ascites, and 
 pleural effusion, especially on the right 
 side, occasion the greatest aggravation of 
 misery ; and the effects of distension 
 upon the ribs and spine are so opposed to 
 readjustment as to amount to serious 
 hindrance to recovery after tapping. 
 More than once the ribs, which have been 
 thrown out like a fan, with the intercostal 
 structures overstretched, have never re- 
 turned to their normal condition. The 
 lungs, which have been confined to a very 
 small space, had so far lost their resiliency 
 that air could not easily expand them 
 again. The pleural cavities, filled with 
 fiuid, have not been freed by absorption, 
 or the lung has not expanded after tapping, 
 and the patient has died from want of 
 breathing power. Occasionally the same 
 
 ^V¥ m ^ 
 
 'difliculty has been met with after ovario- 
 toniy ; and a patient, in whom repair has 
 gone on well so far as the abdomen was 
 •concerned, has had her recovery greatly 
 retarded, or has died, simply in conse- 
 v|uence of the state of her chest. The 
 two accompanying copies of photographic 
 ■portraits show well how limited the breath- 
 ing space sometimes liecomes in conse- 
 t'luence of the excessive growth of a 
 tumour. 
 
 DIAGNOSIS BETWEEN OVAUIAN DIlOPSY 
 AND ASCITES 
 
 Our senses of sight, touch, and hearing 
 -are all required to assist us in distinguish- 
 ing ascites from ovarian dropsy, the 
 physical diagnosis being established — I. 
 By inspection and measurement; IF. By 
 palpation; III. By percussion and auscul- 
 
 tation ; and IV. By chemical and micro- 
 scopical examination of the tluids. 
 
 I. Jnsjiection. — The si:e of the ab- 
 domen is seen to be increased both in 
 ascites and in ovarian dropsy ; and, when 
 an ovarian cyst is large, the abdominal 
 enlargement is general, as it is in ascites. 
 But while the cyst is of moderate size, the 
 abdominal enlargement is often partial, 
 more to one side than the other, more 
 below the umbilictis than above. 
 
 In form, the flanks and sides of the 
 abdomen protrude in ascites, the front not 
 being more convex tlian in the natural 
 state, or it may be flattened : while in 
 ovarian disease the bulging is generally 
 most evident in front, less so at the sides, 
 and often more on one side than the other. 
 These remarks apply to simple cysts only. 
 Alterations in position generally produce 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 13; 
 
 a greater and more immediate change in 
 the form of the abdomen in ascites than 
 in ovarian disease, the free fluid gravitat- 
 ing much more readily than a cyst can 
 move. The normal depression of the 
 umbilicus is altered whenever the general 
 abdominal enlargement is considerable 
 both in ascites and ovarian dropsy ; but 
 in the latter disease, although the navel 
 may be flattened as in pregnancy, it is 
 only prominent and bulging (as it very 
 often is in ascites) when ascitic fluid 
 surrounds an ovarian tumour, or when 
 there is an umbilical hernia also. The 
 superficial veins may be dilated from the 
 lower part of the abdomen to the chest, on 
 one or both sides, in either disease. This 
 varicose state of the veins only assists in 
 diagnosis when much more evident on one 
 side than the other. Such undue im- 
 
 portance has been given to this vasculai: 
 condition as a distinction between ascites 
 and ovatian dropsy, and between simple 
 and maliprnant tumours within the ab- 
 domen, that the following facts should be 
 recollected : 
 
 The appearance of congestion of the 
 episgastric veins, seen merely as a fine 
 network of capillaries, is usually a simple 
 result of absorption of the cutaneous ikr^ 
 the vessels becoming visible through the 
 thinned and distended skin, and has no 
 diagnostic value. When some of the 
 larger veins, dilated or varicose, in their 
 course from the inguinal region upwards^ 
 either cease abruptly in the middle of the. 
 abdomen, or run to the hypochondriac 
 region, or even up to the clavicles, an- 
 astomosing with branches of the mammary 
 and intercostal veins, the impediment to 
 
 the circulation may be of several kinds. 
 It may be either in the heart, the trunk 
 or larger branches of the inferior cava, 
 or in the Portal system. Pregnancy, 
 tumours, or coagula causing obstruction 
 in any of these vessels will throw the 
 circulation into the epigastrics. 
 
 When the integuments are oedematous, 
 the liness albicantes become prominent, 
 and have a knotty appearance, which has 
 led to the mistaken appellation of varicose 
 lymphatics. I have observed it chiefly in 
 cases of tumour surrounded by ascitic 
 fluid. 
 
 The movement on respiration is defec- 
 tive in both diseases, both as regards the 
 soft wall of the abdomen and the lower 
 ribs, while that of the upper ribs is ex- 
 aggerated. The alteration in movement 
 only assists in diagnosis when it is partial 
 
 or affects only one side. On making deep 
 inspirations the upper part of an ovarian 
 cyst may often be seen to rise and fall. 
 This appearance is very characteristic. 
 In ascites it may be simulated by some 
 distended coils of intestine moving with 
 the diaphragm ; but the 2-esonance of the 
 intestine on percussion instantly settles ali 
 doubt on this point. 
 
 On measurement, the enlargement of 
 the abdomen in ascites is equal on both 
 sides, or symmetrical ; and, although the 
 distance from the sternum to the pubes is 
 increased, the umbilicus retains its normal 
 position — about an inch nearer to the 
 pubes than to the sternum — and is about 
 on a level with the highest point of the 
 crest of the ilium on each side, and mid- 
 way between these two points. In ova- 
 rian dropsy there is often a considerable 
 
14 
 
 OVARIAN AND ALLIED TUMOURS 
 
 alteration in tlie measurements between 
 the umbilicus and sternum, and umbilicus 
 and pubes, as well as between the 
 umbilicus and the two cristas ilii. In 
 ascites the greatest circular measurement 
 is at the level of the umbilicus ; in ovarian 
 dropsy it is often some inches lower down. 
 II. On palpation, the abdominal wall, 
 in both diseases, is felt to be harder and 
 more resistant than natural, in the parts 
 made tense by much fluid, but is soft and 
 elastic elsewhere. Consequently the varia- 
 tion in the seat of hardness Avith the 
 position of the patient becomes useful in 
 diagnosis, the fluid in ascites gravitating 
 freely to the most dependent part. Fluc- 
 tuation is perceived with varying distinct- 
 ness according to the degree of tension of 
 the abdominal wall, to the thickness of 
 the layer of flit, to the amount of osdema, 
 to the thickness of the peritoneum or of 
 
 the cyst, to the quantity and character 
 of the fluid, and to the amount of tym- 
 panitic distension of the intestines. It 
 occasionally happens that the abdomen is 
 too forcibly distended to respond to the 
 stroke, and gives no sign of fluctuation. 
 In itself, fluctuation offers no assistance 
 in diagnosis, because a thin-walled ovarian 
 cyst, filled with limpid fluid, with a 
 moderately tense and thin abdominal 
 wall, would give a more quick and 
 decided wave than a moderate quantity 
 of ascitic fluid beneath an abdominal wall 
 thickened by fat or subcutaneous oedema. 
 The characteristic peculiarity of the 
 fluctuation in ascites is that it varies with 
 the position of the patient, and is only 
 perceived in the parts where the fluid 
 gravitates towards the abdominal wall ; 
 while in ovarian dropsy its situation does 
 not vary with position, bitt is perceived 
 
 wherever fluid is to be discovered by 
 percussion. 
 
 III. Percussion and auscultation. — 
 The two preceding diagrams represent the 
 situation of clear and dull soimda obtained 
 by percussion in typical cases of ascites 
 and ovarian disease, the patient lying 
 flat and evenly on her back. The dark 
 parts of the abdomen are dull, the rest 
 clear. In ascites, the stomach and intes- 
 tines are above and in front ; the fluid, 
 behind and on either side. In ovarian 
 dropsy the fluid is in front, extending 
 in different degrees to either side, 
 and pushing the stomach and intestines 
 upwards and backwards, just as a gravid 
 uterus does. The figure to the right of 
 the page, indeed, would represent either 
 a gravid uterus near the full period of 
 jn-egnancy, or an ovarian cyst of about 
 the size of such a uterus, and situated 
 centrally, as many ovarian cysts are at 
 
 this, or a rather later, period of their 
 growth. But quite as irequently they 
 tend towards one side or the other, in 
 such cases the diagnosis being, of course, 
 easier. 
 
 It is seldom that a patient with ascites 
 lies so flat as not to raise the shoulders 
 enough to throw a layer of fluid down- 
 wards towards the pubes. Very often the 
 dulness may extend as high as the um- 
 bilicus, and it generally does so when the 
 shoulders are miich raised by pillows. 
 This might lead a superficial observer 
 to suppose that the disease was ovarian, 
 because there was a dull sound in the 
 front of the abdomen ; but on lowering 
 the shoulders and placing a pillow imder 
 the hips, the fluid at once gravitates 
 towards the diaphragm, the intestines 
 float to the .surliace, and a clear sound is 
 obtained where it was dull before. No 
 such alteration in the situation of dulness 
 
DIFFERP^NTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 15 
 
 can possibly occur in ovarian disease. So 
 on turning from side to side, the ascitic 
 fluid flows over to the side which is low, 
 and the intestines rise to the upper side, 
 with corresponding changes in the situa- 
 tion of dull and clear sounds on percus- 
 sion. This does not take place in ovarian 
 disease. Again, in ascites, at any spot 
 near the level where the resonance of the 
 intestines ends, and the dulness of the 
 fluid begins, and a dull sound is elicited 
 by gentle pressure and percussion, a 
 deeper pressure Avill displace the fluid, 
 and • the resonance of the intestines will 
 be heard. At the most depending spots 
 the amount of pressure necessary to 
 obtain a clear sound is some guide to the 
 estimation of the thickness of the layer 
 of fluid. Superficial and deep percussion 
 cannot produce such difference in the 
 sounds in ovarian disease. 
 
 When fluid is free in the peritoneal 
 cavity the wave of fluctuation may be felt 
 not only where the sound is dull on per- 
 cussion, but also beyond the line of dul- 
 ness, even Avhere resonance may be tym- 
 panitic. The intestines float in the fluid, 
 and the fluid may be thrown in waves 
 among them. But Avhen fluid is con- 
 tained within a cyst, fluctuation cannot 
 be detected beyond the boundaries of the 
 cyst. Hence the outline of the cyst, 
 traceable by dulness on percussion, and 
 the line where fluctuation can be per- 
 ceived must be the same. The wave of 
 fluctuation ends at the limit of resonance. 
 
 It has been supposed that percussion 
 on the loins is a very sure guide in dia- 
 gnosis — that when the patient is sitting 
 up, and one loin is clear and the other 
 dull, the disease is ovarian, but that 
 when there is dulness on both sides it is 
 ascites. One dull side is also supposed 
 to be a proof that the ovary of that side 
 is the one diseased. But there are so 
 many exceptions to these rules, that tliey 
 are of no great value, except as corrobo- 
 rating or counterbalancing other physical 
 signs. 
 
 Auscultation alone affords little in- 
 formation, but it shows the presence of 
 the gurgling sounds of the intestines in 
 the spots clear on percussion, and the 
 absence of these sounds in the dull spots, 
 except on deep pressure. In both dis- 
 eases the fluctuation wave may be heard 
 as well as felt. The aortic sounds and 
 impulses are transmitted by the cystic 
 and solid tum.ours, but not by ascites. 
 
 By applying these general rules, a few 
 seconds will enable the surgeon to clear 
 up all doubt in any ordinary case. But 
 there are various conditions which may 
 lead to the necessity for further examina- 
 tion. The quantity of fluid in the perito- 
 neal cavity may be so large that the firont 
 of the abdomen is pushed far beyond the 
 reach of the intestines. They float as 
 far as the mesentery will allow them, but 
 cannot reach the surface of the abdominal 
 wall. In this case percussion must give 
 a dull note in front just as it does in 
 ovarian dropsy. So, too, when the in- 
 testines are fixed in the back part of the 
 abdomen by adhesions, or by a thickened 
 omentum, the fluid is kept to the front as 
 in ovarian dropsy. 
 
 Or an ovarian cyst may contain air 
 or gas, entering either from a perforating 
 communication with intestine, or through 
 the Fallopian tube, or forming after tap- 
 ping and decomposition of fluid. Percus- 
 sion then gives a clear note in front or 
 above, and a dull note behind or below, 
 as it does in ascites; and occasionally, 
 where there is a mixture of air with, 
 fluid, the sound so well known as metallic 
 tinkling may be heard — air bubbling 
 through fluid — or drops of fluid fiilling 
 in the cavity. In these circumstances 
 physical diagnosis alone cannot solve the 
 doubt, and we have to consider all that 
 can be learned from the history of the 
 case and the general condition of the 
 patient. So, when fluid is free in the 
 peritoneal cavity, we must resort to tap- 
 ping and chemical or microscopical inves- 
 tigation before we can decide whether the 
 fluid is the ordinary non-inflammatory 
 serum which transudes into the cavity in 
 heart, liver, or kidney disease, or the in- 
 flammatory exudation of chronic perito- 
 nitis in its simple or its tubercular or 
 cancerous form, or whether it may be 
 ovarian fluid which has escaped from a 
 perforated or ruptured cyst. 
 
 IV. Chemical and microscopical exa- 
 mination of the fluids. — The normal 
 Graafian follicle of the healthy ovary con- 
 tains a minute quantity of a slightly 
 albuminous fluid resembling the serum 
 of blood. It is alkaline, of pale yellow 
 colour, and transparent. It is not ropy 
 but limpid, readily separating into minute 
 drops. It contains a small quantity of 
 a substance which will coagulate when 
 treated with acids or alcohol, or when 
 exposed to a raised temperature. It holds 
 
IG 
 
 OVArJAN A>"D ALLIED TUMOURS 
 
 in suspension spheroidal, nucleated epi- 
 thelial cells and shreds of epithelium 
 from the membrana granulosa of the 
 ovisac. 
 
 After the ruptnre of the ovisac it 
 would appear tliat the fluid contents, or 
 ' ovarine,' escape into the peritoneal 
 cavity ; but the quantity is so minute 
 ihat it can hardly do more than moisten 
 the fringes of the Fallopian tube. 
 
 There are endless differences in the 
 contents of ovarian cysts, and these diffe- 
 j-ences seem to be in no way dependent 
 on the form of the cysts or the anatomical 
 arrangement of their tissues. Even the 
 many strange ejiithclial developments are 
 not accompanied by any special kind of 
 fluid. In the simple unilocular cysts, it 
 is most common to find a perfectly clear, 
 colourless, or straw-coloured fluid. But 
 it is not always so ; for all gradations of 
 colour and thickness occur, and epithelial 
 cells are almost always floating in the fluids. 
 In some rare cases there are cholesterine 
 crystals which, after standinsr, form a glit- 
 tering pellicle on the surface. But al- 
 though the quantity is really very small, 
 it is so very rarely met with in ascitic 
 fluid, that its appearance may almost be 
 looked upon as diagnostic of the others. 
 True albumen may be present, but in un- 
 certain proportions. It is in the few 
 cases Avhere it is absolutely wanting that 
 simple taj^ping proves curative. Spon- 
 taneously coagulable fibrine is hardly 
 ever a constituent of the simple cystic 
 fluids ; a character which distinguishes 
 them from ascitic effusions, from which 
 there is almost invariably a deposit o£ 
 fibrine taking the form of elastic filaments 
 after washing ; the deposit froni ovarian 
 serum, if any, being soft and not at all 
 elastic. Ascitic fluids never contain more 
 solid matter than the serum of the blood, 
 and the greater niimber of ovarian 
 fluids have even less ; but any serous | 
 fluid, taken from the abdomen of a ! 
 woman, which, when filtered, leaves after j 
 evaporation a dry residue in excess of i 
 that which would be found in blood 
 serum, may be pronounced upon as posi- 
 tively ovarian. Pus and blood are seen , 
 in different conditions; in some cysts j 
 they are mixed with the clearer fluid, | 
 and allowance must be made for them 
 in chemical investigations. Among the 
 many cysts of a coinjunind tumour, some 
 may be seen with almost pure serum, 
 and, after tapping, others may contain pus 
 
 and offensive gases. Blood often mixes 
 with the other contents, and influences 
 the colour as well as other qualities. The 
 yellow, green, brownish, or red lints 
 depend upon the presence of bile acids, or 
 the admixture of blood and pus, which 
 may be recent and pure, or old and un- 
 dergoing changes. The turbidity of the 
 fluid depends on the admixture of these 
 secondary matters. Blood is not unfre- 
 quently effused into the smaller cysts, 
 where it sometimes becomes fibrillated 
 and partially organised, though it more 
 frequently runs into a state of decom- 
 position. 
 
 After Scherer's discovery of paral- 
 bumen, and the subsequent discovery 
 that this derivative, or altered form of 
 albumen proper, is a chief ingredient in 
 ovarian fluids, it was at first believed that 
 it would be a sure means of distinguishing 
 these from all other fluids in abdominal 
 swellings. But later experience has 
 proved that this test alone is unreliable. 
 The presence of paralbumen is certainly 
 not a positive sign that fluid has come 
 from an ovarian cyst. Dr. Schetelig 
 found the contents of a large renal cyst, 
 which he had emptied, to consist mainly 
 of paralbumen with cholesterine, and 
 there was no trace of urea, the proper 
 kidney structure having been annihilated. 
 But Scherer also pointed out the relations 
 of metalbumen to mucin, which, he says, 
 colloid matter always contains inconsider- 
 able quantity ; and he raised the question 
 whether metalbiimen ought not to be 
 considered as a transition state between 
 albumen and mucin or colloid matter. 
 Paralbumen and metalbumen differ froni 
 the true albumen in that they are soluble 
 in boiling acetic acid. You take a test 
 tube and boil the ovarian fluid ; the albu- 
 men is coagulated. You add double the 
 volume of strong acetic acid to the coagu- 
 lum, boil, and shalve it; when, if the 
 albumen be true, the ccagulum does not 
 redissolve in the acetic acid. But coagu- 
 lated paralbumen or metalbumen either 
 dissolves or forms a whitish transparent 
 fluid, or breaks up into a kind of jelly- 
 like translucent mass which is easily dis- 
 tinguishal)le from true albumen coagu- 
 lated by heat. These results led to the 
 belief that we had a means of diagnosing 
 abdominal fluids; and it was said that if 
 the coagulated albumen from them dis- 
 solved in acetic acid they were ovarian ; 
 and if it did not redissolve, they were 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 17 
 
 ascitic. That was frequently right. 
 Sometimes, however, part woull redis- 
 solve and part would not. Then the 
 supposition was that it was a mixed fluid, 
 some ovarian and gome peritoneal ; that 
 an ovarian cyst had burst and some of the 
 fluid was in the peritoneal cavity, making 
 a combined fluid which contained some 
 true albumen and some paralbumen ; and 
 this inference was often true. 
 
 There are sometimes traces of sugar ; 
 and fibrinogen, when a constituent, may 
 be demonstrated by applying A. Schmidt's 
 test — the addition o£ a few drops o£ blood 
 to the fluid. A distinct clot will form 
 with fibrinogen in from 25 to 90 minutes, 
 involving the blood corpuscles which had 
 been added. The clot is generally so firm 
 that it can be raised unbroken, and if 
 squeezed in the hand, a quantity of fluid 
 issues out, leaving a loose bundle of fibril- 
 lated substance. Klob divided the con- 
 tents of an ovarian cyst into two portions. 
 Into the one he poured a few drops of 
 blood, and at the end of three hours the 
 whole was converted into a mass as solid 
 as jelly, while the other portion Avithout 
 blood showed no signs of coagulation, even 
 after long standing. Fibrinogen, how- 
 ever, is also found, according to Schmidt 
 and Virchow, in ascitic fluid and other 
 serous secretions. The presence of fibrine 
 was at one time regarded as a proof of an 
 abdominal fluid having been effused from 
 a serous membrane, not from the secretin^ 
 membrane of an ovarian cyst. And if 
 fluid contained both fibrine and paralbu- 
 men, the supposition was that an ovarian 
 cyst had burst and there was a mixture 
 of two fluids. If no fibrine could be de- 
 tected in the composite fluid taken from 
 the peritoneal cavity, then it Avas supposed 
 that, instead of preserving their own 
 chemical characters after admixture, the 
 fibrinogenous elements of the serous fluid 
 were acted upon by the paralbumen of 
 the ovarian fluid in such a way as to in- 
 terfere with the characteristic coagulation. 
 
 Dr. Schetelig informed me that, in a 
 case he watched at Breslau, the presence 
 o£ fibrine in the fluid at the first tapping 
 showed that it was purely ascitic — while, 
 on the tapping being repeated, coagulation 
 did not take place, and paralbumen was 
 detected. This was accounted for by 
 rupture of an ovarian cyst into the peri- 
 toneal cavity, a supposition which was 
 subsequently proved to be correct at the 
 time of ovariotomy. 
 
 Nor does the presence of fibrine prove 
 that the fluid is not ovarian, for in a 
 dermoid tumour, which I removed in 
 June I8G9, Dr. Schetelig m?.de out three 
 distinct kinds of fluids in a number of 
 isolated cysts. In some there was an 
 emulsion of fat and cholesterine ; in others 
 the albuminoid liquid so common in 
 ovarian dropsy ; and thirdly, in different 
 parts of the large tumour, ' certain small 
 isolated bags full of a limpid thin serum, 
 which, being exposed to the atmosphere, 
 soon coagulated like any other serous fluid 
 overcharged with fibrine.' 
 
 The more consistent colloid substances 
 are occasionally distributed in ovarian 
 cysts in a very peculiar manner. They 
 form conical columns with their broad 
 bases directed outwards. Between these 
 columns, a whitish or yellowish matter, 
 consisting of epithelial cells in a state of 
 degeneration, is placed Avithout any definite 
 arrangement. Such cysts have probably 
 been formed by the confiuence of several 
 smaller cysts of which nothing remains 
 but the epithelial investment undergoing 
 fatty decay, and so tracing out tlie former 
 lines o^ separation. 
 
 The chemical examination of colloid 
 substances and other fluids from multi- 
 locular cysts has given results of the most 
 contradictory kind, as is seen by Dr. 
 Mehu's assertion, that he has never found 
 a trace of mucin in ropy ovarian fluids. 
 But this may be explained by the suppo- 
 sition that operators have not all had the 
 same opportunity of collecting a great 
 variety of specimens, and have not dealt 
 with the fluids in the same stages of 
 transformation. 
 
 While it is certain, therefore, that in 
 cases of doubtful diagnosis comjjlete re- 
 liance cannot be placed on the chemical 
 characters of fluids removed from the 
 abdomen, and that the rule of paralbumen 
 being the characteristic of ovarian fluids, 
 and fibrine of serous fluids, and the con- 
 joint presence of paralbumen and fibrine 
 pointing to a mixture of the two fluids, is 
 open to many exceptions — it is still true 
 that the rule is sufficiently often correct 
 to become an aid of much value in arriving 
 at a diagnosis, and to encourage us to 
 attain more accurate knowledge by more 
 extensive observation and research. 
 
 Ik his ' Etude sur lesLiquides extraits 
 des Kystes Ovariques,' Dr. Mehu states 
 that all his investigations, microscopic 
 and chemical, Avere made upon fluids 
 
 C 
 
18 
 
 OVAMAN AND ALLIED TUMOURS 
 
 drawn from the living patient — never 
 'from cysts after ovariotomy or from the 
 dead body : 
 
 That, while he found the proportion 
 of organic matter to vary from 2-50 
 grammes to more than 140 grammes in 
 the kilogramme of filtered, and 200 
 grammes or more in the unfiltered ovarian 
 fluids, the weight of mineral salts obtained 
 from the same quantity was nearly uni- 
 form, from 7 to 9 grammes, generally 
 between 8 grammes and 8"50 grammes : 
 
 That he could almost always trace the 
 appearance of liquid oil to its use on the 
 trocar : 
 
 That the fatty matters found on the 
 surface of the turbid fluids, after being 
 heated for a certain time and then cooling 
 at rest, are the products of the disintegra- 
 tion of the granular aggregations, and 
 cells containing translucent granules, often 
 floating in the recent fluids : 
 
 That the aggregations of granular 
 matter are simply adherent without enve- 
 lopes : 
 
 That he considers the large transparent 
 cells with granular contents to be leuco- 
 cytes enlarged, and not characteristic of 
 ovarian fluids; as he had seen them as 
 often in the fluids of ascites, hydrocele, 
 old serous cysts and hajmatoceles, espe- 
 cially when the effusion was of long date : 
 
 That he discovered cholesterine only 
 nine times in 115 ovarian fluids taken 
 from Gl jiatients, never in larger quantity 
 than 30 centigrammes in the kilogramme ; 
 that even the small amount of 10 centi- 
 grammes, which was the most frequent, 
 gave the glittering appearance in sunlight ; 
 and that it was very rarely seen in ascitic 
 fluid — only twice in 300 cases, one of 
 which had an ovarian tumour, and the 
 other partial peritonitis with Bright' s 
 disease : 
 
 That the absence of spontaneously 
 coagulable librine is the only characteristic 
 which he has found distinguishing ovarian 
 fluids from those of ascites, since in pure 
 ascitic fluids after twenty-four hours' rest, 
 there is almost ahvays a deposit of some 
 centigrammes per kilogramme of fibrine 
 taking the form of elastic filaments after 
 washing, especially when the effusion has 
 been caused by the irritation of a tumour ; 
 while ovarian fluids never give a deposit 
 of this kind spontanciously, and acetjjacid 
 only causes the separation of a small 
 quantity of soft matter not in any way 
 elastic : 
 
 But that, in connectloit with this ob- 
 servation, it must be remembered that, 
 when containing a large quantity of leu- 
 cocytes, ascitic fluid does not yield a 
 deposit of fibrine, and that it is necessary 
 to make allowance for the admixture of 
 blood in the ovarian fluids : 
 
 That, as ascitic fluids never contain 
 more solid matter than the serum of the 
 blood, any filtered serous fluid from the 
 abdominal cavity of which the dry residue 
 weighs more than 70 grammes per kilo- 
 gramme may be pronounced ovarian, and 
 that with a proportion of 80 grammes or 
 more there can be no longer any doubt : 
 
 That this point of diagnosis only 
 applies to the minority of cases, as the 
 greater number of ovarian fluids leave a 
 deposit of less than 70 grammes : 
 
 That the only cases of cure after 
 tapping are those in which the fluid comes 
 from a simple cyst, is clear, free from 
 albumen, and yields a residue of not more 
 than 18 grammes to the kilogramme : 
 
 That the composition of the fluids 
 varies very much in twin tumours, in the 
 different parts of a multilocular tumour, 
 and at the earlier or later stages of the 
 same tapping : 
 
 That the viscidity of the ropy ovarian 
 fluids is due to paralbumen, which has 
 never yet been produced separately in a 
 pure state ; and that he hVs never found 
 a trace of mucin in them. \ 
 
 It is to be regretted thlit the service 
 afforded to our diagnosis of abdominal 
 fluids by assisted sight is uncertain. 
 Microscopical science in its application 
 to medicine requires the skill, aptitude, 
 and discrimination of an expert. Obser- 
 vations made without wide experience, 
 the most scrupulous precautions, and an 
 absolute freedom from speculative bias, 
 are misleading. In ordinary practice the 
 necessary qualifications and conditions 
 are rarely at command. Such Avork as 
 has been done hitherto leaves us without 
 positive guidance in forming our judg- 
 ment, and we must be satisfied with a 
 confirmation of omnions by the ocular 
 interpretations of objects under magnify- 
 ing power. 
 
 Long ago Hughes Bennett took the 
 investigation of ovarian fluids in hand, 
 and he was i'ollowed by Nunn. Both 
 observed the same granular cells and 
 granular matter in many of their exami- 
 nations, and Drysdalo has done so too. 
 Bennett and Drysdale regarded them as 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 19 
 
 diagnostic, but Nunn accepts them as of 
 only secondary importance as a point of 
 evidence. Peaslee remarked upon their 
 frequent absence from iluids taken from 
 cysts removed from the ovary, and 
 thought the utmost that can be said is 
 that, when seen, they give a presumption 
 of ovarian fhiid. Tlie later work of 
 Foulis and Thornton does not add any 
 greater certainty to this question. But 
 they have gone a step further, and 
 pointed out that in cases of ovarian or 
 peritoneal cancer or sarcoma there are to 
 be found in the abstracted fluid evidences 
 in the shape of Avhat they call ' charac- 
 teristic groups of cells.' These they de- 
 scribe as large pear-shaped, round, or oval 
 cells containing a granular material, with 
 
 one or several large clear nuclei with 
 nucleoli, and a number of transparent 
 globules or vacuoles. The cells compos- 
 ing the groups are many of them very- 
 large, but the great variety in size and 
 shape is the marked feature of the group. 
 The discovery of these objects ought 
 no doubt to put us on our guard when 
 we have to deal with tumours doubtfully 
 malignant. If seen, one may be pretty 
 certain that the tumour is in some way 
 malignant ; or, if they be found in fluid 
 removed from the peritoneal cavity, pro- 
 bably a sort of infecting process has been 
 going on there, from the rupture of an 
 ovarian cyst of a malignant character. 
 These cells may have planted themselves 
 and multiplied, or they may have given a 
 
 taint to the cells of the part and in- 
 fluenced them to a malignant form of 
 reproduction. The truth, however, really 
 is that malignant disease is a condition of 
 degradation. Nutrition is imperfect and 
 development is misdirected. It has no 
 specific form of cell, but such cells as are 
 produced in its growth are deformed, dis- 
 torted, and early necrosed ; and the 
 microscopic objects we find in general in 
 the suspicious ovarian fluids are nothing 
 more than groups of cells, some prolife- 
 rating with rachitic profusion and mon- 
 strous, others either dying or dead ; all 
 being evidence of abnormally rapid growth, 
 retrograde change, and the early death of 
 successive generations of degenerate cells, 
 the essential characteristics of malignant 
 disease. 
 
 CHRONIC INFLAMMATION AND TUBERCLE OF 
 - THE PERITONEUM 
 
 The fluid poured out as the result of 
 inflammation of the peritoneum, instead 
 of lying free in the cavity, is sometimes 
 confined in pouches formed by adhesions 
 among the viscera, or by false membrane, 
 or by attachments of the omentum or 
 mesentery. 
 
 In his classical work ' On Diseases 
 of Women,' West says : ' One instance 
 of this latter occurrence has come under 
 my own observation, in which between 
 four and five qiiarts of a dark fluid were 
 found collected between the folds of the 
 omentum, and during the patient's lifetime 
 frequent discharges of a similar fluid 
 had taken place from the umbilicus. The 
 
20 
 
 OVARIAN AND ALLIED TUMOURS 
 
 dropsy had during the life of the patient 
 been supposed to be ovarian; but, though 
 malignant disease of both ovaries was 
 discoverer], yet neither of them con- 
 tained fluid at all similar in character 
 to that which was found in the omen- 
 tum ; nor, indeed, could either be de- 
 tected till after the fluid in the omental 
 cyst had been let out. I am aware of 
 no means by which such cases are to be 
 discriminated from ovarian dropsy; as iar 
 as I know, tlieir nature has scarcely ever 
 been suspected during the lifetime of the 
 patient.' 
 
 The fluctuation in such cases, even if 
 distinct, is always limited in extent, and 
 confined to the same spots. The intes- 
 tines are found behind or beside the 
 tumour, and do not as in ascites rise up 
 to the front of the abdomen, or vary with 
 the position of the patient. The appear- 
 ance of the belly is flatter than in cases 
 of tense ovarian cysts, the respiration is 
 less impeded, and cedema of the extremi- 
 ties is .seldom seen. Sometimes, too, the 
 small intestine and omentum may be 
 matted together, and the way in which 
 one may be misled under such circum- 
 stances is seen by the following notes 
 from my case-book, 
 
 February 1870. — A lady, aged 44, 
 married for 14 years, was cachectic, pale, 
 and emaciated, Avith fluctuation of the 
 abdomen in all directions; the os uteri 
 open, and the cervix large. By the 
 vagina, what was supposed to be a cyst 
 could be felt behind and above the 
 uterus. "Within the last 2 years there 
 had been some increase of size, but not 
 rapid until the last 9 months. Dia- 
 gnosis : ovarian cyst, chiefly one large 
 cyst. Tapjnng was advised, and 17 pints 
 of fluid were removed, a good deal also 
 being left behind. On March 17 she was 
 filling again, and fluid could be felt in the 
 peritoneal cavity. The uterus was free, 
 but the cyst could not now be found 
 behind it. The operation for removal of 
 the tumour was done on March 31. The 
 whole of the fluid was found to be in 
 the peritoneal cavity. The uterus was 
 roughened on its peritoneal surface, and 
 both ovaries felt large, that on the left 
 side as big as a wahmf. Above and to 
 the left was a mass feeling very like 
 a multilocular ovarian cyst, evidently 
 ibrmed f)y adhering coils of intestine, 
 thickened peritoneum, and omentum. 
 I'liere were no bad symptoms after the j 
 
 operation. In this case the uterine exa- 
 mination and the moving mass above 
 the umbilicus deceived me ; the mass of 
 intestine and omentum felt so very mucli 
 like an ovarian cyst. In subsequent 
 cases percussion has removed doubt. 
 
 Two very similar cases are recorded 
 in the American journals ; one in which 
 McDowell, after considering the dia- 
 gnosis as certain, opened the abdomen 
 and found nothing but a mass of intes- 
 tines conglomerated by adhesions ; in the 
 other the ovaries were discovered to be 
 sound, and the swelling due to thickened 
 and indurated omentum. 
 
 But fluid in the peritoneum may be 
 associated with cancer and tubercle of the 
 membrane, and give rise to difficulties in 
 the diagnosis, as in the case of an un- 
 married lady, aged 22, whom I saw in 
 1862. The abdomen was as large as that 
 of a woman near the full period of preg- 
 nancy, and was distended uniformly by 
 fluid, which gravitated so decidedly to 
 the lowest point with all changes of posi- 
 tion, that it was evidently free in the 
 peritoneal cavity ; and looking to the 
 appearance of the patient, and to the fact 
 that she had occasional pain, I had little 
 doubt as to the disease being a sub-acute 
 form of tubercular peritonitis. With a 
 tonic treatment and diuretics there 
 was temporary improvement. But some 
 months afterwards all the symptoms were 
 aggravated, and a remarkable change was 
 found to have taken place. The abdomen 
 was much more prominent or arched than 
 before; it was dull anteriorly in all posi- 
 tions of the body, and clear in both flanks 
 as she lay on her back. Moreover, on 
 taking a deep inspiration, a cyst appeared 
 to move downwards from the epigastrium 
 beneath the parietes. Fluctuation was 
 evident in all directions. Tliis led me 
 to doubt the accuracy of my first opinion, 
 and she was tapped. The diagnosis still 
 remaining uncertain, I made an explora- 
 tory incision. No cyst appeared. A 
 large quantity of opalescent fluid escaped, 
 and then the whole of the peritoneum was 
 seen to be studded with myriads of tuber- 
 cles. Some coils of small intestine were 
 floating, but the great mass was bound 
 down with the colon and omentum, ail 
 nodulated by tubercle, towards the back 
 and upper part of the abdcanen. The 
 uterus and ovaries were felt to be of the 
 normal size, but their peritoneal coat was 
 very rough. The patient was treated 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOUItS 
 
 21 
 
 precisely as after ovariotomy. She went abdominal wall, but also to the uterus 
 through rather a sharp attack of peri- and sides of the pelvis, that I determined 
 tonitis, but after two or three days suf- not to attempt any separation, especially 
 fered hardly more than from tapping. She | as some hardish white nodules which 
 passed large (luantities of urine, and as it | were irregularly scattered about the cyst 
 f^eemed as if the use of the catheter ex- j walls were very strongly suggestive of 
 cited this diuresis, it Avas continued long carcinoma, and confirmed the previous 
 after the wound had healed. But the ' suspicion which had arisen as to the 
 most remarkable part of the case remains rupture of a cyst before the tapping, and 
 to be told. The patient got well, married, the diagnosis of malignant disease. The 
 and has been well ever since. Whether ' patient died about sixty hours after the 
 the peritonitis set up led to fresh adhe- operation. 
 
 Examination showed that ' the peri- 
 toneum had entirely lost the character of 
 a serous membrane, and was represented 
 by a thick, tough, ash- coloured mem- 
 brane extending all over the abdominal 
 cavity and its contents. It contained 
 about two pints of reddish fluid without 
 clots. Cancer of the mesocolon trans- 
 versum, 10-12 inches in length and 1 
 inch in breadth, extending to the edge of 
 
 sions or not, certain it is that no more 
 fluid was secreted. I heard that she was 
 well in 1884. 
 
 CANCER OF THE PERITONEUM 
 
 may lead to abdominal tumours o£ very 
 different size and consistence, and is 
 generally accompanied by more or less 
 fluid in the cavity ; or, as in a case 
 
 mentioned by Ballard, by an effusion of the spleen, Avhich is not involved. Multi- 
 gelatinous matter, with great elevation of i locular cyst of the right ovary, the size o£ 
 the diaphragm as in ascites, dulness on i a foetal skull. One cjst showed the trace 
 percussion everywhere but at the epigas- ! of tapping during the operation. The 
 trium and along the margin of the ribs on cysts do not contain much fluid, but 
 the right side, and fluctuation in every ' mostly cancerous matter. Uterus small, 
 part. The symptoms produced by this i healthy, except one small point, the sizo 
 condition of the peritoneum have been of a pea, on the fundus which looks white 
 sometimes so closely like those met with ! and cancerous. Cyst of the left ovary the 
 in many cases of ovarian cysts as to size of a walnut; no cancer.' 
 deceive men of very great experience; A similar case was that of a widow, 
 
 and I have repeatedly been sent for under I aged 51, who in July 18G8 had a hard 
 such circumstances expressly to discuss movable nodule xinder the right false ribs, 
 the question of ovariotomy, when the ' and a tumour in the abdomen visibly 
 patient was not far from the end of ■ movable, without any evidence of adhe- 
 her career. Amonc: my. own cases the sions. The parietes of the abdomen were 
 
 coexistence of cancer has been sometimes 
 so masked by the symptoms of ovarian 
 disease that one has been led on by the 
 hope of giving operative relief. For 
 instance, in a case on which I operated in 
 October 1868, the peritoneum exposed 
 was so thick that I doubted whether it 
 was the cyst or not, and so tapped rather 
 than make any separation of it. Some 
 pints of red serous fluid escaped, and 
 more still when the trocar was withdrawn. 
 On enlarging the opening some small 
 intestines appeared floating in the remain- 
 ing fluid. It was then seen that a 
 multilocular cyst had given way behind, 
 and that its sac formed one general cavity 
 with the peritoneum. Below a lai-ge 
 secondary cyst was prominent. This I 
 
 thin, marked with numerous linese albi- 
 cantes, but there were no dilated veins. 
 A wave of fluctuation was felt over the 
 surface of the tumour, and the sounds on 
 percussion were clear two inches above 
 the umbilicus, dull in the lumbar region. 
 The tumour could be felt in front of the 
 uterus, and through the rectum. It began 
 to form about twelve years before, but 
 caused no inconvenience for six years. 
 It then grew rapidly, filling the abdomen, 
 without much pain. The size had much 
 augmented of late. The patient was twice 
 tapped, about 12 pints of clear and slightly 
 coagulable fluid being drawn off from the 
 peritoneum each time. 
 
 On August 3, a tentative incision was 
 made. A white c:listening tumour was 
 
 tapped and emptied, and then found the exposed on dividing the peritoneum. A 
 whole of the outer coat of the large cyst I few pints of clear fluid escaped, and I then 
 so intimately adherent not only to the [ felt the movable nodule under the right 
 
99 
 
 OVARIAN AND ALLIED TUMOURS 
 
 false ribs to be apparently a lump of 
 cancer in the abdominal wall. The uterus 
 and ovaries seemed to be fused together, 
 the intestines adhering behind ; there 
 ■were also some slight but vascular parietal 
 adhesions. The patient died about ten 
 days after the operation. There Avere 
 three or four pints of serum in the peri- 
 toneal cavity, and adhesions of the 
 omentum and transverse colon to the 
 upper part of the tumour. A hard white 
 nodvile as large as a Avalnut, in the 
 abdominal wall below the right false rib, 
 was found to consist of fibrillated con- 
 nective tissue, with large oblong nucleated 
 cells in an advanced stage of fatty de- 
 generation. Both ovaries were fused 
 together, and formed one tumour ; a 
 sebaceous and piliferous cj'st was formed 
 exclusively by the left ovary, and the rest 
 of the tumour by the right. 
 
 In all such cases suspicion of their 
 real nature should be aroused if a patient 
 has either a very thin and tense, or an 
 oedematous abdominal wall, anasarca of 
 the lower limbs, general emaciation, a 
 cachectic aspect, free fluid in the peritoneal 
 cavity, and especially so if the loss of 
 flesh and amount of pain are more rapid 
 and severe than an ovarian or other 
 innocent tumour would account for. 
 
 TYMl'ANITKS AND rHAKTOM TUMOUItS 
 
 Tympanitic distension of the abdomen 
 may give rise to some aAvkward questions; 
 but it is difficvilt to believe that any sur- 
 geon of reasonable experience could be so 
 deluded by such a condition as to think 
 that he had before him a case of ova- 
 rian tumour, and attempt the operation 
 of ovariotomy. Yet Simpson says that it 
 has happened no less than six times, and 
 Bright published the case of a woman 
 who entered Guy's Hospital with an 
 unhealed incision in the middle line of 
 the abdomen said to have been made by 
 a surgeon for removal of a tumour. She 
 had distension of the abdomen, with a 
 variety of hysterical symptoms, and was 
 recognised as having been formerly under 
 the care of Dr. Marcet for the same con- 
 dition. Thoiigli the abdomen bore a very 
 peculiar appearance, strongly resembling 
 an encysted tunionr, the geiKTal symptoms 
 were so marked that a little observation 
 was sufficient to convince any experienced 
 person f<f the real character of the disease. 
 
 Boinet relates also that a miserable 
 
 woman of weak intellect, tympanitic and 
 impressed Avith the notion that she had 
 an abdominal tumour, was unfortunate 
 enough to meet with two or three surgeons 
 Avho persuaded themselves that she had 
 ovarian disease, and gave way to her im- 
 portunate demands for an operation. Their 
 rash gastrotomy only showed the existence 
 of cancer, and killed the woman. 
 
 These hysterical distensions of the 
 abdomen present themselves in a variety 
 of forms. Sometimes the belly is uni- 
 formly bloAvn up to the size of advanced 
 pregnancy, and is rounded, hard, and re- 
 sistant. The hand makes no impression 
 on it, and change of position causes no 
 alteration in shape. But there is no 
 fluctuation — the resonance is universal, 
 hysterical symptoms are generally present; 
 and, under the influence of chloroform, 
 the swelling entirely disappears, leaving 
 the abdomen flaccid, and allowing the 
 hand to rest upon the bones of the spine. 
 In other cases the distensions are local, 
 and it is noticed that they occur more 
 often on the right side. Portions of the 
 abdominal Avail are gathered up into rigid 
 knobs, which remain so long unaltered 
 as to simulate an internal tumour, espe- 
 cially as they are sometimes situated over 
 accumulations of hardened faeces, and are 
 accompanied by a good deal of tenderness 
 of the parts. Careful and patient palpa- 
 tion, purgatives, and chloroform Avill 
 generally lead to a solution of the mys- 
 tery ; or may eA^en disclose the existence 
 of an unsuspected ovarian tumour, Avhich, 
 by its presence in the pelvis, had given 
 rise to the train of hysterical symptoms, 
 and, among others, to the swelling, appa- 
 rently the most important matter calling 
 for treatment. 
 
 The flrst draAving on the next page, 
 from a photograph, shoAvs hoAV very accu- 
 rately one of these phantom tumours, or 
 the condition Avhich I have now been de- 
 scribing as hysteric tympanites, may re- 
 semble a uterine or ovarian tumour. The 
 loAver part of the abdomen arches forAvard 
 exactly as in pregnancy, or as with an ova- 
 rian tumour of moderate size Avhen the ab- 
 dominal Avail is not lax ; and the Avail is 
 so tense, the patient so i-esists pressure, or 
 complains so much of tenderness on pres- 
 sure, and the abdominal muscles contract 
 so spasmodically and irregularly, that it 
 is by no means difficult to fancy that a 
 tumoiu", or even the movements ofafoRtus, 
 may be felt. The girl Avhose portrait is 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOUltS 
 here given was in the Samaritan Hospital j The arched abdomen is seen to have been 
 
 £ — ^ 4-Z — « — -1 ; *. A:ixi — It *„ „^*, I f^i-,\i-n /l^+4-,^«^^l ^-^A It- , ...1 ^1 _ 
 
 for some time, and it was difficult to con 
 vince her, her friends, and even some 
 
 medical friends who saw her with me, 
 that she had no abdominal tumonr. The 
 tympanitic resonance on percussion was, 
 of course, the leading element in the 
 diagnosis ; but the most conclusive test 
 was the comj^lete subsidence of the swell- 
 ing and- the flattening of the abdomen 
 when the girl was fully under the influence 
 
 quite flattened, and it was easy when the 
 abdominal walls were so flaccid, to fieel 
 tlie pulsations of the aorta, the vertebral 
 column, the brim of the pelvis, and to 
 become certain that there was no abdomi- 
 nal nor pelvic cyst of any kind. Yet the 
 instant the effect of the chloroform began 
 to pass away the tumour always began to 
 reappear. This was shown several times 
 when the experiment was tried, and on 
 one occasion a photograph was taken 
 when she was nearly awake, and the 
 tumour was almost as prominent as in her 
 ordmary condition, shown in the first 
 drawing. She was an hysterical girl, but 
 there was no voluntary or conscious impo- 
 sition on her part so far as I could ascer- 
 tain. She improved under a course of 
 purgatives and steel, but I have not seen 
 
 of chloroform. The photograph from 
 which the second drawing was made was 
 taken while she was completely narcotised. 
 
 her since she loft the hospital. In one 
 woman the abdominal wall thus expanded 
 gave rise to a suspicion of double ovarian 
 cyst. The recti muscles formed a distinct 
 line of demarcation between two protu- 
 berances. The supposed tumour seemed 
 to be Avell defined, but the belly resumed 
 its natural shape under chloroform. 
 
 In 1872 a woman was sent to the 
 Samaritan Hospital, supposed to be suffer- 
 ing from a large ovarian tumour. The 
 tympanitic resonance, Avith the absence of 
 fluctuation, at once showed that there 
 could be no large abdominal tumour, but 
 some hardness above the pitbes led to a 
 vaginal examination, when an early preg- 
 nancy Avas detected. On administering 
 chloroform the distended abdomen at once 
 flattened down, and the outline of the en- 
 lar2;ed uterus could be distinctly traced. 
 
24 
 
 OVATUAN AND AIXIED TUMOURS 
 
 This is the only case in which I have seen 
 tympanites occur in a pregnant woman. 
 I have, however, several times seen it 
 accompany small fibroid tumours of the 
 uterus, uterine polypi, uterine displace- 
 ments, and small ovarian tumours which 
 have not risen out of the pelvis. Once 
 only have I met with this voluminous 
 turgidiry in a man, and wilh him I had 
 no difficulty. He was one of the Crimean 
 invalids, and came into my hands at 
 Smyrna. 
 
 FIBRO-PLASTIC AND FATTY TUMOURS OF 
 PERITONEUM, I'MENTUM, AND SUB-PERI- 
 TONEAL CELLULAR TISSUE 
 
 The symptoms caused by the groAvth 
 of large fatty and fibro-plastic tumours 
 from various parts of the peritoneum or 
 mesentery so much resemble those of true 
 ovarian disease, that their real nature can 
 only be determined in some cases by 
 an exploratory incision or tapping. The 
 difficulties and dangers attending the.^e 
 obscure diseases are exemplified in the 
 histories of the cases which now follow. 
 
 In 1867 I operated on a lady aged 40, 
 who for many years had been suffering 
 from an abdominal tumour about the 
 nature of which various opinions Avere 
 entertained. IVIy first incision was ex- 
 ploratory, and showed that the tumour 
 was a mass of fat. It was then arranged 
 that an attempt should be made to remove 
 the tumour. This Avas done, and lobulated 
 Uiasses of fat, weighing 20 pounds, 
 Avere extracted after dividing a loose 
 cellular capsule. A large lobule felt in 
 the neighbourhood of the right kidney 
 Avas not disturbed. The tumour appeared 
 to have originated in the mesentery. Some 
 of the lobules Avere evidently appendices 
 epiploic^ enormously hypertrophied. 
 
 The patient died 58 hours after 
 the operation. The mass of fat left; on 
 the right side involved the right kidney, 
 pushed the ascending colon over to the 
 left, and adhered to the imder surface of 
 the liver. INIany mesenteric glands Avere 
 enlarged and enveloped in lat. There 
 was not more fat than usual in the omen- 
 tum. The Aveight of the ])ortion of fatty 
 tumour not removed during life Avas 
 estimated at 10 or 12 pounds. The 
 uterus and both ovaries Avere liealth}'. 
 
 Mr. Coo])er Forster, in the ' Patho- 
 logical Transactions,' records another case 
 of fibro-fatty tumour of the abdomen, 
 
 weighing 55 pounds. In the greater 
 part of the tumour fat- cells with the usual 
 connective filaments and vessels made up 
 the tissue— histologically perfect fat. 
 
 A Avoman, aged 2G, after her confine- 
 ment in 18G7, felt a small lump in the 
 right iliac region. This increased very 
 slowly ixntil May 1869. After May 
 the growth Avas rapid. On February 23,. 
 ]870, an exploratory incision was made. 
 On exposing the peritoneum 1 perceived 
 that the tumour Avas an extremely Avascular, 
 soft, friable, granular mass, and satisfied 
 myself by stopping the bleeding, Avhich 
 Avas rather free, both from arteries and 
 A'eins. She died March 3, and on 
 examining the body I found the tumour 
 to be firmly adherent to the abdominal 
 wall, to the liver and intestines, and to the 
 uterus behind ; but both uterus and 
 ovaries Avere free from disease. In some 
 parts there Avere detached bodies like large 
 appendices epiploicse, and from some of 
 the intestines there Avere cyst-like groAvths. 
 Dr. Wilson Fox reported that the masses, 
 and groAvths on the intestines, appeared 
 to be of a doubtfully malignant nature, 
 but that he found no secondary implica- 
 tion of other organs. 
 
 In the ' Archives of Pathological 
 Anatomy' (Bd. 63, No. 4) VirchoAV 
 describes a retro-peritoneal tumour, which 
 I had removed from a lady in Pomerania, 
 in May 1875, and left with him for exa- 
 mination on my return througli Berlin, as 
 a ' fibroma molluscum cysticum abdomi- 
 nale.' The patient Avas a Avidow, 40 years- 
 of age. She had been tapped, and a large 
 amount of pus Avithout odour came away. 
 Finding on my arrival a A-ery large ab- 
 dominal tumour only centrally fluctuating, 
 and pressing the perineum and posterior 
 vaginal Avail far doAvn betAveen the thighs 
 so that I could not ascertain the state of 
 the uterus, I Avas in great doubt as to the 
 nature of the case, but at once commenced 
 an exploratory operation. After dividing 
 the abdominal wall to the extent of five 
 inches betAveen the umbilicus and pubes,. 
 some loose fat Avas seen Avith very large 
 veins. Carrying on the incision it passed! 
 into the substance of a solid tumour 
 aj)parently glandular or fibro-plastic ; ancJ 
 on pushing one finger onAvards, a cavity 
 Avas opened from Avhich some 15 to 20 
 pints of pus escaped Avith masses of 
 yelloAvish Avhite curd-like substance. By 
 ; draAving the back part of this cavity 
 I forAvards, thus inverting it and pulling 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 ZJ 
 
 upon it, a large solid mass was withdrawn. 
 It had lain behind and to the right side of 
 the uterus in the loose cellular tissue of 
 the pelvis. Its connection with the left 
 side of the uterus behind was first tied and 
 divided, without interlisrence with the left 
 ovary or tube. A similar connection on 
 the right side was secured by transfixion 
 and ligature. The quantity of fluid re- 
 moved was 7 litres, the .solid matter 10^ i 
 pounds, or about 25 pounds in all. I left I 
 the lady next day going on well, and with I 
 the exception of some bladder trouble, ! 
 recovery may be said to have been unin- i 
 terrupted. I heard of her in 1884 as in ; 
 excellent health. j 
 
 Virchow speaks of this fibroma- 
 molluscum as a common formation in the 
 cellular tissue of the pelvis ; but in my 
 experience tumours of such character 
 attaining a size calling for surgical treat- 
 ment are extremely rare. 
 
 Tumours described as sub-peritoneal, 
 myxoma-lipoma todes, or lipoma-myxoma- 
 todes, have been observed in tlie sub- 
 peritoneal tissues and in the mesentery 
 and cases have been recorded in Avhich, 
 after removal of the abdominal tumoiir, 
 secondary formations of similar structure 
 liave taken place in the neighbouring 
 glands, or in other organs such as the 
 lungs or liver. 
 
 HYDATIDS 
 
 Hydatids growing from some part of 
 the peritoneal sxnface often acquire an 
 enormous bulk, and distend the abdominal 
 walls in proportion. The displacement of 
 the viscera, the encroachment on the 
 thoracic region, and the coincident inter- 
 ference with the action of the heart and 
 lungs, are as marked as in advanced cases 
 of ovarian disease. But the history of a 
 case of hydatids Avill commonly show that 
 the dilatation commenced in the upper 
 part of the abdomen, extended next to 
 the hypochondria, and, lastly, to the pel- 
 vic region. The growth of hydatids is 
 more rapid than that of ovarian cysts. 
 There may be similar irregularities of 
 surface and contour felt by pressure, but 
 the interspaces or depre^isions between the 
 projecting masses will be more distinguish- 
 able in hydatid disease ; and are sometimes 
 marked by distinct resonance, when por- 
 tions of distended intestine happen to be 
 lying amid them. The abdominal reso- 
 nance is more lateral in hydatid disease 
 
 than in cases of ovarian tumour, but in 
 both cases will be limited to the part in 
 which the bowels are pent up. The 
 fluctuation in hydatids is obscure and 
 circumscribed ; but when it can be felt 
 the hydatid fremitus is decisive. It 
 must after all be remembered that hy- 
 datids may originate in any part of the 
 peritoneum, and when they happen to do- 
 so in the region of the broad ligament th& 
 diagnosis will demand additional circum- 
 spection. 
 
 The best-marked case of hydatids 
 of the peritoneum, as distinguished from 
 hydatid cysts of the liver, which I have 
 seen, was a woman who was in the Sama- 
 ritan Hospital in 1870-1. The appear- 
 ance of her abdomen is well shown in the 
 
 drawing, copied from a photograph taken 
 after her admission to the hospital. 
 
 The abdomen had all the appearance 
 of a case of multilocular ovarian cyst. 
 Fluctuation was very distinct, but the 
 chief peculiarity of the case was the exist- 
 ence of numerous hard nodules scattered 
 over the abdominal wall. Some of the 
 best marked of these arc shown on the 
 drawing near the umbilicus. They were 
 quite hard, and suggested the belief that 
 they might be nodules of hard cancer. 
 Some of them being semi-resonant gave 
 rise to the fear that they might be formed 
 on the coat of intestine ; but the fact that 
 the disease was of about twelve years' du- 
 ration, that the patient had borne healthy 
 children during its progress, that she was 
 not much emaciated, did not suffer from 
 
26 
 
 OVARIAN AND ALLIED TUMOURS 
 
 sickness or diarrhcea, nor from much 
 abdominal pain nor tenderness, showed 
 that cancer might be almost certainly ex- 
 cluded from the diagnosis, even before 
 hydatid fremitus was noticed. This was 
 most distinct, and the diagnosis was com- 
 '~M plots'! by the puncture, with a fine trocar, 
 ,!^- r- of one of the nodules felt in the abdomi- 
 g^^t^ nal wall. A little clear fluid escaped, in 
 »/|;^|(^hich the booklets of the echinococcus 
 were distinctly seen. No very urgent 
 symptoms being present nothing more was 
 then done. I afterwards operated and 
 removed 3 or 4 pounds of hydatids. 
 Considerable relief was given, but the 
 woman died at the end of a few months. 
 
 In another woman, thin, anjemic, and 
 of consumptive parentage, sent to the 
 hospital as a case of ovarian disease, I 
 found the abdomen distended, tender and 
 fluctuating, the uterus small and mobile, 
 pressed forwards above the pubes, and 
 Douglas's space occupied by an elastic 
 tuuiour. I made an exploratory incision, 
 opened a cavity, and let out some pints 
 of fetid pus. Then several small cysts 
 attached to the omentum and mesentery 
 Avere removed, and a larger cavity, corre- 
 sponding with Douglas's space, was dis- 
 covered and more pus evacuated. After 
 ■death it was seen that the intestines, 
 omentum, and other viscera were matted 
 together and formed a sac containing thin 
 purulent fluid, while the liver and spleen 
 were filled with hydatids. There Avas a 
 small cyst in the broad ligament on the 
 right side by which the uterus was drawn 
 up in that direction, and on the left side 
 the ovary was masked and the pelvis 
 blocked up by numerous small cysts filled 
 with hard, gristly, calcareous substance 
 evidently of hydatid origin. 
 
 Large hydatid cysts of the liver ex- 
 tending low down in the abdomen, or even 
 into the pelvis, have frequently been mis- 
 taken for ovarian cysts. In one such case, 
 a young lady who was sent to me by Sir 
 James Clark, I Avas able, Avith the assist- 
 ance of Sir AVilliam Jenner, to make an 
 accurate diagnosis, and removed 64 ounces 
 of clear fluid from an hydatid cyst Avhich 
 projected doAVUAvards from tlie liver. Two 
 years elapsed before any of this fluid re- 
 collected. I then tapped again, and found 
 only nine ounces in the cyst, the patient 
 being apparently Avell some fcAV months 
 afterwards. In two similar cases, in 
 the Samaritan Hospital, emptying hydatid 
 cysts of the liver by tapping, assisted by 
 
 an exhausting syringe. Las been followed 
 by what we may confidently hope is a 
 permanent cure. In another case, after 
 tapping, the cyst suppurated, its contents 
 decomposed, the cyst became distended 
 Avith gas, and I inserted a drainage tube. 
 Daily injections of iodine solution Avere 
 used, and the patient completely re- 
 covered. Cases have been recorded 
 Avhere the cyst, before draining, Avas 
 stitched to the abdominal AA'all, but I 
 have not yet done this.-^ 
 
 Such cases are not likely to be mis- 
 taken for ovarian cysts by anyone con- 
 versant with the signs of hydatid diseases 
 of the liver, so Avell described by Frerichs 
 and Murchison. The freedom of the 
 pelvis and hypogastric region from the 
 presence of a cyst, and the limitation of 
 the first evidences of disease to the upper 
 part of the abdomen, are the main points 
 of distinction. I have never seen a case 
 of hydatids in the substance of the ovary, 
 and it is curious that these organs seem 
 to be aA'oided as the seat of parasitic life ; 
 for it is probable that in the reported 
 cases it Avas only by superficial attach- 
 ment to the peritoneal covering that the 
 hydatids had any relation to the ovary. 
 
 PlIEGNANCY AND DISTENDED UTEKUS 
 
 Certainly the most common mistakes 
 in diagnosis occur AA'hen the uterus is en- 
 larged from some cause ; and pregnancy is 
 the most common of all causes of enlarge- 
 ment of the uterus. Circumscribed enlarge- 
 ment beginning and going on Avithout other 
 marked signs of pregnancy leads to the 
 suspicion of cystic groAvth, and to tiu-n 
 this into conviction we have to consider the 
 age of the patient, certain malformations of 
 the genital organs, the state of the general 
 health, some functional irregularities, the 
 progress of groAvth, the configuration of 
 the abdomen, the results of percussion 
 and auscultation, and the manual exami- 
 nation of the uterus. Certain limits of 
 age negative the possibility of conception, 
 although instances are recorded where 
 girls between 12 and 15 and women up 
 to GO have borne children. Still, the 
 limits of 15 and 45 are very rarely 
 passed. So that in patients very young 
 or very old the presumption must be that 
 a voluminous abdomen is the seat of dis- 
 ease. Again, some malformations of the 
 generative organs render pregnancy im- 
 possible; but it must not be forgotten 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 ;7 
 
 that impregnation has been effected 
 where penetration of the vagina by any 
 solid body was impossible ; and in spite 
 of procidentia of the uterus, and of such 
 diseases of the vagina and uterus (vesico- 
 vaginal fistula or uterine cancer, for 
 example) as might appear quite incon- 
 sistent with sexual intercourse. 
 
 Then the size and position of the 
 swelling and the duration of its growth 
 taken together will influence the diagnosis. 
 A tumour of nine months' certain dura- 
 tion, yet no larger than a uterus at tlie 
 fourth or fifth month, or one of only four 
 or five months' standing as large as the 
 uterus at the close of pregnancy, will not 
 be attributed only to foctation. In the 
 case of a tumour the history is Irequently 
 that of its discovery on one side, and its 
 advance is more or less regular according 
 to its nature, while examples of the dis- 
 placement of the early gravid uterus are 
 exceptional. 
 
 It will be found in the majority of 
 cases of tumour which have lasted long 
 enough, and become large enough to 
 simulate pregnancy, that instead of the 
 ordinary sympathetic disturbance of the 
 functions, the health of the patient has 
 materially given way, especially if the 
 disease be assuming a malignant form ; 
 and that owing to the comparative fixity 
 of its base of attachment, and from the 
 want of that mutual adjustment of parts 
 which mitigates the miseries caused by the 
 distending titerus, more than the natural 
 amount of discomfort and pain is encoun- 
 tered. By itself, the absence or excess of 
 the menstrual flow decides little, and the 
 gastric, mammary, and nervous symptoms 
 of pregnancy may also be set up by sym- 
 pathy with the ovarian irritation. In a 
 case where the question is between preg- 
 nancy and ovarian disease, there is hardly 
 time for the modelling oiit of the peculiar 
 facies ovariana, and no one general sym- 
 ptom can by itself be taken as conclusive ; 
 though in most of these consultations the 
 first observation of a patient gives to an 
 experienced eye a right impression as to 
 the real state of matters. 
 
 It is very seldom that a growing ova- 
 rian cyst, even when unilocular, will leave 
 the symmetry of the abdomen unaltered. 
 The compound and dermoid forms are 
 almost invariably lobulated, and give rise 
 to unseemly irregularity and distortion 
 of the contour, and a great difference in 
 the radiating measurements from the um- 
 
 bilicus. The pointing or flattening of 
 the umbilicus tells nothing as to mere 
 growth, but whenever the prominence is 
 considerable, the ring open, the skin thin 
 and distended, there is almost always fluid 
 free in the peritoneal cavity, and any 
 tumour is to be otherAvise recognised. 
 
 The superficial veins of the abdominal 
 wall are seldom so much distended in 
 pregnancy as they often are with large 
 ovarian tumours : but linear albicantes are 
 more common in pregnancy. They are 
 seen, however, over all large tumours of 
 rapid growth. When recent they are of 
 a dark purplish colour; when old they are 
 white, glistening, or silvery. When the 
 abdominal Avail is osdematous, the lines) 
 become very prominent. This appear- 
 ance, common in large solid or semi- 
 solid abdominal tumours, is rare in preg- 
 nancy. 
 
 It is only when the abdominal wall is 
 very thick, or the foetus misplaced or dead, 
 that the heart sounds cannot be heard 
 after the sixth month. Sometimes they 
 are masked by the placental murmur, a 
 blowing sound, synchronous with the beat 
 of the maternal heart, rarely absent in 
 pregnancy, but very similar to a sound 
 common in large fibroids of the uterus, 
 but very rarely perceptible in ovarian 
 tumours. The aortic sound and impulse 
 of the mother, being perceptible both in 
 pregnancy and in many uterine and ova- 
 rian tumours, are of very little diagnostic 
 value. 
 
 Up to the fifth month the pregnant 
 uterus gives no sense of fluctuation ; it 
 has rather the consistence of a glandular 
 or fatty tumour. After the fifth month the 
 sensation conveyed to the finger is that of 
 displacement of fluid, allowing a hard body 
 to be felt. This is the fcetus, which from 
 the sixth to the ninth lunar month may 
 be pushed from side to side. After the 
 seventh month it is often possible to trace 
 the general oixtline of the foetus so clearly 
 that no mistake can be made. But Avhen 
 the abdominal wall is thick, some of the 
 more solid varieties of ovarian tumour 
 may very closely resemble the shape of a 
 foetus. An ovarian tumour surrounded 
 by ascitic fluid, or a mass of small cysts 
 projecting into a large one, may be moved 
 very much like a child in the liquor 
 amnii. But the independent movements 
 of the foetus are very characteristic, and, 
 if felt, conclusive. Sometimes, however, 
 Avith a livino: child these movements can- 
 
28 
 
 OVARIAN AXD ALLIED TUMOURS 
 
 not be felt; and if the child is dead, of 
 course they cannot be made. 
 
 There are no ovarian tumours which 
 give exactly the same sensation as the 
 ballottemeiit of the fatus in utero, though 
 internal like external ballottement may 
 be simulated by a hard tumour floating 
 in ascitic fluid, or by a large cyst con- 
 taining internal projections. The move- 
 ments of a cyst with a long pedicle could 
 hardly be mistaken for those of the 
 uterus, as the corresponding vaginal touch 
 will indicate its independence. The effect 
 which tumours mechanically make upon 
 the position and form of the uterus does 
 not much resemble that of pregnancy, 
 and with the usually open state of the os 
 in ovarian disease, nothing can invalidate 
 the evidence of the sound. And as in a 
 case of disputed pregnancy the symptoms 
 can rarely be so urgent as to require im- 
 mediate operation, the best policy is tOAvaic. 
 
 Happily, cases of malplaced fetation 
 are comparatively unfrequent. It is not 
 clear which is the most common point of 
 attachment of the errant ovum. During 
 the life of the patient, it is admittedly 
 almost impossible to determine in what 
 part of the genital tract or abdomen the 
 ovum is being developed. Hecker states 
 that these pregnancies are mostly abdomi- 
 nal ; Parry, that he finds the greater 
 number recorded as tubal. Wherever 
 they may Ije, and however much they 
 may physically resemble an incipient 
 ovarian cyst, the early diagnosis will 
 very much depend upon the indications 
 of conception. These are absent in the 
 case of ovarian disease, and there are not 
 the distressing symptoms, such as hypo- 
 gastric colicky pains, vaginal htemor- 
 rhages, with sometimes discharge of 
 decidua, which accompany these irregular 
 fcctations. Nor do we meet with the 
 curious moral condition in which the 
 woman persistently believes herself en- 
 ceinte. Too often the diagnostic problem 
 finds its solution in the early death of 
 the subject. If the patient should 
 survive the third or fourth month, the 
 probability is that the gestation is abdo- 
 minal. Seventy-six out of 132 cases 
 noted by Hecker escaped. The attention 
 will then be turned to other matters. 
 The detection of the foetal form, its move- 
 ments, ballottement, the sounds of the 
 heart and the placental murmur will at 
 once settle the (juestion. Still later, or at 
 the full term, the signs of a spurious 
 
 labour, followed by diminution of size, 
 will influence a decision. If, after this, 
 the process of encystraent should con- 
 tinue, the tumour resulting may be either 
 fluctuating or solid. With an accumula- 
 tion of fluid in the amnion, and con- 
 sequently no diminution of size, one 
 must resort to abdominal ballottement, 
 with the patient on hands and knees; and 
 in that position the remains of the foetus 
 would generally be felt. But between a 
 solid mass of a date longer than the nine 
 months of pregnancy and an ovarian 
 tumour, judgment will be mainly influ- 
 enced by the absence of the symptoms of 
 pregnancy during the early stages of 
 development, the absence of false labour 
 at or near the end of the natural term, 
 and the steady regular increase in size 
 after the usual period of gestation has 
 passed. Finally, it is self-evident that no 
 ovarian cyst except a dermoid can come 
 into competition with one of these con- 
 ceptions which has had the privilege of 
 more than half a century of incubation, 
 and has degenerated into a substantial 
 lardaceous compound, or established a 
 claim to the pompous appellation of 
 lithopajdion. 
 
 The greatest difficulty in diagnosis 
 arises when the uterus either undoubtedly 
 contains something, or is enlarged as 
 in pregnancy. The so-called moles or 
 hydatids, which are really hydatidifbrm 
 degeneration of the chorion— intra-uterine 
 polypus — cancer of the body and fundus 
 of the uterus, while the cervix remain.^ 
 unaffected — ha;matometra, hydrometra, 
 and physometra— are all conditions which 
 must be borne in mind, and which may 
 resemble ovarian tumours in some par- 
 ticulars, pregnancy in others. 
 
 If the uterus instead of a foetus sliould 
 contain a mole, the breasts may swell, the 
 catamenia cease, and all the other signs of 
 pregnancy may be present for a time. 
 Usually molar pregnancy comes to an 
 end about the third or fourth month, but 
 cases are on record Avhere it has been 
 protracted to the thirteenth and fourteenth 
 months; and Churchill aUudes to a case 
 where an unmarried woman had a fre- 
 quent discharge of 'uterine hydatids' 
 throughout her menstrual life. In molar 
 pregnancy the uterus does not enlarge 
 so regularly as in ordinary pregnancy. 
 The enlargement is usually more rapid, 
 and the functional disorders are more 
 intense. I once saw a Avoman Avith a 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 29 
 
 supposed ovarian cyst, fully as large as at 
 the end of a normal pregnancy. While 
 we were examining her in the out- 
 patients' room, uterine contraction came 
 on ; and with very little help by fingers 
 in the vagina and pressure on the abdo- 
 men, nearly a pailful of these 'hydatids' 
 was expelled. 
 
 An intra-uterine polypus has often 
 been mistaken for pregnancy. After the 
 dilatation of the cervical canal, and com- 
 mencing expulsion from the os, it has 
 «ven been supposed that abortion or 
 labour was going on. But it is not likely 
 that this condition would be nuKtaken for 
 ovarian disease. 
 
 Cancer of tlie body and fundus of the 
 uterus, causing enlargement above while 
 the cervix is unaffected, may be taken for 
 an ovarian cyst which is lying above the 
 uterus, or for pregnancy. But the general 
 cachexia, uterine discharge, and absence 
 ■of fluctuation Avill be sufficient to dis- 
 tinguish this condition from ovarian dis- 
 ease, and some of the characteristic signs 
 of pregnancy are certain to be absent. 
 
 Collections of blood, or retained clot, 
 the so-called fibrinous polypi, or of 
 masses of dysmenorrhojal membrane with 
 blood or clot, all conditions described 
 its hajmatometra, are more likely to be 
 mistaken for pregnancy than for ovarian 
 disease ; but some of the signs of preg- 
 nancy will certainly be wanting, and the 
 signs of enlarQ-ement of the uterus are 
 sufficient to distinguish this condition 
 from ovarian disease. 
 
 Hydrometra, again, is recognised by 
 the enlargement of the uterus without the 
 other characteristic signs of pregnancy, 
 before any watery discharge clears up 
 doubt. Many supposed cases of hydro- 
 metra have imdoubtedly been cases of 
 ovarian cysts emptying themselves through 
 the Fallopian tube into the uterus and 
 vagina. 
 
 Physometra is a very rare condition — 
 generally the result of decomposition of 
 part of a retained ovum, or of blood clot. 
 The resonance on percussion of the en- 
 larged uterus is sufficiently characteristic. 
 I have never seen a case where a collec- 
 tion of air in the uterus caused an 
 abdominal tumour, but Dr. Yarrow of 
 Washington has treated the subject of 
 Physometra in an able paper published 
 in the ' American Journal of Obstetrics,' 
 August 1883. He gives the history of a 
 very remarkable case where an abdominal 
 
 tumour extending far above the umbilicus, 
 with much lateral enlargement, entirely 
 disappeared with a rush of pent-up gas de- 
 void ot odour, on passing a uterine >-ound. 
 
 Now, bearing in mind the various 
 symptoms and signs of pregnancy while 
 the uterus is still a pelvic tumour, and 
 afterwards when the uterus has enlarged, 
 risen, and become an abdominal tumour, 
 it will be seen how they resemble and how 
 they differ from those which characterise 
 ovarian cysts and tumours, uterine tumours, 
 and extra-uterine foctation. 
 
 When an ovary is only slightly tume- 
 fied, it usually lies behind the uterus and 
 may be felt by vagina or rectum, or better 
 still by combined examination with one 
 finger in the rectum and one in the vagina. 
 It does not at all resemble the enlarging 
 litems of early pregnancy. As the ovary 
 swells, it usually rises up out of the pelvis ; 
 but it sometimes remains low down either 
 from pressure or adhesion, and as it grows 
 it pushes the uterus either to one side, or 
 backwards, or forwards. It may restrict 
 the mobility of the uterus, but the inde- 
 pendence of the one of the other may 
 generally be made out. Increasing in size, 
 the ovary may rise into the abdomen and 
 leave the uterus quite in its normal posi- 
 tion, without any deviation or modifica- 
 tion of mobility, or alteration in the 
 cervix ; or it may drag up the uterus 
 quite out of reach, elongating the vagina, 
 so that nothing but the ovarian tumour 
 can be felt through the vaginal walls ; 
 or the OS may just be reached, high up 
 above the pubes if the ovarian cyst is 
 behind the uterus, or near the promon- 
 tory of the sacrum if the cyst is in front. 
 This displacement of the os backwards 
 by a cyst in front of it simulates preg- 
 nancy, but other signs are wanting. In 
 case of doubt, delay of a month or two 
 Avould clear it up. 
 
 It is possible that the rate of growth 
 of an ovarian tumour may closely resemble 
 the rate of the enlargement of the uterus 
 in pregnancy ; but it is much more likely 
 to advance at a very different and much 
 less regular rate, and to remain for Aveeks 
 or months without much alteration in size. 
 The foetal movements and heart sounds 
 are wanting, and there is probably a less 
 dense or solid, if not a distinctly fluctuat- 
 ing tumour. 
 
 The distinction between pregnancy and 
 fibroid tumour or enlargement of the 
 uterus will be alluded to hereafter. 
 
30 
 
 OVARIAN AND ALLIED TUMOURS 
 
 RENAL CYSTS AND TUJIOUKS 
 
 The diagnosis of ovarian tumours from 
 cystic growths and enlargements of the 
 kidneys is usually made with a readiness 
 which renders a mistake quite an excep- 
 tion. But occasionally an exact diagnosis 
 is impossible. And sometimes, it is only 
 after an exploratory operation, or after 
 the death of the patient, that a mistake is 
 discovered. 
 
 The first case of the kind, which came 
 imder my care, was one of soft cancer of 
 the right kidney in a girl only four years 
 old. She was supposed to be suffering 
 from ovarian disease. Her appearance is 
 shown in the woodcut. 
 
 The diagnosis in this case Avas made 
 without much difficulty, although the 
 urine was quite normal. The groAvth was 
 extremely rapid ; hardly six months from 
 its commencement to its fatal termination 
 — wlicn the diseased mass weighed be- 
 tween 16 and 17 pounds. The tumour 
 occupied the whole of the right side of 
 the abdomen, bulging backwards in the 
 right loin. It was uniformly ehistic, 
 but no fluctuation could be detected. The 
 intestines were pushed downwards, and to 
 the left side. The rapid growth, and the 
 absence of fluctuation, were, of course, 
 strongly against the opinion that the tu- 
 mour was ovarian ; while the rarity of 
 ovarian disease in young children, and the 
 
 comparative frequency of renal encephaloid, 
 led to a diagnosis which was confirmed by a 
 puncture with a fine exploring needle. A 
 few drops of reddish serum were obtained, 
 containing nucleated cells of varied size 
 and shape. After death the whole kidney 
 was found infiltrated with encephaloid. 
 Although so enormously enlarged, the 
 shape of a normal kidney was distinctly 
 preserved. Its surface was soft and elastic, 
 in some spots giving a sense of deep-seated 
 fluctuation ; but no cyst was found, nor 
 were there any marks of suppuration or 
 hcemorrhage. Coils of small intestine 
 adhered to its inner and under surface. 
 The ureter was occluded by the pressure 
 of the tumour. The left kidney was 
 quite healthy. Thus the normal condi- 
 tion of the urine was explained. The 
 diseased kidney added nothing to the con- 
 tents of the bladder, and the healthy 
 kidney supplied only normal urine. 
 
 The following remarks on this point 
 by Dr. Roberts, of Manchester (' Urinary 
 and Renal Diseases,' p. 444), are well 
 worthy of serious consideration. He says : 
 ' The presence of cancer cells in the urine 
 is a sign which usually figures prominently 
 in the catalogue of symptoms of renal 
 cancer, but its value is very doubtful. It 
 is by no means an easy matter to identify 
 cancer cells in the urine, in consequence 
 of their similarity to the transitional 
 epithelium of the pelvis and ureter. . . , 
 In two examples of renal cancer, with 
 hematuria, which I have had an opportu- 
 nity of observing, repeated and careful 
 examination of the urine failed to dis- 
 cover the presence of cancer cells. IMr. 
 Moore ('Med. Chir. Trans.' xxxv. 46G) 
 believes that he sixcceeded in identifying 
 cancer cells in the urine drawn after death 
 from the bladder of a man in whose 
 kidneys cancerous nodules were found ; 
 but his description rather accords with 
 the appearance of the epithelial cells which 
 are always freely detached from the vesical 
 mucous membrane after death.' 
 
 Whether renal cancer be observed in 
 children or in adults — whether it be or be 
 not accompanied by hccmaturia, or by the 
 presence in the urine of albumen, or of 
 epithelial cells from the ureter and pelvis 
 of the kidney — Avhcther the progress of 
 the disease be slow or rapid — whether 
 there may be much, little, or no pain, or 
 emaciation, or gastric symptoms — or great 
 or little effect upon the general health — 
 the abdominal tumour is the most pro- 
 
DIFFEKENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 31 
 
 minent characteristic of the disease. As 
 Brieht observed (' Abdominal Tumour?,' 
 Syd^enham Society's Edit. p. 199) : ' The 
 enlargement shows itself much more 
 towards the anterior part of the abdomen 
 than towards the loins.' It is, however, 
 more or less confined to one side of the 
 abdomen and to the corresponding lumbar 
 region, whence, as a rule, it is immovable 
 — and, equally as a rule, some portion of 
 the intestines are fixed in front of it. But 
 in one case an exception was found to 
 these rules. In the ' Lancet ' of March 
 1865 a case is recorded in which an 
 operation was commenced for the removal 
 of a supposed tumour of the left ovary. 
 The patient was in one of our general 
 hospitals, and it was believed that ' the 
 tumour was ovarian, and that from its 
 great mobility, and the absence of adhe- 
 sions, its removal would be easy.' Yet 
 the uterus and ovary were found to be 
 healthy, and the tumour to be the en- 
 larged left kidney ; wliich, instead of 
 being fixed, was movable — its peritoneal 
 covering being elongated into a sort of 
 mesentery, admitting of free movements 
 — and, instead of pushing the intestines 
 before it, the descending colon and 
 sigmoid flexure were behind it. This 
 enlargement of a movable kidney added 
 greatly to the difficulty of diagnosis. 
 
 The absence of fluctuation is the lead- 
 ing sign by which cancerous or other solid 
 tumours of the kidneys are distinguished 
 from ovarian tumours ; for it is extremely 
 rare to find a large ovarian tumour in 
 some part of which fluctuation cannot 
 be detected. But in some forms of 
 kidney disease fluctuation is as evident as 
 in ovarian cysts. In one case of pyo- 
 nephrosis I punctured the kidney through 
 the abdominal Avail, and so not only 
 cleared up the diagnosis, but restored the 
 patient to many years of health. Cystic 
 degeneration was in another woman 
 attended with symptoms so exactly the 
 same as those seen in enlargements from 
 ovarian tumours, that I only learnt the 
 true nature of the disease by an abdominal 
 incision. And in one of my patients the 
 enormous bulk of a fibro-plastic tumour 
 originating in the right kidney or its 
 peritoneal covering, and weighing 84 
 pounds, effectually obscured ail indica- 
 tions to be gathered from manipulation 
 either externally or by the vagina. 
 
 It is evident from the cases just men- 
 tioned that both solid and cystic tumours 
 
 of the kidney may be mistaken for ovarian 
 tumours. Solid renal tumours, whether 
 cancerous or innocent, may resemble the 
 malignant, pseudo-colloid, or cysto-sarco- 
 matous tumours of the ovaries ; while dif- 
 ferent varieties of ovarian cysts may be 
 closelv simulated by different forms of 
 pyelitis and pyonephrosis, hydronephrosis, 
 cystic degeneration, and the growth of 
 hydatids in the kidney. The diagnosis 
 may be facilitated by attention to the 
 following propositions : 
 
 1. Although intestine is sometimes 
 found in front of ovarian tumours, and 
 sometimes behind movable renal tumours, 
 these are very rare exceptions to the 
 general rule that renal tumours press the 
 intestines forward, and ovarian tumours 
 press tliem backward. In other words, 
 ovarian tumours are in front of the intes- 
 tines, renal tumours are behind the intes- 
 tines. 
 
 2. Large tumours of the right kidney 
 usually have the ascending colon on the 
 inner border of the tumour. Tumours of 
 the left kidney are usually crossed from 
 above downwards by the descending 
 colon. 
 
 3. The discovery of intestine in front 
 of a doubtful abdominal tumour should 
 lead to a careful examination of the urine. 
 It is possible that one kidney may be 
 diseased and the urine quite normal, 
 because the healthy kidney alone secretes 
 urine. But the rule is that either blood, 
 pus, or albumen, or characteristic epithe- 
 lium, is detected — or some history may 
 be elicited of their having been detected 
 at some former period. 
 
 4. If any doubt be entertained whether 
 a substance felt between an abdominal 
 tumour and the integument be or be not 
 intestine, percussion will not always solve 
 the doubt, because the intestine may be 
 empty and compressed. But (a) an 
 intestine when rolled imder the fingers 
 contracts into a firm, cord-like, movable 
 I'oll ; (b) the patient may be conscious of 
 the giirgling of flatus along it, or the 
 gurgling may be heard on auscultation ; 
 (c) the intestine may be distended by 
 insufflation, after passing a long elastic 
 tube through the rectum. 
 
 5. Ovarian and renal cysts may both 
 be subject to i;reat alterations in size. 
 
 j When the kidney is the seat of disease 
 
 ' the fluid usually escapes by the ureter 
 
 I and bladder. An ovarian cyst can only 
 
 empty itself through the bladder, or into 
 
?.9. 
 
 OVAPJAX AND ALLIED TUMOURS 
 
 an intestine, or through the coats of 
 the vagina, after adhesion and a fistulous 
 opening. It may discharge through the 
 Fallopian tube and uterus. In either 
 case the physical and chemical characters 
 of the Huid discharged will be the chief 
 guide in diagnosis. 
 
 6. If a correct history can be ob- 
 tained, it may be expected that a renal 
 tumour has first been detected between 
 the fiilse ribs and ilium, and that it has 
 extended first towards the umbilicus, next 
 into the hypochondrium, and lastly down- 
 wards towards the groin. An ovarian 
 tumour has, in all probability, been first 
 noticed in one inguinal or iliac region, 
 lind has extended upwards and inwards, 
 
 7. It is only a very small ovarian 
 tumour, with a long pedicle, which could 
 be mistaken for a floating or movable 
 kidney. The latter may be recognised 
 by its chai-acteristic shape, though it is 
 olten so misplaced that the hilus is 
 turned upwards. The kidney is usually 
 felt between the umbilicus and the false 
 ribs, and may be pushed upwards and 
 downwards, or laterally, to a varying 
 extent, or into the lumbar region to the 
 normal position of the kidney. When 
 the kidney is pushed away from this 
 position, the sound on percussion there 
 becomes tympanitic. 
 
 8. Just as renal tumours are usually 
 associated with some evidence or history 
 of hasmaturia, calculus, albuminuria, ne- 
 phritic colic, or some notable change in 
 the quantity or state of the urine, so 
 ovarian tumours are usually associated 
 with some change in the quantity and 
 regularity of the discharge, or with suffer- 
 ing at the catamenial periods, and wdth 
 some alteration in the mobility or situa- 
 tion of the uterus. But as in some rare 
 •cases of renal disease the urine may be 
 normal, so in some rare cases of ovarian 
 disease there may be nothing abnormal 
 to be discovered in any of the pelvic 
 viscera, nor in their functions. 
 
 By bearing these facts in mind an 
 accurate diagnosis may Ije made in a 
 very large proportion of cases. Some 
 rare cases of exceptional difficulty may, 
 Iiowever, be occasionally expected. 
 
 DISTENDED BL.\DDi:i: 
 
 A word of caution may not be super- 
 fluous, reminding the young practitioner 
 that the bladder, distended with urine, 
 
 has, in several instances, formed a tumour, 
 which has been mistaken either for aii 
 ovarian cyst or for ascites, and has been 
 tapped, in some cases with a fatal result. 
 I was once present in an hospital when a 
 woman was about to be tapped. The 
 peculiar projection immediately above 
 the pubes at once struck me, and I 
 suggested that the catheter should be in- 
 troduced. Five pints of urine passed, and 
 thetamour disappeared. In this case the 
 patient was supposed to be suffering from 
 incontinence of urine from pressure of 
 the imaginary cyst. But the urine which 
 dribbled away was simply overflow 
 from the jiaralysed bladder. Distension 
 of the bladder is of common occurrence 
 both in uterine and ovarian tumours 
 which are fixed in the pelvis. In some 
 cases it is only by the use of a small and 
 long elastic catheter that the bladder can 
 be reached and emptied. This is espe- 
 cially necessary in cases of uterine tu- 
 mour, where it is not rare to find the 
 bladder drawn up nearly to the level of 
 the umbilicus. In some cases of cancer 
 of the bladder, where the growth extends 
 to the uterus, and the bladder is distended 
 with urine, mistakes are only avoided by 
 using the catheter. 
 
 F.ECAL ACCUMULATIONS 
 
 In his * Clinical Lectures on the 
 Diseases of Women,' Simpson says that 
 there had been 'in the hospital a patient 
 who was sent from the country, and 
 presented on admission the colour and 
 appearance of a person labouring under 
 some malignant disease. The facial ex- 
 pression might have led you to believe 
 that she was the subject of a cancerous 
 diathesis. She had a tumour in the left 
 hypogastric region, about the size of a 
 fist. But under the use of croton oil it 
 readily disappeared, and proved to be 
 only a mass of fa3ces in the colon. You 
 might suppose that it would be difficult 
 to mistake such a tumour for any kind of 
 morbid growth, and you might imagine 
 that the patient would be suffering from 
 sucli a degree of constipation as at once 
 to indicate its real nature. But there is 
 not of necessity any degree of constipa- 
 tion ])resent. On the contrary, there is 
 sometimes diarrhoea. The peculiar feel- 
 ing of such a tumour will generally 
 enable you to decide as to its true 
 character : it feels like no tumour that I 
 
DIFFERENTIAL DIAGNOSIS OF OVAIIIAN TUMOURS 
 
 know of. On being examined either 
 through the abdominal walls or through 
 the rectum, it is felt to be hard and re- 
 sistant; but if one finger be pressed 
 steadily iipon it for one or two minutes, 
 it Avill at last indent like a hard snowball, 
 and, as there is not the slightest elasticity 
 about it, the indentation remains after 
 the pressure is removed. If any doubt 
 should still remain, the persevering use of 
 aperients will clear up for you the dia- 
 gnosis by causing the mass to be dissolved 
 zxnd carried off.' 
 
 Although I have several times seen 
 iLimps, which were fajcal accumulations, 
 in the region of the cfccum and ascending 
 colon, yielding to the pressure of the 
 finger, and, owing to their containing 
 or being surrounded with gas, having a 
 degree of resonance on percussion, yet I 
 have only met with one of such a size as 
 to be mistaken for an ovarian tumour. 
 
 Some years ago I was summoned to 
 ■Chester, and on arriving found that the 
 case was one of obstructed intestine. 
 Stercoraceous vomiting had been going 
 on for many days, and the lady was 
 almost moribund. The abdomen was 
 distended beyond the ordinary size at the 
 full time of pregnancy, by a well-defined 
 solid ttmiour, which I should have 
 imagined to be uterine or ovarian but 
 that it was semi-resonant on percussion. 
 
 Consulting with Dr. Waters as to the 
 performance of Amussat's or Nekton's 
 ■operation, I thought it better to com- 
 mence by an exploratory incision, in 
 order to ascertain what the abdominal 
 tumour was. On dividing the peritoneum 
 the tumour appeared exactly like a very 
 'large uterus, but on passing my hand 
 under its lower border I found the uterus 
 and both ovaries healthy. On percussing 
 the tumour there was sufficient resonance 
 to show that it was either intestinal or a 
 •cyst containing air, and. further examina- 
 tion convinced me that it was the cajcum 
 ■and colon enormously distended. I 
 accordingly performed a modified Nek- 
 ton's operation, first stitching the peri- 
 toneal coat of the cascum to the peritoneal 
 edges of the incision in the abdominal 
 wall and then opening the gut. More 
 than two pailfuls of semi-solid ftecal 
 matter escaped, and the gut rapidly 
 contracted as it became empty. I could 
 not ascertain what the cause of the 
 obstruction had been. The patient re- 
 covered, and some months afterwards I 
 
 closed the artificial anus. She died ia 
 1884. No examination of the body was 
 made. 
 
 PELVIC CLLLULITIS AND ABSCESS 
 
 It is not often that ovarian tumours, 
 even when they are confined below the 
 brim of the pelvis, are mistaken for pel- 
 vic cellulitis or abscess. But it is pro- 
 bable that many of the cases of supposed 
 cures of ovarian or uterine tumours were 
 merely inflammatory exudations into the 
 pelvic cellular tissue, which were either 
 removed by absorption or terminated in 
 suppuration and the discharge of the 
 pus by the rectum, vagina, bladder, or 
 skin. In 1871 I saw a lady Avho had 
 been supposed to suffer from ovarian 
 disease, in whom a pelvic abscess dis- 
 charged not only through the rectum, the 
 bladder, the vagina, and in one loin, but 
 gravitating down the leg, opened in the 
 calf. A suppurating ovarian cyst may 
 end in the same way ; but the history of 
 the case, the severe pain, the high tem- 
 perature at the onset of the disease before 
 any considerable tumour had formed, the 
 remarkable almost bonelike hardness and 
 fixity of the swelling, as if inseparably 
 connected with one or other ilium, and 
 the flexure of the thigh from the way in 
 which the psoas muscle is involved, are 
 sufficiently characteristic of cellulitis. It 
 is very seldom that an ovarian cyst shows 
 any tendency to point in the situation 
 where there is the greatest tendency to 
 point in pelvic abscess, that is in the roof 
 of the vagina, very near the cervix uteri, 
 either behind or in front or to one side of 
 it. An ovarian cyst, or a pelvic abscess 
 which had burst into the peritoneal cavity, 
 would be attended by the same symptoms 
 of perforating peritonitis. Bat in one 
 case the previous history would have been 
 that of pelvic cellulitis, in the other that 
 of an ovarian cyst which had beco:ne 
 inflamed, or had burst after twisting of 
 the pedicle. It is seldom that a pelvic 
 abscess extends upwards above the imi- 
 bilical level. Hardness may be felt in 
 one or other iliac region or above the 
 pubes, and a corresponding hardness or 
 swelling may be felt by the vagina, behind 
 or in front or to one side of the uterus ; 
 and, if pus have formed, fluctuation may 
 be detected. An ovarian cyst is not so 
 firmly fixed in the pelvis ; even if adherent 
 there, it does not give the same impression 
 
34 
 
 OVARIAN AND ALLIED TUMOURS 
 
 of close attachment to the pelvic bones. 
 It rarely leads to such troublesome 
 dysuria, to such rectal pain or tenesmus, 
 to such constant throbbing, or to such 
 enforced quiescence of one or both lower 
 limbs; and the general outline of an ova- 
 rian cyst can be more easily traced than 
 the diffuse bulging of a pelvic abscess. 
 The swelling in pelvic abscess is harder, 
 more painful on pressure, and accom- 
 panied with nervous pains such as are 
 usually called sciatica or pelvic neuralgia. 
 It is not often that an ovarian cyst sup- 
 purates until it has existed for many 
 months, or has attained a large size; but 
 the whole course of a pelvic abscess, from 
 its commencement till the discharge of 
 ■piis is effected, is seldom more than from 
 3 to 4 weeks. 
 
 ILEJrATOCELE 
 
 As in pelvic cellulitis, so in ha^mato- 
 cele, it is only a small ovarian tumour 
 ■which has not risen out of the jDclvis, or 
 a large ovarian cyst Avhich has suppurated, 
 that could be mistaken for either the 
 early and small or the later and large 
 stages of pelvic cellulitis or hsematocele. 
 A small hematocele in the early stage 
 produces much the same local conditions, 
 is accompanied by very similar pain, and 
 almost as much general fever as pelvic 
 cellulitis, and is apt to be associated with 
 about the same amount of pelvic peri- 
 tonitis. Indeed, it is very probable that 
 many of the cases of pelvic cellulitis take 
 their origin from a ha^matocele. Some 
 blood escapes into the loose cellular tissue 
 in the neiglibourhood of the litems about 
 the time of menstruation ; a clot forms, 
 does little harm by itself, but pelvic 
 cellulitis is set up, which ends in abscess, 
 the clot which excited it disappearing. 
 It is only when the effusion of blood is 
 large and sudden, its escape through the 
 Fallopian tube prevented, and its general 
 diffusion in the peritoneal cavity limited 
 >)y peritonitis and adhesions, that a dis- 
 tinct pelvic or abdominal tumour is 
 formed. It is rarely that such a tumour 
 extends as high up as the umbilical level; 
 more frefjuently it is either within the 
 pelvis, behind or to one or other side of 
 tlie uterus, and barely to be felt through 
 the abdominal wall. Tliese characters are 
 quite sufhcient to distinguish it from a 
 large ovarian cyst. Small ovarian cysts 
 do not commence so suddenly, are not 
 
 so closely associated with the catamenial 
 period, nor is their advent ushered in by 
 such acute pain or febrile disturbance. 
 An ovarian cyst is seldom dangerous to 
 the life of the patient before it has 
 attained considerable size, Avhereas a 
 ha?matocele of very moderate extent and 
 of sudden formation may be either rapidly 
 fatal or lead to very dangerous symptoms. 
 The following narrative may serve to 
 illustrate the above remarks, and I have 
 seen several similar cases. A young lady 
 was travelling from Paris to London. She 
 was menstruating and caught cold. The 
 day after her arrival there was consider- 
 able swelling in the right iliac region, 
 with extreme tenderness. The symptoms 
 became more intense during the next few 
 days, and when 1 saw the patient her 
 sufferings were so excessive that the 
 examination could only be made when 
 che was under the infiaence of chloroform. 
 The abdominal swelling was principally 
 confined to the right side, and extended 
 as high as the fidse ribs. The uterus was 
 fixed, pushed forwards and to the left, 
 and there was distinct pointing in the 
 vagina behind and to the right of the 
 uterus. The possibility of the existence- 
 of an ovarian cyst which had rapidly 
 enlarged and become acutely inflamed 
 was carefully considered, but the history 
 of the case indicated so clearly ha^matocelev 
 followed by pelvic abscess, wdiich was 
 pointing towards the vagina, that puncture 
 by the vagina was urged, and was only 
 deferred oAving to the absence of a member 
 of the family, and in the hope that as the 
 abscess was distinctly pointing it would 
 open spontaneously. A few hours after 
 this consultation, sudden collapse and the 
 well-known symptoms of perforating 
 peritonitis set in, followed by death the 
 next day. In another case, a ha^matocele 
 passed below Poupart's ligament, and I 
 opened it in the thigh. It was com- 
 pletely cured by drainage. It had been 
 taken for psoas abscess and spinal disease; 
 but examination l)y the vagina led to a 
 correct diagnosis. 
 
 As curiosities of surgical experience, 
 but not arising sufficiently often to call 
 I'or more than passing notice, and as 
 morbid changes Avhich may possibly be 
 mistaken for ovarian disease, may be 
 enumerated encephaloid tumour of the 
 ilium, enchondroma or osseous tumours, 
 projecting from the sacrum, angular 
 curvature of the lumbar vertebra;. 
 
DIFFERENTIAL DIAGNOSIS OF OVARIAN TUMOURS 
 
 oO 
 
 enlargement or malignant disease of the 
 lumbar glands, or dissecting aneurism 
 of the aorta. I know of one case where 
 a tumour in the pelvis was punctured by 
 tlie vagina ; the patient died from bleed- 
 ing beibre the surgeon leil the room, and 
 after death it Avas found that an aneurism 
 of the aorta above the bifurcation had 
 dissected downwards behind the peri- 
 toneum, and formed a considerable tu- 
 mour in the hollow of the sacrum. I 
 have seen three cases where encephaloid 
 disease, arising in the cancellated bouy 
 tissue of the ilium, had not only pro- 
 jected backwards and towards the but- 
 tock, but so far inwards and upwards as 
 to form a considerable abdominal tumour. 
 In one of these cases the abdominal tu- 
 mour transmitted a distinct pulsation 
 from the aorta. In another the growth 
 
 itself was pulsatile. In the third the 
 rectum was completely occluded by the 
 growth. The other states above enume- 
 rated scarcely need further remark ; a 
 little attentive consideration of the history 
 and progress of the cases will be sufficient 
 to distinguish them from any form of 
 ovarian disease. 
 
 The accompanying woodcut may serve 
 to illustrate a combination of retroverted 
 gravid uterus Avith distended bladder, 
 which might possibly become the cause 
 of an error in diagnosis. 
 
 As a sequel to the preceding observa- 
 tions on diagnosis, it is well to draw 
 attention to the best 
 
 MODE OF INVESTIGATING AND HECOHDING 
 CASES 
 
 Whenever a patient with an ab- 
 dominal tumour falls under the notice 
 
 of a medical student, or consults a 
 practitioner, the case should be investi- 
 gated and recorded. It requires a great 
 deal of practice to do this in a systematic 
 manner. Much that has Ijeen said on 
 the diagnosis of ovarian from other ab- 
 dominal tumours, and of the different 
 kinds of ovarian tumours, should be 
 borne in mind ; but something is very 
 likely to be overlooked if the investi- 
 gation is not conducted methodically. I 
 very soon found that the best and most 
 convenient plan was to have a separate 
 note-book for every patient, and successive 
 editions of this note-book have been pub- 
 lished by Messrs. Churchill — the sixth in 
 1881. Translations have appeared both 
 in French and Italian. I and many of 
 my friends have found these note-books 
 so useful, that I can with considerable 
 confidence recommend their general use. 
 
 On the first introduction of a patient, 
 one of these note-books is inscribed with 
 her name and number of reference, and 
 any letter received from the usual medical 
 attendant, or from any friend of the 
 patient, may be pasted in. Years after- 
 wards the advantages of this habit of 
 preserving the originals, rather than 
 copying extracts, may be found. As 
 the note-books accumulate, they may 
 be arranged in distinct divisions, accord- 
 ing to the nature of the case, and bound 
 together about twenty to each volume. 
 
 As soon as a patient is seen, a note- 
 book is taken, and the first page is at 
 once filled up. The date of the visit is 
 inserted with the index number, and then 
 a few questions are necessary to enable 
 one to fill in the answers as to name, age, 
 residence, occupation, conjugal condition, 
 number and ages of any children, and 
 the name of the usual medical attendant. 
 It saves a great deal of trouble in after 
 years if these particulars are noted very 
 fully and accurately ; and the surgeon 
 may then proceed to note all that he can 
 see and ascertain for himself by inspection 
 of the patient, before he proceeds to ques- 
 tion her further. This plan will be found 
 to save much time, the subjective exami- 
 nation being limited to particulars Avhich 
 the objective examination has shown to 
 be important. Even then the first visit 
 or consultation is necessarily a long one ; 
 but time and thought and tax on memory 
 are spared at subsequent visits. 
 
 It will be observed that four pages are 
 taken up by the objective examination, 
 
 D 2 
 
\i} 
 
 OVARIAN AND ALLIED TUMOURS 
 
 or the notes of what the surgeon can ' 
 see for himself without asking any ques- 
 tions of the patient. These are grouped 
 under the general head, ' State at First 
 Visit.' All the particulars as to the general 
 appearance of the patient, her complexion, 
 the degree of emaciation, her habits of 
 life, and the state of the surface of her 
 body, have some special signification, 
 as pointed out in the preceding pages on 
 Diagnosis. 
 
 Proceeding to inspect and measure 
 the abdomen, a diagram (which differs from 
 those of Bright and others in so far as it 
 has been corrected by photographs of well- 
 formed women) on page 3 of the Note- 
 Book will assist the observer in trac- 
 ing such outlines of the liver and the 
 spleen and thoracic viscera as he can dis- 
 cover by inspection, palpation, and per- 
 cussion, and of any tumour which can be 
 seen or felt. A column is marked for the 
 measurements, in inches, of the girth at 
 the umbilical level — of the distance from 
 ensiform cartilage to umbilicus, from 
 umbilicus to symphysis pubis, and from 
 umbilicus to right and left anterior 
 superior iliac spine. Spaces are leifc for 
 subsequent records of size. At pages 
 5, 6, the import of the visible mobility 
 of any tumour, and the evidence as to the 
 presence and extent of adhesions, have 
 been pointed out ; and the lessons to be 
 learned by percussion and auscultation 
 have been particularly referred to in the 
 sections on Ascites, Renal Cysts, Preg- 
 nancy, Uterine Tumours, and Tym- 
 panites. The points to be observed in 
 the examination of the pelvis have been 
 fully described when considering the 
 diagnosis of pelvic cellulitis, hematocele, 
 uterine tumours, and pregnancy. It is 
 hardly necessary to add the very obvious 
 caution not to use the sound, to ascertain 
 the length of the uterine cavity, in any 
 case where pregnancy is at all probable. 
 But it may not be out of place to urge 
 that examination of the uterus by the 
 rectum is often more useful, and affords 
 much more information, than is commonly 
 supposed. By the vagina the os and 
 cervix are felt and any flexion or version 
 detected ; but alterations in the body or 
 fundus, which cannot be reached by the 
 vagina, may often be felt through the 
 rectum. 
 
 Proceeding to obtain information as 
 to the catamenia, a few questions become 
 necessary; and so with regard to the 
 
 urinary and digestive organs, the nervous 
 system, and the state of the heart and 
 lungs. In an hospital the house surgeon 
 or clinical clerks, and in private life the 
 busy practitioner, are apt to pass over 
 these pages as of no great importance, or 
 to defer the necessary examination to 
 some future day ; but it is very impor- 
 tant that it should be done well and 
 thoroughly before any course of treatment 
 is determined. These points are all indi- 
 cated, and room left for answers to ques- 
 tions on pages 4, 5, 6, and 7 of the Note 
 Book. 
 
 Having completed the examination as 
 to the state of the patient at the first visit, 
 the page (8) relating to the family history, 
 place of birth and residence, the influence 
 of soil, climate, water- supply and drain- 
 age, and the mode of life of the patient 
 should be filled up, especially noting any 
 moral causes, previous diseases, or acci- 
 dents which may have preceded and 
 possibly have influenced the origin and 
 progress of ovarian disease. This may 
 not appear very important in each case 
 by itself, but as the basis of statistical 
 information, it may become of very great 
 consequence. Then we proceed to in- 
 vestigate the early symptoms of the 
 disease, carefully noting, on pages 8 and 9, 
 the first signs of ill-health, and a number 
 of symptoms Avhich are more or less gene- 
 rally complained of, pretty much in the 
 order in which they are enumerated as 
 ' Early Symptoms.' 
 
 The succeeding page contains a list of 
 the symptoms usually noticed as the dis- 
 ease progresses either to spontaneous dis- 
 charge of fluid or rupture of the cyst, or 
 until tapping is practised and repeated, or 
 some further treatment has to be considered. 
 
 A space is left on the next page (11) 
 Avhere the surgeon should enter his dia- 
 gnosis as fully as he can, and then en- 
 deavour to estimate the probable duration 
 of life if palliative treatment only be 
 adopted. A note of the general treat- 
 ment recommended may then be made, 
 including, of course, such rules of living, 
 especially with reference to air and diet, 
 clothing and exercise, as may be advised. 
 Notes of medical and surgical treatment 
 follow, and in the following page (12) 
 the progress of the disease at subsequent 
 visits may be noted and marked on the 
 diagram. 
 
 If ovariotomy be performed, all the 
 essential particulars of the operation may 
 
SUncaCAL treatment of OVArJAN TUMOURS 
 
 be noted in the order sketched ia tlie 
 three succeeding pages. 
 
 A page is then left for a description 
 of the tumour, and seven ruled pages 
 follow for the progress of the patient after 
 operation, daily and hourly notes of tem- 
 perature, pulse, and respiration, and of any 
 medical or surgical treatment. Another 
 page is left for the result, and a few blank 
 pages follow for the subsequent history. 
 
 It is very desirable to ask every 
 patient who recovers to write, once every 
 year on tlie anniversary ot the operation, 
 giving full particulars as to her state of 
 health — if unmarried when operated on, 
 if she has remained so, or has married 
 since — if she has borne children, with 
 any information as to change of name or 
 address, which may render communica- 
 tiou easy if desired. 
 
 CHAPTER III 
 
 TALLIATIYE AND MINOR SUHGICAL TREATMENT OF OVARIAN TUMOURS 
 
 The sum of doctrine on the medical treat- 
 ment of ovarian tumours amounts to 
 this: palliate where you can ; do no mis- 
 chief where you cannot. The state gf 
 health of the patient is the first con- 
 sideration. AW matters of diet, hygiene, 
 tonics for the body, and consolation for the 
 mind, are to be regulated and administered 
 under the conviction that whatever tends 
 to support the strength and cheer the 
 spirits of the patient does as much as can 
 be done in arresting the progress of a 
 disease Avhich, in its essentially parasitic 
 character, flourishes under despondency 
 and preys upon weakness. 
 
 The local miseries which, we have to 
 alleviate mostly arise from pressure or 
 congestion. The due action of the bowels 
 and bladder is interfered with, the veins 
 are pressed upon, and oedematous swell- 
 ing of the extremities shows itself. The 
 area of the chest is encroached upon and 
 breathing is made difficult, a teasing cough 
 supervenes, or the heart is embarrassed 
 and the brain action enfeebled. Common 
 sense will suggest the fitting choice of 
 sedatives or stimulants, aperients or enemas, 
 the use of the catheter, changes of posi- 
 tion, the application of bandages or me- 
 chanical supports, and the possibility of 
 relief sometimes to be obtained by manu- 
 ally altering the position of the tumour 
 when it is low down or impacted in the 
 pelvis. 
 
 Conception is a possibility which must 
 always be borne in mind. It is true that 
 pregnancy may proceed to its end, and 
 labour be accomplished without much 
 more than ordinary difficulty ; yet the 
 complication is a cause of just anxiety, 
 
 and may give rise to a state of things 
 which renders the question between pallia- 
 tive measures and removal of the tumour 
 no longer one of choice. 
 
 But, independently of the troubles 
 incident to the ordinary course of the 
 disease, accidents will happen. The patient 
 may get some local injury from a blow or 
 a fall, or she may be chilled. Inflamma- 
 tion is set up in the tumour or in the 
 peritoneal covering, and judicious treat- 
 ment is called for. Absolute rest, 
 fomentations or poultices, and opium, 
 with or without mercury, must be used 
 so as to avoid, if it can any way be 
 averted, the complication of pus forma- 
 tion or plastic adhesions. 
 
 Many medicines have been proposed 
 for the cure of ovarian cysts. Either no 
 good has been done, or, where benefit has 
 ibllowed the use of the remedy, there has 
 been a mistake in diagnosis. So with the 
 supposed value of drastic purgatives and 
 hydragogues ; if used Avhen the dropsy is 
 ovarian they have often done harm, rarely 
 good. When they have done good, fluid 
 has been free in the peritoneal cavity or 
 discharged into it. Some years ago I met 
 with a curious illustration of this state- 
 ment. I was asked to see a young lady in 
 consultation with Dr. Headlam Greenhow, 
 who had ascertained the presence of a 
 large single ovarian cyst, and recommended 
 tapping. Dr. Marsden had ako seen the 
 patient. He believed the disease to be 
 ascites, said that tapping was unnecessary, 
 and that he could cure the patient by 
 calomel and elaterium. I quite agreed 
 with Dr. Greenhow. The danger of tap- 
 ping seemed to me to be very much less 
 
38 
 
 OVAEIAN AND ALLIED TUMOUES 
 
 than the danger either of spontaneous 
 rupture, or of rupture accelerated by 
 purging. This was fully explained to the 
 friends, but they chose the medical rather 
 than the surgical treatment. It is only 
 fair to the memory of Dr. Marsden to say 
 that his treatment was followed by com- 
 plete success, but I have no doubt that a 
 thin cyst gave way, its contents escaped 
 into the peritoneal cavity, were absorbed, 
 and were carried off by the watery 
 motions excited by the calomel and 
 elaterium. Repetition of similar treat- 
 ment would be followed by many failures. 
 I only record the case as a warning to 
 those who would condemn such attempts 
 as invarialjly useless, and to show the 
 necessity of explaining the possibility of 
 their occasional success. 
 
 Whenever an ovarian cyst or tumour 
 has attained so large a size that the comfort 
 and health of the patient are interfered 
 with, it may be taken as certain that 
 ordinary medical treatment Avill be of 
 little avail. Any specific medical treat- 
 ment by iodine, or bromine, or mercury, 
 or gold, or arsenic, or lime, or potash, 
 used with the hope of checking the growth 
 of such tumours, must be as useless as 
 any diuretics or other medicines expected 
 to lead to absorption of the contents of 
 the cyst; and it would be well if the 
 rule were adopted to prohibit any medical 
 treatment which could possibly injure the 
 health of the patient, or place her in a less 
 favourable condition than she otherwise 
 would be for such surgical treatment as 
 may ultimately be called for. 
 
 The question when surgical aid really 
 is required, or how long a patient should 
 be left to ordinary medical care, undis- 
 turbed by any .surgical treatment, is one 
 which is daily occurring in practice, and 
 the answer should be framed upon some 
 such common-sense rules as the following : 
 so long as the patient does not suffer much 
 pain, is not annoyed by her size and 
 appearance, has no great difficulty in 
 locomotion, and so long as the heart and 
 lungs, digestive organs, kidneys, bladder, 
 and rectum perform their functions 
 tolerably well, nothing need be done. 
 Life is not immediately threatened, and 
 by watching the advancing symptoms the 
 moment for action can almost always be 
 determined. But Avith the experience of 
 the 12 years which have elapsed since 
 the publication of my edition of 1872, I 
 have become more and more disposed to 
 
 advise the removal of an ovarian tumour 
 as soon as its nature and connections can 
 be clearly ascertained, and it is beginning 
 in any way physically or mentally to do 
 harm, since the risk of the operation under 
 such circumstances is certainly less, and 
 the possible evils of delay are eluded. 
 Where, however, the distress of the 
 patient forces her to demand some kind of 
 relief, and there is either reluctance or 
 refusal to face the average risk of exci- 
 sion, or family considerations impose the 
 necessity of delay, the size, nature, and 
 connections of the tumour must guide us 
 in the selection of one or other of the 
 minor methods of palliative surgical 
 treatment, which, though they seldom 
 lead to a cure, have the advantage of 
 enabling us to alleviate the most distress- 
 ing symptoms, and to wait for an oppor- 
 tunity to try some of the expedients 
 adopted for the obliteration of the cyst, 
 or to carry out the last resource of 
 ovariotomy. 
 
 These palliative measures, or substi- 
 tutes for ovariotomy, may be thus enu- 
 merated : 
 
 1. Simple tapping through the abdo- 
 minal wall. 
 
 2. Simple tapping through the vagina. 
 
 3. Simple tapping through the rec- 
 tum. 
 
 4. Tapping followed by pressure. 
 
 5. Tapping and the formation of a 
 permanent intra-peritoneal opening in the 
 cyst wall. 
 
 6. Tapping and drainage, or the 
 formation of an opening through the 
 abdominal wall, the vagina, or the 
 rectum. 
 
 7. Incision. 
 
 8. Tapping followed by injection of 
 iodine. 
 
 TAPPING 
 
 As experience has increased and the 
 mortality after ovariotomy has diminished, 
 professional opinion has been un.settled as 
 to the use or propriety of tapping ovarian 
 cysts. Some writers — Stilling, for exam- 
 ple — have gone so far as to assert that it 
 is an operation which ought to be com- 
 pletely abandoned. Few surgeons would 
 assent to this, but there are many who 
 object to tapping on two grounds — first, 
 that it is dangerous in itself, and can only 
 be of temporary utility ; and secondly, 
 that it is likely to be followed by adhe- 
 
SURGICAL TREATMENT OF OVARIAN TUMOURS 
 
 sions or other conditions which add 
 greatly to the danger of subsec^uent 
 ovariotomy. 
 
 In considering the objection to tapping 
 on the ground of its danger, as compared 
 with the danger of ovariotomy, some 
 Avriters appear to me to have fallen into 
 •error. They take a certain number of 
 cases of ovarian disease, and say that so 
 many patients died after one tapping, so 
 many after five, six, or ten, and conclude 
 that tapping is a very fatal operation. I 
 have heard it gravely asserted that it is a 
 more fatal operation than ovariotomy, 
 because after ovariotomy nine-tenths of 
 the patients recover, while after tapping, 
 sooner or later, they all die. But the very 
 important distinction is overlooked be- 
 tween an operation which either cures or 
 kills, and one which only fails to save life, 
 or kills only under most exceptional cir- 
 cumstances. 
 
 It is seldom that a surgeon is called 
 upon to perform ovariotomy in order to 
 save a patient from imminent death. But 
 this does occasionally happen. Wiltshire 
 published a case where a woman, who 
 was dying from bleeding into an ovarian 
 cyst, was saved by immediate ovariotomy. 
 I have been sent for twice to operate 
 under similar circumstances, but both 
 patients were dead before I arrived. 
 Large veins had burst, and some pounds 
 of blood were found inside ovarian cysts. 
 If, in any of these cases, the death of the 
 patient had followed ovariotomy, it could 
 hardly be said that this operation had 
 killed the patient ; it had only failed to 
 save life. So, if a patient be near death, 
 either poisoned by an ovarian tumour in a 
 state of gangrene from twist in the pedicle, 
 or by the fetid contents of a suppurating 
 cyst, or after bursting of an ovarian cyst 
 into the peritoneal cavity, ovariotomy, if 
 performed unsuccessfully, may be said to 
 fail in saving life — it cannot be said to 
 kill. Yet I have many times operated 
 successfully under such desperate circum- 
 stances. In any such case, ovariotomy 
 must be compared with trephining, 
 tracheotomy, herniotomy, or the ligature 
 of some large artery in a case of wound 
 or burst aneurism, or primary amputa- 
 tion of a limb in compound fracture. 
 It is not the operation which is the cause 
 of death, but the disease or accident from 
 the effects of which the patient is not 
 saved by the operation. 
 
 But in the large majority of cases of ■ 
 
 ovariotomy there is as much time for 
 discussion as in the case of lithotomy. 
 And in both cases the responsibility of 
 operating with the full knowledge that, if 
 the patient be not saved by the operation, 
 he or she is killed by it, must be fairly 
 faced. It is true that death would almost 
 always be caused by the stone or the 
 ovarian tumour ; but it might be at a 
 distant period, and if death follow the 
 operation in a few days^ the operation 
 must then be regarded as the immediate 
 cause of death. 
 
 Tapping stands on a totally different 
 ground. As a rule, when a patient dies 
 after tapping, it is not that tapping has 
 hastened her death, but simply has not 
 succeeded in saving her life. Her life 
 may have been prolonged by repeated 
 tappings, but at last she dies worn out by 
 the disease. 
 
 Tapping may be practised — first, 
 through the abdominal wall ; secondly, 
 through the vagina ; and, thirdly, through 
 the rectum. "Whichever of these methods 
 may be selected, it may be trusted to 
 alone, or it may be followed by pressure, 
 or by the formation of an opening, either 
 in the cyst wall only, with the object of 
 establishing a communication with the 
 peritoneal cavity, or, for drainage, through 
 the abdominal Avail, vagina, or rectum. 
 In the one case the fluid passes into the 
 peritoneal cavity and is absorbed, no 
 external opening being left ; in the other 
 a fistulous external opening is kept up 
 until the cyst ceases to pour out fluid and 
 becomes obliterated. In any of these 
 cases the processes may be assisted by 
 pressure ; and in some tapping may be 
 followed by the injection of iodine. 
 
 TAPPING THROUGH THE ABDOMINAL WALL 
 
 Avas formerly practised with the patient 
 sitting in a chair, a pail between her legs, 
 an assistant on either side of her, keeping 
 a sheet, or long towels, so tightened round 
 the abdomen by pulling at the ends, that 
 the escape of the fluid was supposed to be 
 assisted, and the fainting of the patient 
 prevented. A hole in the sheet, or a 
 space between two towels, left room for 
 the passage of the trocar. The operator, 
 standing in front of the patient, used the 
 trocar like a dagger, stabbing with con- 
 siderable force. A good deal of discussion 
 arose at one time as to the propriety of 
 dividing the skin and fascia Avith a lancet 
 before usina; the trocar. Some thought it 
 
40 
 
 OVARIAN AND ALLIED TUMOURS 
 
 unnecessarily jovolonged the operation, 
 others thought it spared the patient the 
 shock and pain of a forcible stab. Any 
 way the operation was a very distressing 
 one. The fainting of the patient was by 
 no means uncommon ; slie suffered from 
 exposure and shock, her clothing was often 
 wetted by the fluid, and she was taken 
 back to bed frightened, wet, cold, faint, 
 and exhausted. No doubt some of the 
 dangers of tapping depended upon this 
 clumsy method of proceeding. It is diffi- 
 cult to understand otherwise that the 
 mortality after tapping could possibly have 
 been as high as many writers have esti- 
 mated it. Simpson's calculation was that 
 the mortality after first tappings was not 
 less than 1 in G. Under the present 
 simplified mode of tapping, I very much 
 doubt if it is as much as 1 in 60. I 
 believe it has been considerably less than 
 this in my own experience. I have 
 removed 115 pints of fluid from a patient 
 at one tapping, and 121 from another, 
 without the slightest sign of faintness, 
 without wetting either the linen or the 
 bed-clothes, and without disturbing her 
 position in the bed. I have often re- 
 moved 30, 40, or 50 jiints of fluid from 
 patients reclining on one side in bed, and 
 they have been only conscious of the 
 relief afforded by the removal of pres- 
 sure. They should lie on one side near 
 the edge of the bed, so that the abdomen 
 projects over the edge. As a rule, 
 the linea alba is the preferable site for 
 puncture, but any hard portions of the 
 tumour should be avoided, and the most 
 elastic or distinctly fluctuating points of \ 
 the tumour selected. Before puncturing, 
 great care should be taken by palpation 
 and percussion to ascertain that no intes- 
 tine is lying, or adhering, between the 
 cyst and the abdominal wall, at the point 
 selected for tapping ; and any visible 
 superficial veins should be avoided. It is 
 certainly advantageous to puncture the 
 skin with a lancet before using the trocar, 
 and if the patient is very sensitive to pain 
 the seat of puncture may be frozen by 
 ether spray. And every now and then 
 with a very nervous subject, or where the 
 excessive accumulation of fat on the abdo- 
 men gives a formidable look to the pro- 
 ceedings, and may perhaps occasion some 
 little difficulty in driving the canula to its 
 destination, it may be as well to adminis- 
 ter a slight amount of some anassthetic so 
 as to calm the timidity, or give the opera- 
 
 tor the opportunity of doing what he has 
 to do with greater facility. 
 
 The condition of the cyst wall may 
 also be the cause of embarrassment or 
 danger in tapping. I have many times 
 observed it so far gone in degenerative 
 changes as to make it friable ; and though 
 it has been kept entire by the equable 
 support of the surrounding parts, any 
 essays to puncture with a trocar must 
 have crushed it and caused the discharge 
 of the contents. In at least 3 operations 
 whore I came upon fluid free in the 
 peritoneum, on examining the cyst,, the 
 hole made in a previous tapping was 
 quite open, a piece of inelastic matter 
 having been forced away so that there 
 Avas no possibility of closing. There have 
 been, too, some examples of bony deposit 
 in the tissue sufficiently hard to turn the 
 point of a trocar. Ritchie reported of 
 one of my cases, a partial thickness of 2 
 inches, enough to arrest any ordinary 
 operator under the impression that he 
 had come in contact with a solid fibroid. 
 In other multilocular cysts one compart- 
 ment may have walls of almost impene- 
 trable solidity, and an adjoining one of 
 not more than a line in thickness, so that 
 a first attempt to draw off fluid may be 
 an utter failure and lead to an erroneous 
 conclusion, Avhile the next, from shifting 
 of the position of the mass or change of 
 point of puncture, may fall upon a thin 
 loculus, give vent to the contents, and 
 alter the diagnosis completely. 
 
 The trocar has been greatly improved: 
 of late years. The old instrument was so 
 short that, if the abdominal Avail Avas thick, 
 the trocar never reached the cyst, or it 
 may just have punctured the cyst, and the 
 canula Avas too short to folloAv it. In the 
 first case no good, but no harm, Avas done; 
 in the second the results were dangerous 
 or fatal. The punctured cyst poured out 
 its contents into the peritoneal cavity, and 
 dangerous symptoms or death followed,, 
 the danger arising not from the tapping, 
 but from the bad Avay in which it Avas 
 done. 
 
 Great difference of opinion has been 
 expressed as to the effect of admitting air 
 into an ovarian cyst Avhile the fluid iii 
 escaping. Some Avriters h.ave argued that 
 it can do no harm. My OAvn opinion, 
 founded upon the few cases where I have 
 been sure that air has entered, is in accord- 
 ance with those who assert it to be fre- 
 quently folloAved by cyst inflammation, 
 
SURGICAIi TREATMENT OF OVARIAN TUMOURS. 
 
 41 
 
 by fever, and by decomposition of the 
 fluid which remains in the cyst, or is 
 secreted soon after the tapping. I there- 
 fore regard the improvement in the trocar 
 ■which provides against the entrance of 
 air into the cyst during the escape of fluid 
 as an important element in the diminution 
 of the mortality after tapping. We are 
 indebted to Mr. Charles Thompson for 
 introducing one of the first instruments 
 by which this object has been attained. 
 In his own words, ' It consists of a cylin- 
 drical silver canula about 4 inches long, 
 into which opens at near its middle a 
 short silver conducting tube of the same 
 
 calibre, to which a piece of india-rubber 
 tubing about a foot long is attached by a 
 screw. In this canula plays a solid steel 
 
 ^=TI^ 
 
 piston, with a trocar point, its body being- 
 of such length that, when fully pushed 
 forward, as in the above figure, its point 
 protrudes sufficiently from the canula, and 
 its other extremity seals the entrance of 
 the conducting tube; and, when fully 
 withdrawn, as in this fio-ure — 
 
 it retires so far as to open the conducting 
 tube. This piston must fit the canula so 
 ])erfectly as to be air-tight when greased. 
 The little cap of the canula unscrews to 
 admit of the removal of the piston for 
 greasing or cleaning. The outer half of 
 the canula is mounted in a solid wooden 
 handle to give a firm grasp of the instru- 
 ment.' 
 
 As soon as I read this description of 
 Thompson's trocar, I saw how useful it 
 would be, both in tapping ovarian cysts 
 and in ovariotomy, and I had instruments 
 made with canulas of different lengths 
 and calibre, suitable for both purposes, 
 and continued to use them for some 
 months. I found that admission of air 
 was prevented, the syphon action assisting 
 in keeping up a continuous flow of fluid, 
 while the escape could be stopped at any 
 desirable moment. If the tube or canula 
 became blocked it was easily cleared. 
 The fluid was conveyed into the re- 
 ceiving vessel, while the patient was kept 
 perfectly dry, not alarmed by the splash- 
 ing of the fluid, and not disturbed by the 
 changing of the basins, which was so 
 troublesome when the old instrument was 
 used. 
 *" While still desirous to carry on the 
 principle of the syphon, as adapted to the 
 trocar, I became anxious to avoid the 
 momentary delay between the introduc- 
 tion of the trocar and the escape of the 
 fluid, while the piston was being with- 
 drawn. I was led to this by observing 
 that, when using the large-sized instru- 
 
 ment in ovariotomy, there was sometimes 
 a rush of fluid between the cyst and the 
 outside of the canula before the piston 
 could be withdrawn, and it was evident 
 that the same thing might occur during: 
 ordinary tapping. After two or three 
 trials, it occurred to me that a hollow 
 piston, something like a steel pen slidingr 
 in the pencil-cases in ordinary use, might 
 be a convenient mode of effecting the 
 object in view. I first carried out thi& 
 idea in an instrument of the size for 
 ovariotomy, adding, to the outside of the 
 canula, grooves upon which the cyst could 
 be tied as it became lax. Modifications 
 which I have since made in this instru- 
 ment are described in the chapter on 
 Ovariotomy. When the instrument is- 
 made of the size for simple tapping, the 
 canula is perfectly smooth. A lancet 
 puncture is made through the skin, andl 
 the instrument is then easily thrust into 
 the cyst. Fluid escapes immediately, and 
 the point is withdrawn to prevent injury 
 to the cyst as it contracts. It is impor- 
 tant that the edges of the canula should 
 not be thin, but perfectly smooth and well 
 rounded off. There would otherwise be 
 danger of injury to large veins on the 
 inner surface of the cyst ; and the maker 
 should be careful, in sharpening the cutting 
 end of the hollow trocar, to leave one half 
 of the lips quite blunt. If sharpened all 
 round it would act as a punch, and cut a 
 circular hole in the skin. I have seen a 
 tube blocked in this Avay, and more than 
 once a round piece of skin floating in tlae 
 
42 
 
 OVARIAN AND ALLIED TUMOUES 
 
 fluid, or so nearly detached after the canula 
 was withdrawn that it was better to cut 
 it awav. If the instrument is properly 
 finished, only a semilunar cut is made in 
 the skin and cyst, which closes much more 
 readily than the triangular puncture made 
 by the old trocar. 
 
 Instead of the india-rubber tube, it is 
 quite easy to fix to the end of the canula 
 an ordinary india-rubber enema syringe, 
 by which more powerful exhausting suc- 
 tion can be brought to bear upon the j 
 contents of the cyst than can be obtained I 
 by the syphon tube; and if it be desirable 
 to wash out the cyst, or to inject iodine 
 or any other antiseptic into it, this can be 
 readily done by reversing the syringe 
 without removing the canula. 
 
 When using this syphon trocar, care 
 should be taken so to introduce the instru- 
 ment that the point passes into the fluid 
 at a lower level than at the commence- 
 ment of the tube, as shown in the sketch. 
 
 Air will not descend except under strong 
 suction, or into a vacuum, and there is 
 no fear of air passing up the tube and 
 down the canula into the cyst. The 
 instant the canula enters the cyst, fluid 
 rushes into it, pressing the air before it, 
 and if the tube be properly mounted so 
 that it does not bend or narrow the canal, 
 the tube, which should be about three 
 feet long, at once becomes the long arm 
 of a syphon. The atmospheric pressure 
 and syphon action of this long column of 
 fluid are so great, that the air can be 
 heard bubbling into the tube through 
 the well-fitting bayonet joint provided 
 for the Avithdrawal of the point of the 
 instrument. It is better to keep the 
 end of the tube under the fluid when 
 the cyst is nearly empty, to avoid any 
 accidental drawing inwards of air as a 
 patient makes some deep inspiration or 
 
 expiration, leading to a kind of vacuum 
 within the abdomen. In withdrawing 
 the instrument it is always well to press 
 the abdominal wall close down i;pon the 
 cyst, and with the finger and thumb of 
 the other hand so to hold the abdominal 
 walls together behind the escaping canula 
 as to prevent any entrance of air. 
 
 Instead of the syphon -trocar some 
 surgeons have used aspirators of different 
 sizes and modifications. But they are all 
 open to the objection that as the cyst 
 becomes empty its flaccid walls are sucked 
 into the end of the canula and stop the 
 flow of fluid. 
 
 Should any bleeding follow the re- 
 moval of the instrument and not be 
 stopped by a little pressure, a hare-lip pin 
 may be passed completely across the 
 opening, deeply enough beneath the skin 
 to compress any injured vessel. Two or 
 three turns of silk twisted round the pin 
 make sufficient pressure to stop any 
 bleeding. It will not do simply to bring 
 the edges of the skin together with a pin; 
 this might only conceal dangerous internal 
 bleeding. In some cases internal haemor- 
 rhage, even fatal, has followed the punc- 
 ture, and this may be explained either by 
 the opening of varicose vessels in the cyst 
 wall, where they sometimes attain enor- 
 mous development, or by the presence of 
 such enlarged veins in the omentum as 
 were found in the examination of the 
 woman operated on as my 731st case, 
 Avhere the size was such as to have made 
 the suppression of bleeding impossible 
 without immediate laparotomy. One of 
 my neighbours lost a case within a few 
 hours after tapping ; upwards of five 
 pints of blood, Avhich had escaped from a 
 varicose vein, having been found in the 
 peritoneal cavity. The vein ran directly 
 in front of the peritoneum, immediately 
 beneath the linea alba, from the umbili- 
 cus towards the liver. A pin through 
 the whole thickness of the abdominal 
 wall would have compressed this vessel. 
 
 Whenever it is doubtful if a cyst has 
 been completely emptied, or there is some 
 escape of fluid after the removal of the 
 trocar, the comfort of the patient is greatly 
 increased by closing the opening with a 
 hare-lip pin and twisted suture, but the 
 pin need not be passed so deeply as in case 
 of bleeding. I was led to adopt this 
 practice from the remark made to me by 
 Mr. Ca'sar Hawkins upon a case where 
 oozing after tapping Avas going on. He 
 
SURGICAL TREATMENT OF OVARIAN TUMOURS 
 
 43 
 
 said, ' When tliey ooze they always die,' 
 so I determined tliat they should not ooze 
 imless I wished to drain. In ordinary 
 cases a pin is not necessary, a small pad 
 of lint and a strip of adhesive plaster 
 being quite suOicient to cover the open- 
 ing. The abdomen should be supported 
 by an ordinary binder. 
 
 In order to prove that simple tapping 
 throujrh the abdominal Avail is occasion- 
 ally foUoAved by a radical cure, I can 
 refer to many cases in my note-books. 
 Sometimes it has been necessary to empty 
 the cyst a second time ; and, contrary to 
 expectation, there Avas no return of filling 
 in one case Avhere I had drawn off fluid 
 dark brown in colour and rather viscid. 
 Some of the earlier patients remained 
 under observation for many years alter 
 the operation. For the most part they 
 kept in good health ; a fcAV died of other 
 diseases, Avhile others married and had 
 children. lu one case I tapped the 
 patient only the day before she was 
 married. She became pregnant at once, 
 and has had several children since, Avith- 
 out any refilling of the cyst. 
 
 My experience accords Avith the con- 
 clusions draAvn by Dr. Mehu from his 
 researches on the abundant material sup- 
 plied to him by the hospitals and ])racti- 
 tioners of Paris, that in spite of a fcAv 
 exceptional cases, it is only when single, 
 and probably broad-ligament or extra- 
 peritoneal cysts, are tapped, and clear, 
 non-albuminous fluids are evacuated, 
 there is a reasonable hope of fluid not 
 iigain accumulating. 
 
 In order to Aveigh the value of the 
 A'arious objections to tapping, I have gone 
 over the records of my first 500 cases of 
 ovariotomy. 265 of these 500 patients 
 had been tapped previously, from 1 to 
 18 times. 193 of these tapped patients 
 recovered, and 72 died, giving a mortality 
 of 27*16 per cent. 
 
 The general mortality of the 500 cases 
 was 25*4 per cent., and 235 patients, or 
 nearly one-half, had never been tapped. 
 In them the mortality was 23*4 per cent., 
 just 2 per cent, less than the general mor- 
 tality. In other Avords, the mere fact that 
 a patient has or has not been tapped (so 
 far as can be judged from 500 cases in 
 the hands of the same operator) does not 
 aifect the result of the operation by more 
 than 2 per cent. Indeed, the mortality 
 of the patients not tapped, though less 
 by about 10 per cent, than that of the 
 
 patients avIio had been tapped tAvice, is 
 greater than that of the patients Avho liad 
 been tapped once and three times. Thus 
 140 — or rather more than one-fourth — 
 had been tapped once, and the mortality 
 Avas 23 57 per cent. Of 32 Avho Avere 
 tapped three times, tlie mortality was 
 2l"87 per cent. Of the 49 Avho Avere 
 tapped twice, the mortality Avas nearly the 
 same as tliat of the group of cases tapped 
 from 4 to 18 times, namely 3 4' 6 9 per 
 cent., or about 1 in 3. 
 
 An investigation of the details of sub- 
 sequent cases confirms the impression that 
 the mortality of ovariotomy is but little 
 affected by previous tapping. The fact 
 of a patient not having been tapped, or 
 having been tapped very often, is by itself 
 of little or no value in prognosis. I have 
 stated elsewhere that such adhesions as 
 are apt to foUoAv tapping do not greatly 
 increase the mortality after ovariotomy ; 
 and I can noAV add that in some of the 
 patients Avho have been tapped most fre- 
 quently there Avere no adhesions, and 
 there Avere firm adhesions in some Avho 
 had never been tapped. 
 
 Although more impressed of late years 
 by the danger of putrefactive changes in 
 the fluid after tapping Avithout antiseptic 
 precautions, I still adhere to the folloAving 
 propositions : 
 
 1. That in cases of simple ovarian or 
 extra-OA'arian cysts, it is right to try the 
 effect of one tapping before advising a 
 patient to undej-go a more serious risk. 
 But in compound or multilocular cysts 
 the third proposition holds good. 
 
 2. That one or many tappings do not 
 increase considerably the mortality of 
 ovariotomy. 
 
 3. That tapping may sometimes be a 
 useful prelude to ovariotomy, either as a 
 means of gaining time for a patient's 
 general health to recover — of clearing the 
 urine of the albumen Avith Avhich it is 
 sometimes charged under the mere influ- 
 ence of pressure — or of lessening shock, 
 by relieving her of the fluid a feAv hours 
 or days before removing the solid portion 
 of an ovarian cyst ; and 
 
 4. That when the syphon- trocar, Avhich 
 I brought before the profession in 1860, 
 is carefully used [in such a manner as to 
 prevent the escape of OA'arian fluid into 
 the peritoneal cavity, and the entrance of 
 air or of putrefactive material into the 
 cyst, the danger of tapping is extremely 
 small. 
 
44 
 
 OVARIAN AND ALLIED TUMOURS 
 
 TAPPING THROUGH THE VAGINA 
 
 is more liable to be followed by inflamma- 
 tion of the cyst than tapping through the 
 abdominal wall, because it is not easy to 
 prevent the entrance of air. We should 
 always endeavour to avoid this accident 
 by attention to the level of the cauula, 
 but the attempt does not invariably 
 svicceed. The operation of tapping 
 through the vagina is selected not so 
 much with the intention of simply empty- 
 ing the cyst, as for the chance that, should 
 the fluid escape by the opening as fast 
 as it is secreted, the cyst may gradually 
 contract and the puncture close. This 
 favourable result, however, is seldom 
 secured. As a rule, air enters the cyst, 
 the opening fills up, and the fluid remain- 
 ing in the cyst, or that freshly secreted, 
 putrefies. Suppurative inflammation of 
 the lining membrane of the cyst comes 
 on, and is accompanied by a low form of 
 septic fever or pytemia, which can only be 
 relieved by maintaining a free outlet for 
 
 the discharge. The frequency of these 
 consequences should make tapping through 
 the vagina an exceptional practice. But 
 it may be adopted in cases where an 
 ovarian cyst is bound down in the pelvis 
 by adhesions, and it is necessary to relieve 
 the distress caused by pressure on the 
 bladder and rectum. The puncture should 
 then be made where the fluctuation is 
 most evident, but as near the median 
 line as possible. The canula, or an elastic 
 catlieter, may be left in the cyst, though 
 it is safer practice either to introduce a 
 wire seton, or a drainage tube, so as to 
 prevent the opening from closing, and 
 make sure of the free and immediate 
 escape of any fluid that may be secreted. 
 Whether a canula or tube be used, it is 
 necessary to adopt some contrivance to 
 prevent it from slipping out ; and I find 
 a piece of wire doubled at the inner end 
 answers this purpose well. The ends 
 open out, as shown in this drawing, and 
 maintain either canula or tube in the 
 cavity until the Avire is withdrawn. 
 
 It is now about 20 years since I 
 treated a case of ovarian dropsy in this 
 way. This shows my reluctance to face 
 the risks incurred by it. Though none of 
 my early cases had an immediately fatal 
 result, and two of them were followed by 
 restoration to perfect health, the others 
 died within a few years, either from 
 exhaustion by the continuous discharge, 
 or from recurring suppuration. 
 
 It must always be borne in mind that, 
 to carry out this practice with any chance 
 of success, the opening, Avhich is not 
 merely for evacuation, but drainage, must 
 be free and well placed, so as to avoid the 
 possiVjility of any accumulation. The 
 utmost cleanliness must be observed, 
 injections of sulphurous acid, or some 
 other disinfectant, are incessantly re- 
 quired ; and everything must be done to 
 promote the health of the patient. 
 
 The impression left on my mind by 
 what I have seen of vaginal tapping, 
 leads me to the conclusion that simple 
 
 tapping is more hazardous than tapping 
 followed by drainage, and that drainage 
 should be so complete that no reaccumula- 
 tion of fluid can take place, the cavity 
 being kept open until its walls collapse and 
 imite, so that it is completely obliterated. 
 Even then, patients are so apt to suffer 
 from some of the ill effects of long-con- 
 tinued suppurative processes, that I am 
 more than ever confirmed in the opinion 
 that it is better, even at considerable risk, 
 to remove a cyst, if at all possible, than 
 to trust to any mode of drainage. 
 
 TAPPING TIinOUGII THE liECTl'M 
 
 has been supposed to possess some advan- 
 tages over tapping through the vagina. 
 It was said that there would be no con- 
 stant discharge of offensive fluid, for any 
 ovarian fluid Avhich entered the rectum 
 would be retained, just as a liquid motion 
 is retained by the sphincter aui, and dis- 
 charged when the patient pleased. But a 
 dysenteric tenesmus has been occasionally 
 
SURGICAL TREATMEIsT OF OVARIAN TUMOURS 
 
 observed, which has proved very distress- 
 ing. It was supposed that the objection 
 to vaginal tapping fiom entrance of air 
 into the cyst would be guarded against in 
 rectal tapping by the contraction of the 
 sphincter ani. But the entrance of fa3cal 
 gas into a cyst would be quite as likely to 
 occur, and would be more injurious than 
 the entrance of atmospheric air in vaginal 
 tapping. Fatal inflammation has followed 
 the entrance of faecal gases into the cyst. 
 I had one such case with Dr. Priestley. 
 We tapped an adhering cyst through the 
 rectum, and the patient died some days 
 afterwards of cyst inflammation. The 
 cavity was filled with faecal gas. 
 
 INJECTION OF IODINE 
 
 Notwithstanding the advocacy of 
 Boinet, the practice of injecting ovarian 
 cysts with iodine has quite fallen into 
 discredit ; and, so far as my own trials 
 and means of observation enable me to 
 judge, not in any way to the disadvantage 
 of patients. The few cysts which I in- 
 jected and which did not refill for several 
 years were single, with limpid contents, 
 and in such cysts I believe tapping is as 
 effectual alone as it is with the injection 
 of iodine in addition. 
 
 The only cases in which iodine injec- 
 tion is really useful, and where its employ- 
 ment should be recommended, are those in 
 which, after tapping either by the abdo- 
 minal wall, vagina, or rectum, cyst inflam- 
 mation has occurred, and the patient is 
 suffering from absorption of the decom- 
 posing contents of the cyst. Here free 
 drainage becomes necessary to save the 
 patient from pya?mia or septicaemia ; but 
 •she may suffer considerably in appetite 
 and strength if the fluid which escapes is 
 offensive; and it ought to be deodorised. 
 For this purpose iodine, or phenol, or sul- 
 phurous acid, or chromic acid may be 
 tised in tolerably strong solution; and 
 iodine I used to think preferable to all 
 the others. A solution of 1 part of iodine 
 and 2 of iodide of potassium to 20 
 parts of water was used night and morn- 
 ing, injected through the catheter after 
 washing out the cyst with warm water ; 
 and the greater part of the iodine solution 
 injected was allowed to run away again at 
 once. But a little was left in the cyst, 
 partly to act on its walls and partly to 
 deodorise the fluid contents of the cyst if 
 they putrefied. Latterly I have had 
 reason to prefer sulphurous acid to iodine. 
 
 I have used with excellent effect a mixture 
 of one part of the acid of the British 
 Pharmacopccia with G or 8 parts of tepid 
 water. 
 
 XnEATMENT I!Y INCISION 
 
 The practice of laying open ovarian 
 cysts by incision no doubt arose when, 
 during tapping, the instrument used 
 proved to be too small for the escape of 
 thick fluid. On withdrawing the canula 
 it would be found filled with glue-like 
 matter, and similar matter would be ob- 
 served exuding from the opening. The 
 natural result would be that the surgeon 
 would enlarge the opening, until the con- 
 tents of the cyst could escape or be 
 squeezed out. This has occurred to me 
 more than once. I was present when Mr. 
 Armstrong Todd tapped a young lady. 
 After a little fluid had escaped, the canula 
 became clogged with hair and fat, and it 
 was withdrawn. Fluid continuing to ooze 
 away, the opening was enlarged until first 
 one finger, then two, and then a tablespoon 
 could be used to scoop out many pounds 
 of semi-solid fat, with masses of hair and 
 bony spiculee, from a cyst which Avas inti- 
 mately adhering over a large extent of the 
 abdomen. Ovariotomy was proposed to 
 the parents, but they preferred the alterna- 
 tive of drainage, and the patient only sur- 
 vived a few days. 
 
 In another case, where the contents of 
 a large cyst consisted of colloid, I made 
 an incision 2 inches long, and squeezed 
 out many pounds of matter. In this case 
 relief was given for a time, but the patient 
 ultimately died exhausted from the con- 
 tinuous discharge. 
 
 In the cases hereafter described, where 
 it has been impossible to complete ova- 
 riotomy, and the cyst, or a portion of it, 
 has been left Avithin the abdominal cavity, 
 the edges of the opening in the cyst have 
 been fixed to the abdominal Avail by 
 suttire, and such cases have become simi- 
 lar to those treated by incision. I have 
 not adopted the practice of incision tinder 
 any other circumstances, but it has been 
 repeatedly done by others, and A-arious 
 means have been taken to preA'-ent the 
 escape of the fluid into the abdominal 
 cavity. Adhesion betAveen the cyst and 
 the abdominal wall has been secured by 
 caustic issues, or by the insertion of 
 needles, or by the use of special instru- 
 ments, or by suture after laying bare the 
 cyst. As soon as adhesion Avas believed 
 
46 
 
 OVARIAN AND ALLIED TUMOURS 
 
 to be complete, the incision was made, 
 and the cyst kept open until the oblitera- 
 tion of its cavity took place. So far as I 
 can learn, from my own experience and 
 the study of recorded cases, this practice 
 is far more dangerous than ovariotomy, 
 and very much less likely to be followed 
 by complete cure. I think, therefore, it 
 should only be considered admissible in 
 
 cases where ovariotomy cannot be com- 
 pleted. Then after incision and emptying 
 the cyst as far as possible, and securing 
 the opening in the cyst to the opening in 
 the abdominal wall, the cavity is kept 
 empty by draining and the injection of 
 disinfecting or deodorising agents. The 
 conditions are then the same as those of a 
 drained abscess. 
 
 CHAPTER IV 
 
 THE RISE AND PROGRESS OF OVARIOTOMY 
 
 Ovariotomy. From wapior, ovary ; and 
 7o;i»'/, incision, [Syn. Ovariotomie, Fr. 
 and Ger. — Ovariotomia, Ital. and Sp.] 
 Ovariotomy, as performed by surgeons 
 when one or both ovaries are diseased, is 
 a very different proceeding from the ex- 
 tirpation of healthy ovaries, which . has 
 been practised from remote antiquity on 
 domestic animals for economical purposes, 
 and both in ancient periods and in the 
 Middle Ages on Avomen, almost exclusively 
 for immoral purposes. 
 
 At the present day it seems to be a 
 common practice among some of the 
 natives at the antipodes. Dr. Junker 
 reports that the aborigines of Australia 
 and of New Zealand perform ovariotomy 
 on young girls by incision in both in- 
 guinal regions. They do this for two 
 purposes : to prevent the propagation of 
 hereditary diseases and deformities and 
 other disabilities, and to keep up a supply 
 of barren prostitutes. 
 
 It was not earlier than in the 17th 
 and 1 8th centuries that ovariotomy was 
 proposed and suggested as a radical 
 cure for diseased ovaries. As late as 
 the beginning of the 18th century 
 thi.s operation was first performed, and 
 it remained long in discredit. It is 
 only within the last 30 years that it 
 has been at all frequently or generally 
 practised. 
 
 The subject began to be discussed 
 by surgical writers in the 17th cen- 
 tury. But they got no farther than an 
 expression of belief that extirpation of 
 dropsical ovaries, if it could be done, 
 would lead to a permanent cure of the 
 disease. In the first 50 years of the 
 next century the operation was not only 
 
 admitted to be possible, but was recom- 
 mended, though with so many qualifying 
 conditions that no one did it. Some 
 authorities, such as De Haen and Mor- 
 gagni, opposed it altogether, while a few 
 more sanguine prophesied its ultimate 
 success. Later on, in our own country, 
 the Hunters took up the question. 
 
 Dr. William Hunter, in a paper * On 
 Cellular Tissue,' pviblished in 17G2, says: 
 ' It has been proposed by modern sur- 
 geons, deservedly of the first reputation, 
 to attempt a radical cure by incision or 
 suppuration, or by excision of the cyst.' 
 Having pointed out difliculties during 
 the operation, and dangers following it, 
 in support of his opinion * that incision 
 can hardly be attempted,' he concludes 
 with the following words, which fore- 
 shadow some of the recent modifications 
 in the operation : * If it be proposed, 
 indeed, to make such a Avound in the 
 belly as will admit two fimjers or so, and 
 then tap the bag and draio it out, so as to 
 bring its root or peduncle close to the 
 wound of the belhj, that the surgeon may 
 cut it Avithout introducing his hand, surd// 
 in a case otherivise so desperate it viiijht 
 be advisable to do it, could Ave beforehand 
 knoAv that the circumstances would admit 
 such treatment.' {Op. cit. p. 45.) 
 
 In a lecture delivered in 1785, John 
 Hunter has this passage : * I cannot see 
 any reason Avhy, Avhen the disease can be 
 ascertained in an early stage, Ave should 
 not make an opening into the abdomen 
 and extract the cyst itself. Why should 
 not a Avoman suffer s]iaying, Avithoiit 
 danger, as Avell as other animals do? The 
 merely making an opening into the abdo- 
 men is not highly dangerous. In a sound 
 
THE IIISE AND PROGRESS OF OVARIOTOMY 
 
 47 
 
 constitution, perhaps, a wound merely into 
 the abdomen Avould never be followed by 
 death in consequence of it.' 
 
 Not many years later ( 1 798 ) ovariotomy 
 found an enthusiastic advocate in Cham- 
 bon ('Maladies des Femmes'). He con- 
 cludes a speculative chapter, on its 
 applicability to other diseases besides 
 ovarian dropsy, with the words, ' I am 
 convinced that a time will come when this 
 operation will be considered practicable in 
 more cases than 1 have enumerated, and 
 that the objections against its performance 
 will cease.' 
 
 John Bell, of Edinburgh, never per- 
 formed ovariotomy, but in his lectures 
 dwelt with peculiar force and pathos upon 
 the hopeless character of ovarian tumours 
 Avhen left alone, and upon the practicability 
 of removing them by operation. Ephraim 
 McDowell, a Virginian, and a student in 
 Edinburgh, attended Bell's course of lec- 
 tures in 1794. It is said of him by his 
 biographer, Gross, that he was ' enrap- 
 tured by the eloqi'.ence of his teacher ; 
 and the lessons which he imbibed were 
 not lost upon him after his return to his 
 native country. It is not improbable 
 that the young Kentuckian, Avhile listen- 
 ing to the teaching of the ardent and en- 
 thusiastic Scotchman, determined in his 
 own mind to extirpate the ovaries of the 
 first case that should present itself to him 
 after his return to his native country. The 
 subject had evidently made a strong im- 
 pression upon him, and had frequently 
 engaged his attention and reflection. He 
 had thoroughly studied the relations of 
 the pelvic viscera in their healthy and 
 diseased conditions, and felt fully per- 
 suaded of the practicability of removing 
 enlarged ovaries by a large incision through 
 the walls of the abdomen.' 
 
 McDowell returned to Kentucky in 
 1795, and commenced practice at once; 
 but it was not until 14 years afterwards 
 that he was consulted (in 1809) by 
 a patient upon whom he performed ova- 
 riotomy. 
 
 No one can dispute the validity of the 
 direct claim of McDowell as practically 
 the first successful ovariotomist. At the 
 same time it must be maintained, that 
 the still greater merit of pointing out 
 the absence of any physiological reasons 
 against the operation, the possibility of its 
 safe performance in the human female, and 
 the class of cases in which it ought to be 
 admissible, is due to the teaching of the 
 
 ' Hunters and of John Bell. But in this 
 I country, such is the sacredness of human 
 i life, even when threatened by fatal 
 disease ; so strong is the consciousness 
 that the introduction of innovations like 
 ovariotomy insures the destruction or 
 shortening of a certain number of lives 
 during the tentative stage of the practice, 
 that men even of the stamp of the Hunters 
 and Bell naturally shrank from the re- 
 sponsibility, imposed upon them by their 
 position and reputation, of adopting and 
 inaugurating it as a part of legitimate 
 surgery. And it must be remembered 
 that, at that time, the mortality from all 
 operations was much greater than it is 
 now ; that the diseased were more pas- 
 sively quiescent under their maladies and 
 less tolerant of any surgical suggestions, 
 just as we ourselves find to be the case 
 among the population of an outlying 
 agricultural district ; and that they were 
 not buoyed up, as modern women are,, 
 by the promises of painless extirpations 
 under chloroform or methylene. Every- 
 one looked upon the ending of the dis- 
 ease in death as a matter of course ; and 
 this led to stolid endurance and content- 
 ment with such relief as medicine and 
 tapping could afford. 
 
 But McDowell was a free man, in a 
 new country, clear from the conventional 
 trammels of old-world practice. He 
 found his patients in the most favourable 
 conditions of animal life, and seems to 
 have had one of those incomprehensible 
 runs of luck upon which a man's fate 
 and reputation so often turn if he has the 
 sagacity and energy to put such fortunate 
 accidents to good account ; and was 
 happy, as those usually are who can 
 afford or constrain themselves to wait, in 
 finding suitable time, place, persons, and 
 opportunity for working into fact the 
 notions of his tutor Bell. He lost 
 only the last of his first 5 cases of 
 ovariotomy, and thus, as it were, es- 
 tablished at the outset what until recently 
 was regarded as a satisfactory standard 
 of mortality for so serious an operation. 
 
 The details of his first operation, as 
 recorded by Gross, are interestinG; enough 
 lor repetition : 
 
 ' It Avas performed on J\Irs. Crawford, 
 of Kentucky, in December 1809. The 
 tumour inclined more to one side than the 
 other, and was so large as to induce her 
 professional attendant to believe that she 
 was in the last stage of pregnancy. She 
 
48 
 
 OVAELIN AND ALLIED TUMOURS 
 
 was affected with pains similar to those 
 of labour, from Avhich she could find no 
 relief. The wound was made on the left 
 side oE the median line, some distance 
 from the outer edge of the straight muscle, 
 and was inches in length. As soon 
 as the incision was completed, the intes- 
 tines rushed out upon the table ; and so 
 completely was the abdomen filled by the 
 tumour that they could not be replaced 
 during the operation, Avhich was finished 
 in 25 minutes. In consequence of its 
 great bulk, Dr. McDowell Avas obliged 
 to puncture it before it could be 
 removed. He then threw a ligature 
 round the Fallopian tube, near the uterus, 
 and cut through the attachments of the 
 morbid growth. The sac weighed 7^ 
 pounds, and contained 15 pounds of a 
 turbid, gelatinous - looking substance. 
 The edges of the wound being brought 
 together by the interrupted suture and 
 adhesive strips, the woman was placed 
 in bed and put upon the antiphlogis- 
 tic regimen. " In 5 days," says Dr. 
 McDowell, " I visited her, and, much 
 ■ to my astonishment, found [her engaged 
 in making up her bed. I gave her 
 particular caution for the future ; and in 
 25 days she returned home in good 
 health, which she continues to enjoy." 
 
 ' It will not be uninteresting here to 
 state that Mrs. Crawford, at the time of 
 the operation performed upon her by Dr. 
 McDowell, lived in Green County, Ken- 
 tucky, from whence she removed, some 
 time afterwards, to a settlement on the 
 "Wabash River, in Indiana, where she 
 died, March 30, 1841, in the 79th year of 
 her age. There was no return of her 
 disease, and she generally enjoyed excel- 
 lent health up to the period of her death. 
 She had no issue after the operation. 
 The youngest child, Mr. Thomas H. 
 Crawford, who has kindly communicated 
 to me these facts, was born in 1803, 
 nearly six years before the operation.' 
 
 McDowell, as a surgeon, was exceed- 
 ingly cautious, calm, and firm ■ paying 
 great attention to the details of his opera- 
 tions and treatment, and selecting and 
 drilling his assistants with much care. 
 Up to the time of his last sickness, he 
 -was one of the most active men in 
 Kentucky, and he died, literally, in har- 
 ness. 
 
 McDowell was buried in the cemetery 
 near the scene of his life-work, and in 
 1879 it was deemed a fitting thing to 
 
 perpetuate the world-wide association of 
 his name with ovariotomy by a granite 
 obelisk and some characteristic inscrip- 
 tions. 
 
 McDowell's case has long been con- 
 sidered the first ovariotomy on record ; 
 for the operation of L'Aumonier of Rouen, 
 in 177G — which Atlee, in his table, 
 enumerated as the first operation of ova- 
 riotomy — was in a case of pelvic abscess, 
 which he opened by an incision through 
 the wall of the abdomen above Poupart's 
 ligament, six or seven weeks after parturi- 
 tion. He seems also to have separated 
 the fimbria3 of the Fallopian tube from the 
 sac of the abscess, and to have removed 
 the ovary without any necessity, and 
 without any idea of ovariotomy. 
 
 Another case, included in some of the 
 tables of ovariotomy by Professor Dzondi, 
 is one in which a pelvic tumour was cured 
 by drawing out a cyst through an incision 
 in the abdominal wall of a boi/ 12 years 
 old. 
 
 Atlee, however (in the ' American 
 Journal of Medical Sciences,' 1849), 
 brought into notice an operation which 
 claims the priority to that of McDowell 
 by more than a century. It is the case of 
 Dr. Robert Hoiistoun, wRich may be 
 found in the ' Philosophical Transactions ' 
 (London, 1734), under the head, ' A 
 dropsy of the left ovary of a woman, 
 aged 53 years, cured by a large incision 
 made in the side of the abdomen.' From 
 this case it will appear that ovariotomy 
 originated with British surgery, on British 
 ground, inasmuch as though the operation 
 was not one of complete excision of the 
 tumour, it was planned with that inten- 
 tion. 
 
 Dr. Robert Hoiistoun operated, in 
 August 1701, near Glasgow, on a Mrs, 
 Margaret Miller, who since her last 
 confinement, 13 years before, when 
 23 years of age, suffered from ovarian 
 dropsy. She was much wasted, had 
 great diflficulty in breathing, want of 
 appetite and sleep, and bed-sores from 
 long confinement. The tumour had grown 
 to a monstrous bulk. This case is in many 
 respects a very curious one, and the opera- 
 tor's own words are worthy of record. 
 He says: 'After having obtained the 
 patient's consent that, in order effectually 
 to relieve her, I must lay open a great 
 part of her belly, and remove the cause 
 of all that swelling . . . I prepared Avith- 
 out loss of time what the place would 
 
THE RISE A^D PROGRESS OF OVARIOTOMY 
 
 49 
 
 allow, and with an imposthume lancet laid 
 open about an inch ; but finding nothing 
 issue, I enlarged it 2 inches ; but even 
 then nothing came forward but a little 
 thin yellowish serum, so I ventured to lay 
 open 2 inches more. I was not a little 
 startled, after so large an aperture, to find 
 it stopped only by a glutinous substance. 
 All my difficulty was to remove it. I 
 tried my probe — I endeavoured with my 
 fingers, but all was in vain ; it was so 
 slippery that it eluded every touch and 
 the strongest hold that I could take. I 
 wanted in this place almost everything 
 necessary, but bethought myself of a very 
 odd instrument, but as good as the best, 
 because it answered the end proposed. I 
 took a strong fir-splinter, Avrapped some 
 loose lint about the end of it, and thrust 
 it into the wound ; and by turning and 
 winding it, I drew out about 2 yards in 
 length of a substance thicker than any 
 jelly, or rather like glue that is fresh 
 made and hung out to dry ; the breadth 
 of it was above 10 inches. This was 
 followed by 9 full quarts of such matter 
 as I have met with in steatomatous 
 and atheromatous tumours, with several 
 hydatids of various sizes containing a 
 yellow serum, the least of them bigger 
 than an orange, with several large pieces 
 of membrane, which seemed to be parts 
 of the distended OA^ary. Then I squeezed 
 out all I could, and stitched up the wound 
 in 3 places, almost equidistant. The 
 lower part of the wound was kept open by 
 a small tent. Some serosity discharged 
 from it for 4 or 5 days. The Avound 
 Avas covered in its whole length Avith a 
 pledget spread Avith some home-made 
 balsam, over that several compresses 
 dipped in Avarm brandy, then several 
 tOAvels ; all these dressings Avere fastened 
 by swathing her round the body. An 
 anodyne Avas given several times a day. 
 The next morning the patient Avas found 
 much refreshed by a good night's rest, 
 the first she enjoyed for 3 months past. 
 After 3 Aveeks she was able to sit out- 
 doors, wrapped up in blankets, superin- 
 tendingherfarm-labourers. She recovered, 
 and lived in perfect health firom that time 
 till October 1717, Avhen she died after 10 
 days' illness.' 
 
 Although this isolated case undoubt- 
 edly strengthens the claim of British 
 surgery to the honour of originally at- 
 tempting ovariotomy, it will hardly de- 
 prive McDowell of his undeniable merit 
 
 of having been the firit Avho, guided 
 by scientific principles, enriched modern 
 surgery with the operation Avhich he per- 
 formed 13 times between 1809 and 
 his death in 1830. The precise number 
 of deaths cannot be ascertained ; but 
 of 8 cures there can be no doubt. 
 McDoAvell's successes Avere followed up 
 by other American surgeons. In 1822, 
 Mr. N. Smith, of Connecticut, remoA^ed a 
 cyst containing G pints of fluid, through 
 an incision 5 inches long. lie broke 
 down extensive adhesions betAveen the 
 tumour and the abdominal Avail and the 
 omentum. The Avound Avas united Ijy 
 means of adhesive plaster and roller. No 
 unfavourable symptom occurred until 
 the separation of the ligature, Avhen 
 an abscess formed, Avhich had to be 
 opened. The patient, 23 years of age, 
 was able to Avalk after 3 Aveeks, and 
 speedily recovered. In another case 
 Smith Avas unable to complete the opera- 
 tion on account of extensive adhesions.. 
 He emptied the cyst, and the patient 
 recovered. But the cyst filled again. 
 
 In 1823, G. Smith removed an OA^arian 
 tumour from a negress, through an in- 
 cision extending from the umbilicus to 
 the OS pubis, after having emptied the 
 contents of the cyst. The pedicle Avas 
 secured by a ligature. The patient re- 
 covered Avithin 25 days. 
 
 Lizars, of Edinburgh, Avas the first 
 to attempt ovariotomy in this country. 
 He performed 2 operations in 1825, of 
 Avhich the first was successful, the second 
 fatal in 56 hours. He opened the abdo- 
 men on 2 other occasions, but only to 
 prove errors of diagnosis. Both patients 
 recovered. 
 
 The first attempt to perform ovario- 
 tomy in London Avas made in 1827, by 
 Dr. Granville, who operated in 2 cases. 
 In one the operation was abandoned on 
 account of the extent of the adhesions ; 
 the Avoman recovered. In the other case 
 a fibrous tumour of the uterus, Aveighing 
 
 8 pounds, was removed ; but the patient 
 died on the third day. 
 
 The ill-success of Lizars and Gran- 
 ville, Avho both operated by the long 
 incision, brought discredit upon the 
 operation ; and it Avas not until 183G, 
 
 9 years after Granville's failures, that 
 a provincial surgeon, Jeafireson, of Fram- 
 lingham, acted upon the suggestion of 
 William Hunter,and performed ovariotomy 
 by the small incision for the first time 
 
 E 
 
50 
 
 OVARIAN AND ALLIED TUMOUES 
 
 in Great Britain. A bilocular cyst was 
 removed through an opening only an 
 inch and a half long. The patient 
 afterwards gave birth to 1 boy and 3 
 girls, and was alive in 1859, 5G years of 
 age. 
 
 In the same year (LS3G), another 
 provincial surgeon, Mr. King, of Sax- 
 mundham, successfully removed an ova- 
 rian cyst through an incision 3 inches 
 long ; and Mr. West, of Tonbridge, also 
 had a successi'ul case, the incision being 
 only 2 inches long. In 1838, Mr. 
 Crisp, of Harleston, removed a multi- 
 locular cyst through an incision only 1 
 inch long. The patient lived 15 years 
 after the operation, and enjoyed good 
 health. 
 
 In 1839, Mr. West, of Tonbridge, 
 had a second successful case ; a single 
 cyst, which contained 22 pints of fluid, 
 having been removed by the short in- 
 cision. Mr. West also had an imsuccess- 
 ful case of completed ovariotomy, and 
 one in which the adhesions prevented the 
 completion of the operation. In the same 
 year the first attempt to perform ovario- 
 tomy in a London hospital, of which I 
 have been able to find any record, was 
 made at Guy's, by Mr. Morgan. A small 
 incision Avas made, adhesions were found, 
 the tumour was not removed, and the 
 patient died in 24 hoiu-s. 
 
 In 1840, Benjamin Phillips ope- 
 rated at the Marylehone Infirmary, and 
 completed the operation for the first time 
 in London ; but the result was unsuc- 
 cessful. 
 
 In 1842, Dr. Clay, of Manchester, 
 commenced his series of operations, per- 
 forming ovariotomy 4 times, and in 3 
 out of the 4 with success. In 1843, 
 lie also operated 4 times, twice success- 
 luUy. In 1843, Aston Key removed 
 both ovaries from a patient in Guy's 
 Hospital. His incision extended from 
 the ensiform cartilage to the pubes, 
 and death followed on the 4th day. 
 Later in the same year, Bransby Cooper 
 operated in the same hospital by the long 
 incision, and removed a large midtilocular 
 cyst, but the patient died on the 7th 
 day. 
 
 So that 42 )-cars ago, although 
 ovariotomy had been performed with 
 success in 1 case in Scotland, and in at 
 least 10 cases by surgeons in our own 
 provinces, it had never been peribrmed 
 buccessfully in London. It was the good 
 
 fortune of Mr, Walne to perform the first 
 successful operation in London, in No- 
 vember 1842; and he had 2 other 
 successful ca.ses in May and September 
 1843. In that year, and in 1844, Dr. 
 Frederic Bird had 3, and Mr. Lane 
 2 successful cases. Mr. Lane's first 
 patient was still alive in 18G7, and had 
 7 children. In 1843 and 1845, Mr. 
 Southam, of Salford, and in 1845, Mr. 
 Dickson, of Shrewsbury, published suc- 
 cessful cases. In 1846, Mr. H. E. Burd 
 operated, his patient recovered, and had 
 a child 2 years after the operation. 
 
 In the same year Mr. Solly took ad- 
 vantage of an un.successful case which 
 occurred in his practice in St. Thomas's 
 Plospital to point out that retraction of 
 the pedicle behind the ligature is very 
 likely to occur and to lead to fatal 
 haBmorrhage, unless prevented by groat 
 care. His published lecture on this case 
 contains a masterly review of the argu- 
 ments for and against the operation, which 
 must have had considerable eff'ect upon 
 the mind of the profession at the time. 
 
 The year 184G is also noteworthy 
 in the history of ovariotomy. In the 
 month of September, Ctesar Hawkins per- 
 formed the operation for the first time 
 successfully in any London hospital. 
 Even now, after this long interval, with 
 all our accumulated experience, it is not 
 only interesting but useful to look back 
 upon this initial glimpse of success and 
 reopen the pages of the clinical lecture 
 Avhich was its record and commentary. 
 The cautioiis delibei-ation Avith which the 
 operation was decided upon, the attention 
 to all the maxims of scientific surgery 
 which went with every step of the work, 
 the skill and • precaution with wdiich it 
 was executed, and the judicious after- 
 treatment of the patient, all offered an 
 example for imitation as much as the 
 lecture furnished a lesson for study in the 
 exactitude of its details, the lucidity of 
 its expositions, and the judiciousness of 
 its advice. It was a simple case admir- 
 ably recorded. Mv. Hawkins did not 
 repeat the operation, and his example 
 was not much followed by othei's for 
 several years. Dr. F. Bird and IVIr. Lane 
 were the only operators in London, 
 exceiDt Dr. J^-otheroe Smith, Avho had 
 succes.sful cases. Dr. Clay continued his 
 operations at jNIanchester, and successful 
 cases were recorded by Dr. Elkington, 
 of Birmingham, and by Mr. Crouch, in 
 
THE RISE AND PROGRESS OF OVARIOTOMY 
 
 51 
 
 ]84:9, and by Mr. Cornish, of Tuunton, 
 and Mr. Day, of Walsall, in 1850. 
 
 In Ls5r3, Mr. Duffin inaugurated a 
 new era in ovariotomy, by raising the 
 ciUGstion of the danger of leaving the tied 
 end of the pedicle within the peritoneal 
 cavity, and by insisting upon the in:iport- 
 ance of keeping the strangulated stump 
 outside. He was brought to the resolution 
 of adopting this extra-peritoneal treat- 
 ment of the pedicle not by any accidental 
 necessity, but by ' reflecting on the 
 fatal termination caused, as it appeared to 
 him, on separation of the slough, by putre- 
 factive decomposition within the j^eri- 
 toneal cavity.' It suggested itself to him 
 that ' this latter consequence, as Avell as 
 the irritation caused by the ligature in 
 the abdomen, might be obviated by keep- 
 ing the tied portion completely out of 
 the cavity.' He determined, therefore, 
 to fix the end of the pedicle outside the 
 edges of the wound ; but in the only case 
 lie reported, he was obliged, to content 
 himself by stitching the cut extremity 
 iind. ligature in the wound. It answered 
 ■completely. The only objection was the 
 dragging of the abdominal wall towards 
 the spine ; biit no adhesions formed, and 
 the abdomen soon returned to its natural 
 Ibrm. 
 
 Whatever may be cur opinions and. 
 practice at the present time, and Avhatever 
 views we may hold upon the question 
 whether this extra-peritoneal treatment 
 of the pedicle has advanced or retarded 
 the success of the operation, Mr. DufEn's 
 arguments led to great changes and re- 
 sults — to the use of the clamp and to all 
 the modifications of treatment attendant 
 upon it, and ultimately to researches as to 
 the physiological and pathological phe- 
 nomena of ligatured stumps within the 
 peritoneal cavity, and to the study of the 
 important subject of drainage by Kceberle 
 and others. 
 
 Some German writers think that the 
 credit here given to Duffin should be 
 awarded to Stilling; because in 1841 he 
 published a case in which he sewed the 
 pedicle with a part of the cyst between 
 the lips of the wound in the abdominal 
 wall, after he had stopped the bleeding 
 by torsion, ligature, and the cautery. 
 But this can hardly be called a truly 
 extra-peritoneal treatment. It is more 
 like Avhat Langenbeck in 18.51 described 
 as ^Einnahen,' and Storer in 18G7 as 
 'pocketing the pedicle.' It was after 
 
 Duffin that Stilling adopted a complete 
 extra-peritoneal method by transfixing 
 the tied pedicle with a needle outside the 
 closed wound. Martin afterwards thus 
 far varied Stilling's method, sewing only 
 the peritoneal coat of the pedicle, instead 
 of the base of the tumour, to the abdomi- 
 nal wall. This question was first dis- 
 cussed in any work of authority by 
 Erichsen, in the first edition of his 
 ' Science and Art of Surgery,' published 
 in 1853. He haji then done the opera- 
 tion twice — one very successful case re- 
 lated in the woi-k, and one where the 
 operation was not completed. These 
 operations Avere performed in 1852. 
 
 I began work in London in 1853, and 
 in the following year joined what is now 
 called the Samaritan Hospital. At this 
 time I did nothing but out-patient work, 
 and in January 1855 went off to the 
 Crimea. But in the April before, I had 
 made my first acquaintance with ovario- 
 tomy. Baker Brown invited me to see 
 him operate, and I went with Mr. Nunn 
 and assisted him. It was his 8th case, 
 a dermoid cyst with adhesions, which 
 made the proceedings long and trouble- 
 some. Nine days after, the patient died 
 of what we can now recognise as 
 septicajmia. This so influenced Brown 
 that he only did one more case, and 
 that unsuccessfully, during the next four 
 years and a half, saying that ' it was 
 of no use, peritonitis would always beat 
 one.' I was not favourably impressed, 
 but had learnt how some of the great dif- 
 ficulties might be overcome so far as the 
 operation itself Avas concerned. Away 
 from England, in all the excitement of 
 Avar-surgery, of course the subject Avas at 
 rest. But after my return in 1856 I re- 
 sumed out-patient Avork in Orchard Street. 
 We did not often see cases of OA^arian 
 disease at that time, but they did appear 
 occasionally. As I have said, Bi-own had 
 given up the operation ; very few others 
 Avere attempting it, and most men Avere 
 lapsing into the old state of indifference, 
 if they Avere not loudly protesting against 
 it. During the autumn of 1857 a young 
 Avoman was under treatment for Avhat 
 appeared to be an ovarian tumour on the 
 left side. Opinions Avere confidently ex- 
 pressed that this could not be an OA^arian 
 tumour, because intestines could be 
 felt in front of it. But I determined 
 to see Avhat it Avas, and in December 
 1857, 27 years ago, I prepared for my 
 
 E 2 
 
O-i 
 
 OVARIAN AND ALLIED TUMOURS 
 
 first ovariotomj'. Reflecting upon all 
 the ways and forms of using the liga- 
 ture, I had resolved to use the ecraseur 
 for the division of the pedicle, as was done, 
 some months after the publication of my 
 suggestion, by Dr. John L. Atlee. We 
 cleared out the waiting-room, got a bed 
 there, and secured a nurse. As soon as I 
 opened the peritoneum, and it was proved 
 beyond all doubt that the tumour was 
 behind the intestines, I was induced very 
 unwillingly to close the Avound and do 
 nothing more. The patient recovered 
 without any bad symptom, but died 4 
 months afterwards in St. Bartholomew's 
 Hospital, when it was found that there was 
 a tumour of the left ovary, which might 
 have been removed quite easily. This 
 Avas not encouraging for a beginner, but 
 it attracted the notice of Mr. Bullen, of 
 the Lambeth Workhouse, and he offered 
 me a patient then in his in6rmary who 
 had been tapped 3 times in Guy's 
 Hospital and 4 times in Lambeth Work- 
 liouse, and had had iodine injected. 
 As she was willing to face any risk, I did 
 ovariotomy for her in February 1858. The 
 pedicle was treated by whipcord ligature, 
 the ends hanging out at the lower angle of 
 the wound after the fashion of Clay, Bird, 
 Brown, and the earlier ovariotomists. At 
 that time we had a house-surgeon, Mr. 
 Cooke, and greatly owing to his constant 
 care the poor girl recovered. She became 
 a nurse in the hospital, went into service, 
 then emigrated, and I heard of her in 
 18C8, married to the German overlooker 
 of a large estate in Queensland, whose 
 salary was 240/. a year. Had ovariotomy 
 not been performed, slie must have died 
 in 1858 a pauper in a workhouse. 
 
 Between this 1st case, in February 
 1858, and the 2nd in August of the 
 same year, we had removed to Scvmour 
 Street, where the hospital now is, and tlie 
 2nl operation was /done in one of the 
 rooms in Avhich 1 afterwards completed 
 the long series of 408 hospital cases. 
 
 The 3rd case was in the following 
 November, and haj^pily all the three 
 women recovered. Had tliey died, such 
 was ilie state of professional opinion at 
 tliat time, the progress of ovariotomy 
 might have been sadly retarded. 
 
 I lost my 4th ovariotomy without 
 l)eing able to account for the death. It 
 was the fir.st post-mortem I had occasion 
 to make. Dr. Aitken assisted me, and he 
 found that the hare-lip pins which I then 
 
 used as sutitres were bare on the inner 
 aspect of the abdominal wall, the cut edges 
 of the peritoneum were retracted, and a 
 portion of intestine was in contact witb 
 the wound, the impress of which was 
 obvious on the surface of the gut. Some 
 coagula of blood and an abundant con- 
 sistent lymph exudation tipon the peri- 
 toneal surface of the intestine corresponded 
 with the edges of the incision and the 
 sui-face of the wound. Recent lymphs 
 glued the opposing surfaces of the intes- 
 tines to each other. I saw at once how* 
 much better it might have been if t he- 
 peritoneal edges had been brought accu- 
 rately together, and thought of doing this 
 in my next case. But I found instruc- 
 tions in text-books and treatises carefully 
 to avoid the peritoneum. These doctrines 
 were at variance Avith the facts before my 
 eyes. Physiological principles had been 
 overlooked. I did not question them, but 
 now that an important practical question 
 Avas raised which bore distinctly upon the 
 failure of my operation, I determined to 
 put them to the test. I made experiments 
 upon dogs, rabbits, and guinea-pigs, for 
 Avhich I have been vilified, but for Avhicli 
 I do not reproach myself. The prepara- 
 tions Avhich I procured fi-om these animals 
 are still preserved in the Mu.seum of 
 the Royal College of Surgeons. They 
 corroborated Avhat Avas knoAvn Jjefore^ 
 that abdominal Avouuds Avell auj^J§ted 
 unite readily. This Avas not Avhat "t*- 
 Avanted. They proved more, and Avere 
 the visible, standing evidence Avhich I 
 did Avant, that though the other tissues 
 might be brought together, if the cut 
 edges of the peritoneum Avere left free, 
 they retracted,- direct union did not take 
 place, and secondary evil consequences 
 resulted. In the specimens Avhere the 
 divided edges or rather surfaces of jieri- 
 toneum have been pressed together, the 
 smooth serous inner coat of the abdominal 
 wall is perfectly restored. The stitches 
 cannot be seen on the inside, though 
 plainly visible on the skin, and there i.s- 
 no adhesion of intestine or omentum. 
 But in other specimens, Avhere the peri- 
 toneal edges Avere purposely excluded 
 from the sutures, and the animal Avas not 
 killed for a day or two, intestine or 
 omentum adheres to the inner surface of 
 the abdominal Avail, thus completing the 
 peritoneal sac at the great risk of intestinal 
 obstruction, to say nothing of a Avant of 
 firm union and subsequent ventral hernia. 
 
THE KISE AND PllOGRESS OF OVARIOTOMY 
 
 Without tills convincing demonstration in 
 my hands, I might have gone on for years 
 bowing to precepts and oblivious of prin- 
 ciples, sometimes taking up the peritoneum 
 and sometimes leaving it loose, with per- 
 plexity to myself and danger to my 
 pntients. But my lesson was learnt, and 
 I cannot too strongly inculcate it upon 
 'Others. When skin or mucous membrane 
 is divided, the edges must be brought 
 together to secure direct union. If they 
 be inverted, union is prevented. The 
 <jxact opposite holds good with serous 
 membranes. The edges should be in- 
 verted, and two surfaces of membrane 
 pressed together, so that the sutures are 
 not seen. The effused lymph then makes 
 so smooth a surface that even the line of 
 UQion cannot be seen. This appeared to 
 be good and promising work for 1859, 
 and 1 felt that I was announcing what was 
 indisputably true ; but, as often happens 
 at first, the fruits did not equal my ex- 
 pectations, for I had the misfortune to 
 lose 5 cases out of the 11 which I did 
 during the year, 3 in hospital and 2 in 
 private practice. 
 
 The translation in 1860 of Kiwisch's 
 Chapters on Diseases of the Ovaries by 
 ■Clay, of Birmingham, with the very valu- 
 able tables appended to the work, must be 
 regarded as greatly assisting in the pro- 
 gress of ovariotomy in this country. 
 Baker Brown's success with the cautery, 
 Tyler Smith's revival of the practice 
 ■of returning the pedicle Avith the ligature 
 around it, and the numerous published 
 cases of Hutchinson, Bryant, Murray, and 
 •other surgeons, all had their share in the 
 general result. 
 
 Within the next 5 years I completed 
 114 operations, and in 1864 published 
 my first book, which Avas a record of 
 •every case, Avith such commentaries as 
 the experience acquired and tlie dis- 
 cussions of the day seemed to make it 
 a duty to lay before the public. On 
 taking up this subject as a matter of 
 study and trial, just at the crisis Avhen 
 obloquy was the thickest and opposition 
 the strongest, I felt that nothing but the 
 most open frankness would carry con- 
 viction of success, or in case of failure 
 justify the operation. I was not uncon- 
 scious of the fact that, however much I 
 might devote myself to it as a professional 
 obligation, and as a response to a despair- 
 ing cry from a crowd of hopeless women, 
 it was looked upon as a surgical enter- 
 
 prise wliich had baffled otiiers, and from 
 which many had withdrawn discom- 
 fited. I therefore pledged myself to make 
 known tlirough the press all that I did 
 and all that befell me, and my book Avas 
 the formal redemption of that pledge, 
 gathering up as it did all the isolated 
 details of my practice, and the scattered 
 remarks published from time to time in 
 the journals. During this period of 5 
 years, and in treating, as it then seemed, 
 the long series of cases, nearly all the 
 questions of practical importance and 
 speculative interest came up for considera- 
 tion, and Avere rendered intensely pertinent 
 from the urgency of their actual applica- 
 tion. Up to the time of my beginning to 
 operate, there Avas but little concord among 
 my predecessors as to the mode of doing 
 the operation, and scarcely any reference 
 to scientific principles in choosing this or 
 that course. Ignorance of anajsthetics 
 had long kept so formidable a proceeding 
 out of the hands of all but the most daring 
 of surgeons, and out of the thoughts of any 
 but the most desperate of patients. But 
 noAV, in the calmness of ether and chloro- 
 form, and Avith the possibilities of the 
 older surgeons reduced to demonstrated 
 facts, attention began to be concentrated 
 upon details and accidents. Problems of 
 diagnosis, the means, as Hunter expressed 
 it, ' of knoAving beforehand that the cir- 
 cumstances Avould admit of such treatment,' 
 the relative safety of long or short inci- 
 sions, the mode of dealing Avith the pedicle, 
 the tolerance of the peritoneum, the best 
 Avay of closing the Avound, the real 
 value of opium in the after treatment, 
 the temperature and regimen to be ob- 
 served, the distinction between peritonitis 
 and reaction, the nature and cause of 
 septicaemia, and the after consequences of 
 the operation ; all these and other subjects, 
 affecting, by the Avay in Avhich they might 
 be decided, the results of ovariotomy, were 
 presenting themselves to the practitioner 
 and demanding his judgment. It Avould 
 have been absurd on my part to pretend 
 that I Avas arriving at absolute truth, or 
 to enunciate anything like un(]uestionable 
 maxims. But as facts accumulated, as I 
 became familiarised with difficulties, aAvare 
 of sources of danger, and learnt, either by 
 trial or from others, better modes of pro- 
 cedure, I formed opinions, acted upon 
 them, and offered them for criticism. 
 1 have often regretted that I failed to 
 become sooner acquainted with the 
 
o4 
 
 OVARIAN AND ALLIED TUMOURS 
 
 clinical lecture of Ca-sar Hawkins, whicli 
 would have cleared my "way through 
 some difficulties, and dissipated some 
 shadows which perplexed me. But on 
 reference to my volume of 18G4, it will 
 he seen that I soon came to the con- 
 clusion that it was a matter of no in- 
 superable difficulty to decide u-pon the 
 practicability of the operation, and that 
 an exploratory incision was a justifiable, 
 sometimes useful, and almost always a 
 harmless proceeding. With regard to the 
 incision, it wanted no magician to demon- 
 strate that length was a i-elative quantity, 
 that it would bs as stupid to make a cut 
 ten inches long for the extraction of a 
 tumour the size of a cricket-ball, as it 
 would be madness to try to drag a semi- 
 solid multilocular mass through Jeaffre- 
 son's minimum opening. I therefore 
 acted upon the rule of giving myself room 
 according to the size and solidity of the 
 tumour, keeping as near the safe medium 
 length as possible ; and when an opening 
 was too small for a large multilocular 
 tumour to pass through as it was, I 
 soon began to break down the interior 
 of the tumour with my hand, thiis render- 
 ing the operation easier, and insuring its 
 completion in many cases which Avould 
 formerly have been abandoned. 
 
 As to the pedicle there was more 
 hesitation. No one knew exactly what 
 should be done. I tied it and left the liga- 
 tures hanging out through the wound, as 
 others had advised. I tied it and let it 
 drop into the abdomen. I fixed it in the 
 wound with a ligature and pins. I secured 
 it outside the wound with a clamp. I 
 cauterised it and left it. I combined 
 the cautery and ligature. I made a 
 solitary essay with the ecraseur, and I 
 conjoined and modified most of these 
 procedures. Every plan had its special 
 difficulties and dangers, and one pecu- 
 liarity of all this tentative work was, that 
 it brought the disadvantages more con- 
 spicuously into view than the advantages. 
 It is impossible now, with the results of 
 the experience of more than five-and- 
 twenty years tabulated and criticised, 
 and practice running in two or three 
 ecjually approved grooves, for anyone to 
 form an idea of the perplexity which 
 formerly made every movement in advance 
 dubious. Circumstances sometimes took 
 away the groxmd of option, as when the 
 pedicle was too short to be l)ronght out 
 of the wound and clamped. But upon 
 
 the whole, in accordance with M'hat was 
 the then belief, that a tied pedicle, whether 
 inclosed or left to drain through an 
 aperture, must undergo the process of 
 gangrene and sloughing, the notion of 
 extra-peritoneal treatment was theoreti- 
 cally right; and it was this conviction, 
 together with some practical objections to 
 the ligature and cautery, that led me to 
 give the preference to fixation exter- 
 nally by the clamp. The greater part of 
 the pedicles during this section of my 
 operative work were treated in this way. 
 There were no statistics to judge by, but 
 I seemed to be doing better with it ; and 
 later on, when numbers augmented, they 
 proved that the mortality in clamp cases 
 Avas less than the general average, and 
 vastly lower than that given by the 
 ligature. It is true that the cases I did 
 with the cautery turned out well, but 
 they were few in number; and though 
 Baker Brown was concurrently doing 
 better still with it, I was not assured of 
 the fact at the time. Besides, it is not in 
 the nature of things that one man can 
 guarantee himself the same success as 
 another in adopting his practice, especially 
 when that practice is a matter of manipu- 
 lation. And further, I must admit such 
 a want of confidence in the efficacy of the 
 cautery as would have morally inca- 
 pacitated me from continuing the opera- 
 tion by such means. "Whether right or 
 wrong, then, the clamp gained its ascen- 
 dency and I continued to use it. It has 
 since been imputed to me that by so 
 doing I retarded the progress of ovario- 
 tomy, by deterring others from A^entur 
 ing upon an operation involving a mor- 
 tality of 1 in 4 or 5. It is easy to 
 make such reflections retrospectively, and 
 I can only retort that Avithout the leading 
 of the clamp and the support which the 
 clamp results gave to the trial of other 
 surgical expedients, some of those Avha 
 are the successful ovariotomists of to-day 
 would never have been ovariotomists at 
 all. 
 
 The primitive clamp was nothing more 
 than the carpenter's callipers. Mr. Hut- 
 chinson introduced them, and his first im- 
 provement was to make the handles mov- 
 able. IMy first attempt to improve upon 
 this instrument resulted in the manufacture 
 of two lencstrated blades, which were made 
 to exert parallel compression by a screw at 
 each end. After using this instrument for 
 some months I found it less easy of applica- 
 
THE RISE AND PROGRESS OF OVARIOTOMY 
 
 00 
 
 tion than the modified calliper clamp, and 
 I made some improvements in the latter. 
 I found the most trustworthy was that 
 suggested by KUchenmeister, of Dresden, 
 where oblique ridge and furrow on one 
 blade exactly meet the corresponding 
 elevations and depressions on the other. 
 If properly made, these surfaces, when 
 pressed together, will not allow a piece of 
 tine tissue paper to be drawn between 
 them. The straight instrument lying 
 awkwardly after application, and some- 
 times causing painl'ul pressure at its 
 angles, I had it ciu'ved and all the edges 
 carefully rounded off. I substituted I'or 
 handles a large pair of forceps made to fit 
 clamps of all sizes. "When well made this 
 instrument holds securely in most cases 
 Avherea clamp can be applied, but occasion- 
 ally the auxiliary aid of a ligature is neces- 
 sary ; for instance, if the pedicle be made 
 up partly by the thickened Fallopian 
 tube or utero-ovarian ligament, and partly 
 by thin membranous expansions of the 
 broad ligament running towards the colon 
 or CMCum, the clamp alone is not trust- 
 Avorthy. The thin part of the pedicle is 
 not compressed because the thicker parts 
 of the pedicle keep the blades too far 
 apart ; and after the cyst is cut away, the 
 thin portion of the pedicle is very apt to 
 slip inwards. I have seen very trouble- 
 some bleeding arise in this way, Avhich 
 might easily have been prevented if the 
 circular compression of a ligature had 
 been exerted before- the application of a 
 clamp. I attempted to make a circular 
 clamp, but I found that it would cut 
 through some pedicles just like scissors, 
 so that after a short trial I returned to 
 the use of the calliper clamp, with the 
 modifications which I have described. 
 The mode of applying the clamp will be 
 shown, when the various plans of dealing 
 Avith the pedicle are considered, in the 
 chapter on the operation. 
 
 The introduction of the extra-peri- 
 toneal treatment, as I have said, had 
 more to do with the fear of shutting up 
 putrefactive matter coming from the stran- 
 gulated pedicle than anything else. But 
 Ave all at that time had an exaggerated 
 fear of meddling Avitli the peritoneum. 
 No one had any clear notion of its toler- 
 ance of everything that Avas not in its 
 nature harmful. IMen Avho had cut it 
 open, torn through adhesions on its sur- 
 face, and left it exposed for perhaps half 
 an hour Avhile they Avere liberating a 
 
 tumour, Avere anxious to .shut it up her- 
 metically as .soon as they had finished. I 
 was not fir behind tlie ruling opinions, 
 and if anyone had a.sked mo Avhy I united 
 the Avound so closely round the pedicle, 
 he Avould have found the answer in 
 these Avords in my book : ' The fear is that 
 peritonitis may be set up by leaving any 
 opening.' It Avas a curious instance of 
 inconsistency, because in the very .same 
 page I advocate a free opening for the 
 exit of serum if any there should be. It 
 Avasa remnant of antique superstition, and 
 Ave liad not yet fully learnt to estimate the 
 eclecticism of the peritoneum. We soon, 
 however, found out that while a very little 
 fluid Avhich had no business to be there 
 irritated as much as a .sponge, Ave might 
 profitably reopen, Avash, cleanse and drain. 
 The step from this to making a free 
 passage through the vaginal Avail was 
 simple, and this I did in my .36tli 
 case, thereby saving the life of the patient, 
 AfterAvards I had to regret sometimes not 
 having done it Avith sufficient boldness, 
 and the process Avhich came to be called 
 the toilette of the peritoneum, both primary 
 and secondary, soon made progress, and 
 is noAV not the least efficient factor of the 
 general success of the operation. 
 
 Some of the surgeons Avho had operated 
 before me placed the patient in a .sitting 
 posture near the edge of the bed, Avith her 
 legs Avidely separated, her feet supported 
 on stools, and her back and head resting 
 on pillows. A fcAv do so still. I fol- 
 loAved this practice in my first three cases; 
 but it Avas so difficult to keep the patient 
 properly covered, she Avas so apt to become 
 faint under the influence of chloroform, 
 there Avas so much difficulty in preA'enting 
 the escape of the intestines, and in com- 
 pleting satisfactorily the various steps of 
 the operation, that I tried the recumbent 
 position in my fourth case, and I have 
 kept to it ever since. 
 
 Two common dressing-tables, placed 
 "P fashion, soon commended themselves as 
 better than a special table, and have 
 served me ever since. The recumbent 
 position is incontestably safer for the 
 patient as Avell as more conA'euient to the 
 surgeon, and I believe it is partly owing 
 to my adherence to it that through all my 
 operations I have never had any serious 
 trouble from fainting and collapse. 
 
 As Avith my experiments ou animals 
 so Avith my patients, I began closing the 
 Avound Avitli hare-lip pins, passing them 
 
56 
 
 OVAEIAN AND ALLIED TUMOURS 
 
 through the whole thickness of the abdo- 
 minal wall at intervals of an inch. Each 
 pin perforated the skin about an inch, and 
 the peritoneum about half an inch from 
 the incision on either side, so that when tlie 
 two opposed surfaces "were pressed together 
 upon the pin, the two layers of peritonetmi 
 ■were in contact with each other. But I 
 soon began to use and prefer sutures to 
 pins, and. tried different materials for this 
 purpose. jNIetallic sutures were then 
 in vogue, and in 18G1 I was trying 
 silver. In 18G2, remembering the in- 
 troduction of platinum sutures twenty 
 years before by Mr. Morgan at Guy's 
 Hospital, I used them for my SGth 
 case, to ascertain if any advantage Avould 
 arise from the employment of a metal 
 •which -would not oxidise like silver or 
 iron. But I have scarcely ever seen so 
 much suppiu'ation in the track of the 
 sutures as in this case ; and it taught me 
 to look to the size of the needle, the size 
 and smoothness of the thread or silk, the 
 tightness with -which it is tied, and the 
 time it is left, as having more to do with 
 suppuration or sloughing than the material 
 of which the sutiire is composed. 
 
 Later in the same year I made a series 
 of experiments -with various animal and 
 vegetable matter.-^, to ascertain their relative 
 value as sutures and ligatures, ending in 
 a conviction of the superiority of good 
 silk, well twisted, if tied tightly enough 
 to bring the edges of the wound together 
 accurately, yet not so tight as to strangu- 
 late the intervening tissues. Silk need 
 never be removed before the 7th day, 
 and may be left till the 9th or 10th, if 
 so desired, without any harm. The liict 
 that I have uniformly used only silk for 
 ligatures and sutures all through the 
 several stages of my gradually improving 
 results, shows that the material is of less 
 importance than the way of managing it. 
 It was not long after changing the pins for 
 sutures in fixing together the edges of the 
 wound that, finding there Avas a chance of 
 suppuration from their being left too long, 
 and wishing to ascertain how Poon they 
 could be removed with safety, I adopted 
 the plan of supporting the abdominal wall 
 with long straps of adhesive plaster, and 
 I still continue to use them and a simple 
 flannel bandage. 
 
 In looking over the notes of the period 
 about which 1 am now writing, it is curious 
 to mark the vagueness of all our notions as 
 to the import of certain symptoms and 
 
 conditions. Even such a point as the 
 difference between reaction and peritonitis 
 was not clear to every one. My 40tli 
 patient was a very yoimg woman, who, in 
 two years' time, had. been modelled by 
 her disease into the perfect type of an 
 ovarian martyr, and who rebounded into 
 health with a rapidity absolutely marvel- 
 lous when once relieved from her oppres- 
 sion. 
 
 ' At first the sudden removal of such a 
 strain seemed to be almost too much for 
 the system ; it seemed as if it were diffi- 
 cult for heart and lungs to play with even 
 balance under so much lighter a task — the 
 pulse was a little hurried, the face flushed, 
 the skin rather hot. But soon we had a 
 free perspiration, and all went well. Just 
 at this time I was a little amused by the 
 different views taken of the case by two 
 worthy friends of mine. Each observed 
 the same symptoms, but interpreted them 
 very difFerentl3\ One, more at home in the 
 dissecting-room and the dead-house than at 
 the bedside, began to speak ominously of 
 peritonitis, to suggest leeches and calomel 
 and opium, and seemed surprised at my 
 being content to let what I thought well 
 alone. My other friend, a true pathologist, 
 whose life had been passed in watching 
 and treating disease, saw nothing to alarm 
 him in the quickened pulse, the warm 
 skin, or the flushed, face ; he looked, 
 quite delighted, and exclaimed, "What 
 nice reaction ! " He exactly expressed 
 my own thoughts, and two small opiates 
 given during the night after the operation 
 to qiiiet pain, were the only medicines of 
 any kind Avhich this patient took during 
 her convalescence.' 
 
 Nor has her subseqiient career belied 
 the good augury of her vigorous recovery. 
 She maiTied and bore children, has buried 
 o husbands, and was in 1884 in good 
 health. 
 
 I have more than once had occasion 
 to refer to my 4th case, and I turn to 
 it again, because there is often much 
 practical good to be gained by sifting the 
 details, or dwelling on the history, of an 
 unfortunate event. I have said that I 
 did not know why my patient died, and 
 at the time that was quite true. In the 
 published table of cases the cause of death 
 was set down as septicaemia. This was 
 an after-thought. For what, in truth, did 
 any of us know about septicaBmia in 
 1859 ? One may judge how little it -was 
 by the way in which I expressed myself 
 
THE RISE AND PROGRESS OF OVARIOTOxMY 
 
 57 
 
 in a paper read, before the Medical and 
 Cliirurgical Society, the month after I had 
 operated. 
 
 I was asking the meeting to endeavour 
 to help me in estimating the share which 
 each o£ four agencies that I suggested had 
 in causing the deatli. I had my doubts 
 about the opium she had taken, for just 
 then it was the custom to use it very 
 freely. I suspected bleeding from tlie 
 pedicle, at the moment of removing the 
 tumour, might have done mischief. And 
 I was not disinclined to fortify myself 
 against self-reproach by calling to mind 
 the collapse which Simpson had so well 
 described as an accident peculiarly liable 
 to occur after operations about the pelvic 
 organs, and for which no sufficient ex- 
 planation has been offered. But I em- 
 phatically asked, ' Did she die from 
 peritonitis ? ' adding, ' Some Avho consider 
 the amount of lymph effused, and the 
 quantity of serum found in the peritoneal 
 cavity, would answer this question un- 
 hesitatingly in the affirmative. But I 
 ■doubt if simple peritonitis was sufficient 
 to cause such sudden collapse. It was 
 partial, confined to the visceral layer 
 opposed to the Avounded surface only, not 
 dipping down among the coils of intes- 
 tine. My impression is, that if peritonitis 
 killed her, it was indirectly, by the for- 
 mation of a morbid poison. The serum 
 was very acrid, it made Dr. Aitken's 
 hands smart for some time ; had he 
 wounded, himself, in all probability he 
 would have suffered from morbid poison- 
 ing. Had he attended a woman in labour, 
 in all probability tliat woman would have 
 had puerperal peritonitis. If, then, my 
 patient could generate a poison capable 
 of killing other people, may it not have 
 killed her ? It was probably formed 
 only from the inflamed portion of the 
 peritoneum, the other portion being quite 
 capable of absorbing rapidly.' Here then 
 was the idea of poison superadded to 
 that of peritonitis ; but the patient was 
 blamed for making it herself, and perhaps 
 fairly, as she had suffered from an eruj)- 
 tion of herpes on one side of the chest 
 only a feAv days before. But nothing 
 was as yet said about the likelihood of 
 its having been brought to her. Two 
 years later I had personal proof of what 
 this poison could do. I pricked myself 
 in examining the body of a patient who 
 died under similar circumstances, and I 
 was ill enough to make me say in writing 
 
 the report of the case : ' A poison which 
 affected me so severely in a small dose 
 might easily kill anyone in a larger dose. 
 I recovered after the absorption of a 
 fraction of a drop ; but the poor woman 
 was overpowered by the quantity taken 
 up by her own absorbents.' Here again 
 one part of the peritoneum was accused 
 of distilling and another part of absorbing 
 the venomous fluid. Now I thought I 
 had learnt a grand practical lesson, which 
 I reiterated in all that I wrote, that our 
 business was to let out this fluid as soon 
 as we saw signs of its collecting in the 
 peritoneal cavity ; either by opening the 
 wound or tapping by the vagina, or any 
 other means by which we could give it 
 exit. This policy of ejectment was very 
 well so far as it went, and without ques- 
 tion some lives were saved by it. But 
 it -was working at the wrong end of the 
 problem. Still the missing link in the 
 ratiocination of this subject was close at 
 hand. A parturient woman fulfilling one 
 of the natural functions of life could not, 
 except under the most abominable con- 
 ditions, be looked upon as a focus of 
 self- engendering poison. Yet she was 
 occasionally overtaken by puerperal peri- 
 tonitis, and the cry immediately Avas, 
 ' Where did it come from ? ' Importation 
 was the accepted explanation, and ac- 
 coucheurs fell into the category of ' sus- 
 pected persons.' I had now the clue in 
 my hand, and in less than a year it led 
 me to an understanding of my difficulties. 
 Two cases, my 74th and 75th, proved 
 fatal, and the surroundings were more 
 than suspicious. This led to the 
 exclusion of all midwifery practitioners 
 from my operations unless they could 
 present a clean bill of health ; and subse- 
 quently to the declaration, so much 
 quizzed, which Avas obligatory upon every 
 person Avishing to see my hospital cases. 
 Then followed other precautions, and I 
 Avas to be seen using carbolic acid and 
 the hyposulphites in my ovariotomy 
 Avards. 
 
 The famous asseveration and prophecy 
 of Sir James Paget before the meeting of 
 the British Medical Association in 1862, 
 ' that some of the deaths after surgical 
 operations Avere preventible, and that the 
 mortality icill be reduced if the members 
 of the association Avill decide that it shall 
 be,' Avere not Avithout influence. At the 
 Cambridge meeting in 1864, I treated 
 of hospital atmosphere, organic germs as 
 
oS 
 
 OVAFJAX AND ALLIED TUMOURS 
 
 causes of excessive mortality, and com- 
 mented on the researches of PoUi with 
 sulphur and the sulphites. Here then 
 were theory and practice brought into 
 accord, and my quarantine, spongings, 
 pads, "Nvool, drainage, vaginal tappings, and 
 chemical remedies combined the essentials 
 of antiseptic treatment. 
 
 The progress of ovariotomy in Eng- 
 land has thus been brought to the issue 
 of my first book at the end of the year 
 1864. It is a simple record of what I 
 did, of the oscillating opinions on many 
 points of practice, of the way in which 
 light dawned upon some of the obsciirities 
 of the subject, of the anxious unravelling 
 of some of the mixed threads of logic and 
 experiment which led to definite lines of 
 action, of the discussions, consultations, 
 and W'orkings with a great number of 
 estimable and accomplished men. As 
 none of my cases have since been so fully 
 described, it even now serves as a wreck- 
 chart and a guide. 
 
 During the seven years and a half 
 which succeeded, I completed 500 
 cases of ovariotomy, and in the au- 
 tumn of 1872 published my book on 
 ovarian disease. I still continued to do 
 the surgical Avork of the hospital, having 
 been all through assisted by a succession 
 of younger colleagues, among whom I 
 may mention especially Charles Ritchie, 
 Junker, and W. Thomson. The promis- 
 ing career of Ritchie, to my great regret, 
 was cut short by a melancholy accident, 
 and both Junker and Tliomson have seized 
 opportunities of distinguishing themselves 
 otherwise than as ovariotomists. It Avas 
 during this time that Dr. Richardson 
 brought to my notice methylene as an 
 anaesthetic, and Junker invented an ap- 
 paratus, for its convenient administration, 
 Avhich has been in use ever since. Chloro- 
 form liad been given from the first with 
 the exception of a few trials of ether and 
 other combinations, but it was quite 
 supjilanted by methylene. By its use we 
 have been spared the anxiety and danger, 
 and most of the annoyances which so often 
 attend the employmentof other anaesthetics. 
 
 The work of ovariotomy Avas noAv 
 becoming a matter of routine. Series of 
 hundreds succeeded to series of hundreds, 
 and Avith reguhu'ly diminishing losses. 
 Instruments v/ere new-modelled, and 
 there Avere modifications of manipulative 
 details and after-treatment, but Ave Avere 
 now acting upon principles Avhich kept us 
 
 pretty nearly in a given course, and made 
 the service of the sick-room compara- 
 tively easy. Dr. Bantock and Mr. 
 Thornton Avere installed as joint surgeons 
 Avith me in hospital, and not only took a 
 part in my operations, but commenced 
 their oAvn Avork as ovariotomists in IS?.") 
 or 1876. 
 
 The incident of Lister's arrival in 
 London in the year 1877 raised the 
 question of the applicability of his sys- 
 tem to ovariotomy. The mortality from 
 my OAvn hospital operations being at this 
 time not much more than 9 per cent., I 
 hesitated about venturing upon any un- 
 tried proceedings Avhich might interfere 
 Avith results so satisfactory. But jNIr. 
 Thornton introduced Listerian practice 
 in all its integrity at the Samaritan, 
 and Dr. Bantock for a time folloAved his 
 example. Some other novelties, such as 
 Dr. Bantock's non-alcoholic after-treat- 
 ment and Mr. Thornton's ice-cap a little 
 diversified the routine of our Avards. 
 
 After 20 years' service as ope- 
 rating surgeon to the Samaritan Hospital 
 I felt myself not only Avarranted in re- 
 tiring, but bound to make Avay for my 
 junior colleagues, and at the end of the 
 year 1877 placed my resignation in the 
 hands of the committee. At their re- 
 quest, hoAvever, I retained the post of 
 consulting suigeon. My last ovariotomy 
 as surgeon to the hospital Avas done on 
 December 12, and after it I made a few 
 remarks to those present, giving a sum- 
 mary of my Avork in these cases. The 
 following table shoAved the distribution of 
 my hospital operations over these 20 years: 
 
 Years 
 
 Cases 
 
 Recoveries 
 3 
 
 Deaths 
 
 1858 
 
 3 
 
 
 
 1859 
 
 G 
 
 4 
 
 2 
 
 1 8<)0 
 
 2 
 
 1 
 
 1 
 
 18fil 
 
 G 
 
 ;j 
 
 3 
 
 ISC. 2 
 
 1.3 
 
 10 
 
 3 
 
 lK(;;j 
 
 IG 
 
 11 
 
 5 
 
 1SG4 
 
 14 
 
 11 
 
 3 
 
 1865 
 
 17 
 
 13 
 
 4 
 
 18G6 
 
 15 
 
 10 
 
 5 
 
 1H67 
 
 '21 
 
 17 
 
 4 
 
 ISGS 
 
 t\2 
 
 25 
 
 7 
 
 ]8G'.) 
 
 21 
 
 14 
 
 7 
 
 1870 
 
 24 
 
 17 
 
 7 
 
 1.S71 
 
 2G 
 
 18 
 
 ,s 
 
 1872 
 
 30 
 
 23 
 
 7 
 
 1873 
 
 Hi 
 
 115 
 
 9 
 
 1874 
 
 29 
 
 20 
 
 9 
 
 187.") 
 
 28 
 
 20 
 
 8 
 
 187G 
 
 42 
 
 o8 
 
 4 
 
 1877 
 
 29 
 
 26 
 
 3 
 
 Total . 
 
 408 
 
 309 
 
 99 
 
 
 ' 
 
 
 - '' 
 
THE PJSE AND PllOGRESS OF OVAEIOTOMY 
 
 59 
 
 Another table, dividing the 20 years 
 into 4 successive periods of 5 years 
 each, gives at once tlie number of cases, 
 the nuinlier of deaths, and the percentage 
 of recoveries : 
 
 Dates of Comi-letion of tiik successive 
 
 HLNI)Ur,DS OF OVAUIOTOMY OpKKATIOXS 
 FIIOM IHoS TO 1880 
 
 Series of years 
 
 First five years (1858 
 
 to 18G2) .... 
 Seconrl five years(18G3 
 
 to l«(i7) .... 
 Third five years (18G8 
 
 to I.S7-2) . . . . 
 Fourth live years (187o 
 
 to 1877) . . . . 
 
 Total . . . . 
 
 Last two vears (1.S7G 
 and 187/) , . . . 
 
 Cases 
 
 Is 
 
 
 p 
 
 30 
 
 9 
 
 83 
 
 21 
 
 133 
 
 3G 
 
 102 
 
 33 
 
 99 
 
 408 
 
 71 
 
 7 
 
 llccovcries 
 
 70 per cent. 
 74 „ 
 73 „ 
 80 „ 
 
 90 
 
 It appears from this that in the — 
 
 about 1 in 3 died 
 ,, 1 „ 4 „ 
 „ 1 „ 5 „ 
 „ 1 „ 10 „ 
 
 First 5 years 
 
 Second and third 5 years 
 
 Fourth 5 years 
 
 Last 2 years 
 
 A moment's consideration of these 
 figures, showing the changing proportion 
 between recoveries and deaths as time 
 went on, will carry the conviction that 
 increasing experience had been accom- 
 panied by diminishing mortality ; and 
 enabled me in the last years of my prac- 
 tice in the hospital, Avith a return of 
 90 per cent, of recoveries after operation, 
 to set up a standard of success far beyond 
 what we had reason to hope for under the 
 conditions of a London institution. The 
 way in which, my successors have carried 
 on the operative work justifies the course 
 I took in leaving it in their hands, and 
 makes it clear that the patients have no 
 cause to regret the change. 
 
 The four years from 1878 to 1881 
 were memorable to me for two reasons : 
 that during them I completed 1,000 
 cases of ovariotomy ; and that I took up 
 the antiseptic system adopted elscAvhere, 
 so as to judge by my own experience, not 
 of its general scientific claims, but of the 
 utility of the Lister spray and dressings 
 in abdominal surgery. 
 
 My exclusively private practice began 
 January 1878 with the 888th case, and 
 in the month of June 1880 the number 
 of 1,000 cases was made good. The 
 table which I annex notes in detail the 
 times in Avhich the several series of hun- 
 dreds were accumulated and other mat- 
 ters connected Avitli them which have a 
 statistical interest. 
 
 No. 
 
 Dates 
 
 1 From Feb. 1S58 to .Tune 1864 
 
 2 „ June 1 8G1 „ Mar. 1867 
 
 3 „ Mar. 18U7 ,, .Jan. 1869 
 
 4 I ., Jan. 18G9 „ Dee. 1870 
 .o! „ Dec. 1870 „ June 1872 
 G I „ June 1872 „ Jan. 1874 
 
 7 1 „ Jan. 1874 „ Apr. 1875 
 
 8 ., Apr. I.s7r) „ Oct. 187G 
 
 9 „ Oct. 187(1 „ June 1><78 
 10 „ June 1878,, June 1880 
 
 B 
 
 100 
 100 
 100 
 100 
 100 
 100 
 100 
 100 
 100 
 100 
 
 768 232 i 1,000 
 
 General mortality, 23-2 per cent. ; largest 34, 
 smallest 11. 
 
 The Avhole time occupied was 22 years and 5 
 months. 
 
 Before touching upon the question of 
 what influence the so-called ' antiseptic 
 precautions ' or details of the Listerian 
 method have had upon my results, I 
 Avill explain to what extent their adop- 
 tion Avas an addition to my previous 
 practice. 
 
 Long before Lister had tried any 
 of his methods, indeed from the very- 
 beginning of my practice of ovariotomy, 
 I had insisted upon all possible care in 
 protecting patients before, during, and 
 after operation from all the known causes 
 of excessive mortality ; and I took un- 
 usual precautions against any risk of 
 contagioxis or infectious disease being 
 communicated to a patient, and against 
 the entrance from without, or the develop- 
 ment from Avithin, of anything Avhich 
 could set up traumatic fever or blood- 
 poisoning. I contended that obstetrics 
 and operative surgery should seldom be 
 permitted in the same building, or by 
 the same surgeon in private practice ; and 
 that such an operation as ovariotomy 
 should never be performed Avhere patients 
 with uterine cancer, or offensive dis- 
 charges of any kind, may pollute the 
 place. Li 1875, a separate branch of the 
 Samaritan Hospital Avas opened, and since 
 that year the surgical Avards have been 
 much freer from such sources of danger. 
 The good effects of this change Avere 
 noted before other antiseptic measures Avere 
 insisted on, and to such an extent that 
 the death rate after my operations Avas 
 reduced by one- half. And cleansing or 
 purification of the Avard or room, of 
 everything about the operating table and 
 
60 
 
 OVARIAN AXD ALLIED TUMOURS 
 
 bedding, of the patient herself and the 
 parts near the seat of operation, of the 
 surgeon, assistants, and nurses, and of all 
 the instruments, sponges, and water used, 
 had been rigidly enforced, before carbolic 
 acid was used, or any antiseptic precavition 
 added to those adopted before 1878. 
 
 As the material for tying vessels and 
 limiting the Avound, the same pure twisted 
 silk, unmixed with any vegetable fibre, 
 which I have trusted to for about 20 
 years has been used. Various forms of 
 quilled and twisted sutures have been 
 tried and abandoned. But since 1878, 
 all the silk for ligatures and sutures has 
 been soaked before use in a 5 per cent, 
 solution of carbolic acid or phenol. I 
 have not always boiled the silk, as Bill- 
 roth and others have done. 
 
 Dry dressing of the wound has been 
 continued ; but in place of the pads 
 formerly used, of 5 per cent, of oil of tar 
 •vrith 95 per cent, of chalk, either thymol 
 or iodoform gauze, or cotton pads charged 
 with borax or phenol, have been used. 
 These are more comfortable to the pa- 
 tient, and are better absorbents of mois- 
 ture. As a rule they are not touched 
 before the seventh or eighth day, when 
 the sutures are removed, and the wound 
 is almost invariably found to be com- 
 pletely united. 
 
 The two most important additions to 
 previous antiseptic precautions are, first, 
 ■carbolising the sponges and instruments, 
 and secondly, the use of the spray. I 
 had long insisted on the great import- 
 ance of always using sponges perfectly 
 purified Avith sulphurous acid ; and after 
 <in operation I continue my old plan of 
 keeping the cleansed sponges in a weak 
 solution of sulphurous acid. And during 
 the operation, in addition to washing in 
 jmre Avater, every sponge before iise is 
 •wetted Avith a 2 to 3 per cent, solution of 
 •carbolic acid or absolute phenol. Soft 
 clean linen cloths, Avetted with a Avarm 
 solution of phenol, may be used to lessen 
 the number of sponges required ; and 
 (nurses must be cautioned not to put any 
 •of the soiled sponges into the solution 
 imtil after they have been washed Avith 
 pure Avater, otlierwise albumen may be so 
 ■coagulated as to prevent thorough cleans- 
 iog. As nurses often fall into this eri'or, 
 it is well to have two or three difierent 
 sets of sponges, all carefully numbered, 
 (kept separate for the successive steps of 
 the operation. 
 
 Nearly all my instruments used in 
 ovariotomy are protected from rust by a 
 coating of nickel. They are then more 
 easily and thoroughly cleaned after use, 
 and the cleaned instruments should be 
 placed before, and replaced during the 
 operation, in trays or dishes filled with a 
 Avarm solution of phenol. 
 
 These additional precautions as to 
 sponges, silk, and instruments, I believe 
 to be really important. I have been 
 always doubtful about the spray. ' Striv- 
 ing to better, oft Ave mar Avhat's Avelh' 
 In prolonged operations, I have had reason 
 to fear that its chilling effect upon the 
 patients has been injurious. But I have 
 never once seen any other ill effect Avhich 
 I could attribute to it, nor anything like 
 carbolic poisoning. The misty cloud 
 occasionally obscures the field of opera- 
 tion, but not to an}' serious extent, and it 
 is always easy to protect the peritoneal 
 cavity against the continued action of the 
 spray by a large Avarm sponge. After a 
 foAv trials I gave up thymol spray as use- 
 less, and for more than four years past 
 have used a spray of absolute phenol of 
 a strength of one in forty. This I con- 
 tinue to use, belieA'ing it to be safer than 
 the irrigation or sponging proposed as 
 substitutes. We require a far greater 
 number of trustworthy experiments, or 
 of comparative observations, made under 
 similar conditions with and Avithout spray, 
 than have yet been made knoAvn, before 
 Ave can receive any satisfactory ansAver to 
 the questions Avh ether carbolised A-apour 
 or air can destroy or render innocuous 
 infective or putrefactive substances or 
 germs floating in the air ; or what is the 
 share Avhich the spray, among other addi- 
 tional antiseptic precautions, has had in 
 obtaining the better results Avhich have 
 undoubtedly accompanied their combined 
 employment. 
 
 The only modification in the mode of 
 operation Avhich calls for further remark 
 is the very much more frequent, almost 
 constant, employment of the intra-'peTi- 
 toneal treatment of the pedicle since the 
 trial of the antiseptic system Avas begun. 
 For several years, the extra-peritoneal 
 treatment Avas by far the more success- 
 ful in my practice. When comparing 
 the results of the two methods at the 
 College of Surgeons in June 1878, I 
 shoAved that of 027 e.r^ra-peritoneal cases, 
 130 had died, or 2073 per cent., while of 
 157 t«<ra- peritoneal cases, GO died, or 
 
THE RISE AND PROGRESS OF OVARIOTOMY 
 
 61 
 
 3S'2 per cent., the mortality with the ! 
 ligature having been nearly double that ! 
 with the clamp. Latterly this disparity 1 
 disappeared, and the results from the two 
 modes of treating the pedicle were about ' 
 equal. I am quite sure that, as has been ! 
 suggested, the f.r^/'a-peritoneal did not : 
 represent the simple, and the infra- \ 
 peritoneal the complicated, cases. The i 
 difference was simply that of long or ' 
 short pedicle. Whenever the pedicle was 
 long enough, I used to employ a clamp 
 whatever might be the complications of 
 the case ; and in short pedicles I used the '• 
 ligature or cautery, Avhether the case was 
 otherwise simple or the reverse. Before 
 antiseptic treatment was generally fol- 
 lowed, septic changes, which are now 
 scarcely ever observed, frequently took 
 place in or about the tied pedicle. Since 
 the additional antiseptic precautions have 
 been adopted the many disadvantages of 
 the ea;/ra-peritoneal method, Avhich were 
 only counterbalanced as long as greater 
 success lasted, have no longer to be 
 endured. 
 
 Another great gain from the anti- 
 septic system is that drainage of the 
 peritoneal cavity is now scarcely ever 
 necessary. In the paper which I brought 
 before the Medical and Chirurgical So- 
 ciety in 1876 on completing 800 cases, I 
 contended that drainage should only be 
 an exceptional practice. But I did not then 
 imagine that it could be almost entirely 
 discarded. I can now say that I have not 
 di-ained one case in which antiseptic pre- 
 cautions have been taken ; and on look- 
 ing back, I cannot believe that there are 
 more than two or three in which, if a 
 drainage tube had been used, it could 
 have been useful. The simple explana- 
 tion is, that the mixture of blood, other 
 fluids and air left in the peritoneal 
 cavity, or oozing into it after operation, 
 formerly went through putrefactive 
 changes, and if not drained off produced 
 septictemia, whereas now no putrefaction 
 takes place, and absorption is quite 
 harmless. 
 
 I now come to the question of results. 
 The great hindrance to the success of the 
 operation was, in 1878, the same as it 
 had been 20 years before, when B. Brown 
 quailed before what he called peritonitis, 
 but which we have since learned was really 
 the frequent occurrence of blood poison- 
 ing. The difference in respect to this 
 matter was that that which formerly scared 
 
 us as an incomprehensible mystery, was by 
 1878 in a great measure understood. We 
 began to see what septicajmia meant, and 
 how it reached our patients. Various pre- 
 cautions had bettered the situation, but 
 the evil Avas still formidable. This Avili 
 be seen by looking at my returns for the 
 years 187G-77. In those 2 years I did 
 152 operations, including both hospital and 
 private patients, and had 29 deaths. This 
 gives a mortality of 18"4. But of those 
 29 deaths, only 5 were accidents of the 
 operation which we may in some pro- 
 portion be sure or encountering, such as 
 haemorrhage, shock or cancer. So that 
 20 years' experience may fairly be said 
 to have reduced the mortality of the 
 operation upon my uncontaminated pa- 
 tients to 3 "6 per cent. The remaining 
 24 deaths were caused by septicaemia, a 
 mortality of 15"8 per cent. 71 of these 
 152 patients were in the hospital. Of 
 these, 7 died, all from septicaemia. There 
 were no deaths among them really attri- 
 butable to the operation. All were from 
 contagion, and but for that would have 
 recovered. Among my 81 private cases 
 during the same time, 5 deaths were 
 more or less directly connected with the 
 operation, and 17 were from communi- 
 cated septicajmia. This shows how the 
 success of ovariotomy was marred at that 
 time by the great evil which till then 
 had persistently attended it. Still as an 
 operation which, when done, either failed 
 to save life, or was fatal to the extent 
 of 18'4< per cent., ovariotomy was worth 
 doing. But when I could show by my 
 experience that the operation could be 
 done on patients, if screened from the 
 effect of contagion, with a loss of only froni 
 3 to 4 per cent., it became an imperative 
 obligation to seek out some means of giving 
 patients all the benefit of further antiseptic 
 measures. The microbe to which, either 
 as spore or vibrio, septicaemia had been 
 experimentally traced, was like any other 
 beast of prey, to be exterminated or held 
 in subjection. These infinitely small beings, 
 existing everywhere, and multiplying with 
 ' a rapidity which defies calculation, could 
 ; not be dealt with like wolves or poisonous 
 ; reptiles. That was out of the question, 
 and the alternative was, if possible, to- 
 ; prevent their access to our patients ; or,. 
 j failing on that point, to put our patients= 
 in such a condition that they did not afford 
 I a nidus favourable for multiplication. The 
 • mature vibrios offered no great difficulties^ 
 
62 
 
 OVARIAN AND ALLIED TUMOURS 
 
 They are anaerobic, and will not live either 
 in air or acid. But the spores are aerobic, 
 ■with a much stronger vitality, and may 
 be looked upon as the arch-enemy. By 
 force of circumstances ^ye are obliged to 
 pass over the point of defence from in- 
 vasion, and to restrict our efforts to the 
 accumulation of all hindrances to de- 
 velopment in the body to which they find 
 access. Pasteur had already indicated, in 
 a general way, what shovild be done with 
 the sick and all that pertains to them. 
 Lister presented to us his system as effi- 
 cient, and, as I have shown, I have now 
 for 7 years adopted all that he sug- 
 gested, in addition to my own habitual pre- 
 cautions. I have used the carbolic spray ; 
 but I have never attached much import- 
 ance to it, except that it tends to general 
 cleanliness, and may sometimes carry its 
 influence into parts which would other- 
 wise be overlooked or inaccessible, so 
 as to prevent the formation of suitable 
 niduses for the propagation of the spores 
 of the septic microbe. I have systema- 
 tically passed everything used in the 
 operations through the carbolic solution, 
 have used it for myself and assistants, 
 and have as much as possible enforced 
 washings with it upon the nurses. 
 
 The dressings of carbolic or thymol 
 gauze, and boracic wool, have proved satis- 
 factorv, as well as convenient, and latterly 
 salicylic wool has been pat on in abund- 
 ance. Every antiseptic principle has been 
 kept in view during the after-treatment. 
 There may have been some shortcomings 
 in the details of my Listerian work, ac- 
 cording to the notions of a few enthusiasts ; 
 but upon the whole it has been as practi- 
 cally complete as it is in the power of any 
 surgeon not a mere dilettante to make it. 
 What has happened in these 7 years is 
 satisfactory; but how far it can be called 
 the result of antiseptic treatment, and how 
 much is due to other coincident changes, 
 must always remain uncertain. The lacts, 
 however, are these. From January 1878 
 to the end of 1884, in private practice 
 only, I have completed ovariotomy in 247 
 cases, with a loss of 27 patients, making a I 
 mortality of 109 per cent. If I compare 
 these figures with those of my last 2 
 years of hospital work, it would seem that 
 no change of importance had taken place, 
 that ovariotomy could be done as success- ' 
 fully without as with antiseptic'*, since the 
 difference of 1 per cent, in the mortality j 
 might be accidental. But if I take the , 
 
 ' whole 152 cases in the years 1876-77, 
 with their mortality of 18'4 per cent., and 
 place them against my 247 subsequent 
 j cases, there comes out at once a change 
 for the better of more than 7 per cent, in 
 the result. This is soraething, but it might 
 be accounted for otherwise than by anti- 
 septic influences. Then if I go still further, 
 and make it a question of relative mor- 
 tality from contagion ; if I investigate not 
 only the fact of death, but the cause of 
 death, the question assumes another aspect. 
 In the 2 years 1876-77. out of 29 deaths, 
 there were 24 from septica3raia, whereas in 
 the 7 following years, out of 27 deaths, 
 only 10 could be placed to that cause. 
 Here we seem to have proved that anti- 
 septics had done a great deal ; for if the 
 old ratio of septicajmia had continued, 
 namely, in the proportion of 1 case of 
 death from it after every 6 operations, I 
 ought to have seen, in the following 7 
 years, among my 247 operations, at least 
 40 cases of septicaemia. Again, if I ab- 
 stract the 7 hospital cases, and calculate 
 only on the 17 which happened among 
 the 81 private cases in 1876-77, the 
 number of cases which would have 
 occurred in the following 7 years, in 
 the same proportion, would have been 49 
 or 50. That is to say, I had passed 7 
 years, and done 247 operations with a mor- 
 tality from septicaemia of only 10 cases, 
 instead of the 50 which I should have had 
 to deal with if the proportion of 1876-77 
 had been kept up. 
 
 If there were no other points to be 
 considered besides those involved in mere 
 figures, a difference of mortality to this 
 extent would be decisive, and I am ready 
 to admit that the Listerian additions to 
 my precautions have been in many respects 
 eminently serviceable. I am further con- 
 vinced that by the use of antiseptics, espe- 
 cially of phenol, those patients who have 
 recovered have suffered much less from 
 fever, Avhile convalescence has been more 
 rapid than it used to be. Formerly tem- 
 peratures of 100"^ to lOo'' were usual, and 
 104° to 107° not very uncommon. And 
 the head was cooled by ice in at least half 
 the cases. Now cold to the head is scarcely 
 ever thought of, certainly not used in 1 
 case in 20, and a temperature of 102° is 
 rare. Recovery Avith a temperature which 
 never ri.ses above 100° is the rule. This 
 alone is an important step in advance, 
 especially as it affects the well-being of a 
 great majority of the patients, and for those 
 
THE RISE AND PROGRESS OF OVARIOTOMY 
 
 63 
 
 in hospitals lessens considerably the cost 
 of their maintenance. I have never felt 
 any inconvenience myself, nor have I seen 
 any of my patients suffer from carbolic 
 poisoning. Still as other surgeons have en- 
 countered that double objection, it must 
 be taken into account, as well as the de- 
 pressing influence of the cold spray on a 
 sick woman prostrated by anesthetics, and 
 the inconvenience caused by its inter- 
 ference with light. We may, however, 
 give up the spray without abandoning the 
 principle of Listerism, or the most impor- 
 tant details of the practice. So far as the 
 operation itself is concerned, independent 
 of its giving access to microbes or their 
 spores, I do not sec that Listerism can 
 have much influence. It does not render 
 the manipulation either more or less diffi- 
 cult, nor does it in any way diminish the 
 chance of the accidents common to all 
 capital operations. But with regard to 
 septicPemia, even though we cannot pro- 
 portion the effect of the coincident causes, 
 the diminution which I have recorded as 
 having taken place in my last 7 years' ex- 
 perience is a most happy result. 
 
 Much may be due to antiseptic dress- 
 ings, and to the persistent diffusion of an 
 antiseptic atmosphere ; but it must be 
 remembered that, at the same time, my 
 patients since 1878 have all had not only 
 the advantages belonging to a position in 
 life above that of hospital cases, but they 
 have been exempt from the risks of the 
 possible importation of hospital contagion. 
 The abandonment of the clamp, and the 
 use of the ligature with the intra-peri- 
 toneal treatment of the pedicle, took place 
 at the same time as the introduction of 
 the antiseptic treatment; and since 1878 
 I have never put a drainage tube into any 
 peritoneal cavity. Then, too, as an addi- 
 tional security to my patients, I have 
 never made a post-mortem examination, 
 have been free from all but the most 
 casual contact witli hospital influences, 
 have never carried about Avith me the 
 infections picked up in general practice, 
 and having had fewer persons present 
 at my operations, have eliminated a great 
 part of an incalculable soiirce of danger. 
 Still after all, this plngue of abdominal 
 surgery is not abolished, and Listerism 
 has not l:>rought me to the point of seeing 
 no deaths from septicajmia. There yet 
 remains a contingent mortality of 4 per 
 cent, from septicaBmia which must be got 
 rid of, and carbolic acid does not seem 
 
 likely to do it. These microbes all have 
 their peculiarities, and perish or flourish 
 under the most unexpected conditions. 
 What Ave Avant now to knoAV is, the agent 
 we can employ in surgery Avhich is lethal 
 to the microbe or spore of septicaemia, 
 and not injurious to patient or surgeon. 
 Or can Ave look to tlie possibility of 
 protective inoculation Avith an attenuated 
 virus ? 
 
 Resuming our survey of the history 
 and progress of ovariotomy since its 
 revival in Great Britain, I must refer to 
 a letter ivritten by Dr. Keith on Decem- 
 ber 17, I.S.S4, in which he informs me 
 that his number of ovariotomy cases Avas 
 then 490. Of these 4.5 died, showing a 
 death rate of 911 per cent. 
 
 Dr. Keith adds that his son has 
 had 37 ovariotomies Avith only 1 
 death ; and I most cordially AAish him 
 the same increasing success that has re- 
 Avarded the skill and judgment of his 
 father. 
 
 We have now to folloAv the advance 
 of the operation in France, Belgium, 
 Germany, Russia, Italy, and Spain, and 
 in America and our colonies, although 
 any such revicAV must necessarily be brief 
 and imperfect. 
 
 In France, ovariotomy made but 
 tardy progress. Nor was this to be Avon- 
 dered at, Avhen Ave find a man like Vel- 
 peau opposing it in 1847 ; and that, not- 
 Avithstanding Cazeaux's spirited and ener- 
 getic advocacy, the Academic de Medicine 
 condemned it in 1856. A paper by Dr. 
 Worms, in 1860, had hoAvever a better 
 result. Dr. Worms's paper Avas founded 
 upon an examination of some of my 
 OAvn early cases. He took the precau- 
 tion of writing to the medical attendants 
 of the patients, in order to ascertain 
 their condition from the time of opera- 
 tion up to the date of his paper, and this 
 able advocacy attracted very general 
 attention in France. Perhaps its most 
 important effect was to induce M. 
 Nelaton to visit England for the pur- 
 pose of Avitnessing the operation, and 
 studying its details. He Avas here in 
 1862, and Avitnessed several operations. 
 He assisted me at one A-ery complicated 
 case, Avhich terminated successful! v, and 
 Avas much interested in another Avhere 
 tetanus proved fatal. On his return to 
 Paris, he operated himself, and published 
 a classical clinical lecture, from Avliich 
 may be dated the reA'ival of ovariotomy 
 
G4 
 
 OVARIAN AND ALLIED TUMOURS 
 
 in France. Koeberle, of Strasburg, per- 
 formed his first operation in 18G2, which 
 was also the date of Nelaton's first opera- 
 tion. It had certainly been performed in 
 France before Nelaton's visit to England. 
 The first case was in 1844, by a country 
 surgeon, Dr. Woyerkowski, of Quingez. 
 This case may be looked upon rather as 
 an accidental than an intentional ova- 
 riotomy. The next case was in 1847, 
 Avhen another country surgeon, M. Vaulle- 
 geard, of Conde-sur-Noireau, operated 
 successfully. Since 18G2, the example of 
 Nelaton in Paris, and the influence of 
 Boinet, followed by the many successful 
 operations of Pean, have done much for 
 the operation of ovariotomy in France ; 
 but the larger experience of Koeberle, 
 of Strasburg, has probably had even a 
 still greater effect. 
 
 Eustache, of Lille, reports Koeberle 
 to have had more than 320 operations 
 early in 1881. Pean sent me his report 
 up to the month of October 1881. His 
 gastrotomies then amounted to 449 ; 
 306 of these were for the removal of 
 ovarian cysts, with 245 recoveries and 
 (Jl deaths. But it has been the same 
 with Pean as Avith most other surgeons. 
 His latest work is his best, for out of 
 the last 100 ovariotomies there have been 
 only 14 bad results; and curiously 
 enough, exactly 7 in each of the last two 
 fifties. 
 
 I believe I was the first to perform 
 ovariotomy in Belgiimi, in July 1865, in 
 the chief hospital at Brussels, upon a 
 patient of Dr. De Iloubaix. It was hoped 
 the example would soon be followed in 
 Belgium ; but the patient died from 
 infiuences almost inseparable from a large 
 general hospital. This unsuccessful re- 
 sult probably retarded for a time the 
 progress of ovariotomy in Belgium. The 
 first successful case in that country was 
 by a pupil of my own, Dr. Boddaert, of 
 Ghent. I had a successful case in Ghent 
 in 1871, and Dr. Boddaert had 2 
 successful cases in 1872. These 4 
 cases, I am informed, Avere the only 
 instances of success out of about 20 
 operations in that country up to that 
 time. Dr. Boddaert assures me that it 
 would bo impossible to obtain accurate 
 statistics for Belgium, as many cases 
 ]emain unpublished. His personal ex- 
 ficrience, however, to the end of 1884 
 amounts to 21 cases with 12 reco- 
 veries and 9 deaths before antiseptics; 
 
 71 cases since antiseptics, Avith 64 re- 
 coveries and only 7 deaths. Besides these, 
 there were 4 cases of cysts of the broad 
 ligament, 3 of Avhich recovered, 1 dying. 
 This makes Dr. Boddaert's total to be 96 
 cases, 79 recoveries and 17 deaths. 
 
 I led the Avay to the practice of 
 ovariotomy in Switzerland by operating 
 at Zurich in July 1864, on a lady Avho 
 recovered perfectly Avell and has enjoyed 
 good health up to the present time. Up 
 to 1882 I had accounts of 231 cases, the 
 recent cases having been treated according 
 to Lister's system. The results Avere 177 
 recoveries and 54 deaths, a mortality of 
 23'3 per cent. One of the fatal cases 
 was most deplorable, as shoAving that, in 
 spite of the most exact precautions, the 
 life of a patient and the reputation of an 
 operator are at the mercy of thoughtless, 
 if not culpable, imprudence. According 
 to custom, the sponges Avere coimted 
 before, and Avere counted again after, the 
 operation. They Avere fixed in number, 
 and not one Avas Avanting. But a sponge 
 Avas left in the abdomen, and the sister 
 accused an assistant of having torn a 
 sponge in two during the operation. A 
 similar folly was just stopped in time here 
 not long ago, proving that the sponges 
 should not only be counted but iden- 
 tified. 
 
 In Germany, in 1819 and 1820 ope- 
 rations by Chrysmar, and in 1820 by 
 Dzondi, only served to bring the opera- 
 tion into discredit. Dieffenbach, Avho 
 had long condemned the operation, ope- 
 rated in 1826. Martini, Ritter, and others 
 followed Dieffenbach's example, but Avith 
 so little success that for several years 
 the operation ceased to be practised. la 
 1866 my volume on * Diseases of the 
 Ovaries' Avas translated into German by 
 Kiicheumeister. Billroth, Avho had as- 
 sisted me, and Avho had carefully studied 
 the Avhole subject, began to use his great 
 influence Avith his countrymen to promote 
 the acceptance of the operation. Nuss- 
 baum, of Munich, came twice to England, 
 assisted me seA'eral times, and has per- 
 formed ovariotomy more frequently than 
 any other German surgeon except Schroe- 
 der ; and Spiegelberg entered upon ;% 
 long career of successful operations. 
 Grenser, of Dresden, made known the 
 results of a long visit to England in an 
 able review of what he saAv here ; and 
 ovariotomy is now generally practised in 
 Germany Avith great success. 
 
THE RISE AND PROGRESS OF OVARIOTOMY 
 
 Go 
 
 Billroth, writing in November 1H71, 
 says : ' Up to the present time, I am 
 tolerably contented with my results. I 
 have personally no reason for supposing 
 that the results will be less cheering in 
 Vienna than they are in London. 
 
 Up to the beginning of 1877 01s- 
 hausen tabulated 613 cases by German 
 operators of completed ovariotomy, with 
 353 recoveries, or 43 per cent, of deaths 
 and 57 per cent, of recoveries. 
 
 Recently the results obtained by 
 Schroeder, Nussbaum, Olshausen, Es- 
 max'ch, and many other German surgeons 
 are, to say the least, equal to those 
 announced in any other country. 
 
 Professor Schroeder, of Berlin, writing 
 to me on November 30, 1884, says 
 that up to that date he had perlbrmed 
 514 ovariotomies, and that the results in 
 successive series of 100 cases were as 
 follows : 
 
 1st hundred . 
 2nd „ 
 3rd „ 
 4th „ 
 6th „ 
 
 SOO 
 
 1 7 deaths 
 
 18 „ 
 7 „ 
 
 16 „ 
 
 7 „ 
 
 65 
 
 Mortality, 13 per cent. 
 
 Professor Nussbaum, of Munich, 
 writing to me November 1884, gives 
 the total number of his ovariotomies as 
 415. Of the first 100, 37 died ; of the 
 second 100, 26; of the third, 16; and of 
 the last 115 cases there were 10 deaths. 
 He adds, that of the 89 deaths, 44 were 
 from septicasmia. His youngest patient 
 was 17. and his oldest 75. This old lady 
 recovered. 
 
 Professor Olshausen, of Halle, writing 
 on December 26, 1884, says that he has 
 performed 270 ovariotomies. Of these 28 
 died. Of the first 170, 24 died, or 14-1 
 per cent. Of the last 100, only 4 died. 
 Of the 28 deaths, 13 were from septicaemia 
 and peritonitis, 6 shock, 2 exhaustion, 2 
 pulmonary embolism, 2 tetanus, 2 ob- 
 structed intestines, and 1 amyloid kidneys. 
 Six of the operations were done upon 
 women during pregnancy, and all the 
 patients recovered. In the last 60 opera- 
 tions the pedicle was almost always secured 
 by elastic ligature, which he left on the 
 pedicle. 
 
 Professor Billroth, of Vienna, sends 
 me the following report of his ovario- 
 tomies from 1865 to end of December 
 1884: 
 
 
 ki 
 
 
 ^^ 
 
 Operations arranged in serie? 
 
 .2 
 
 "S 
 
 ~ ? 
 
 according to tlie ditTlaulties 
 
 s 
 
 3 
 
 S o 
 
 
 y< 
 
 
 as 
 
 I. None or very sli;;lit adhe- 
 
 
 
 sions of omentum . 
 
 91 
 
 9 
 
 9-5 
 
 II. Extensive adhesions to 
 
 
 
 
 anterior abdominal wall 
 
 130 
 
 33 
 
 25-4 
 
 III. I'Lvtensivc adhesions deep 
 
 
 
 
 in the pelvis, or with 
 
 
 
 
 nicsenterv, intestine, 
 
 
 
 
 bladder, uterus, fee. 
 
 95 
 
 .53 
 
 55-7 
 
 IV. Suppurating or putrefy- 
 
 
 
 
 ing cysts — fever i)atieiits 
 
 8 
 
 
 
 77-7 
 
 Total number . 
 
 327 
 
 101 
 
 31-5 
 
 Treatment of pedicle : 
 
 
 
 
 1. Extra-peritonea', with 
 
 
 
 
 clamp .... 
 
 79 
 
 2h 
 
 31-6 
 
 2. Intra-peritoneal 
 
 248 
 
 70 
 
 oO-O 
 
 Ovariotomies before the use of 
 
 
 
 
 boiled carboliscd silk . 
 
 76 
 
 31 
 
 40 8 
 
 Ovariotomies after the us3 of 
 
 
 
 
 carbolised silk 
 
 251 
 
 70 
 
 27-8 
 
 Of those with spray . 
 
 71 
 
 29 
 
 40-8 
 
 ,, without spray . 
 
 180 
 
 41 
 
 22-7 
 
 Billroth, writing to me in 1881, made 
 the following interesting remarks : ' I 
 must explain that only within the last 3 
 years have I begun, in cases really too 
 difl[icult, to close the abdominal incision 
 and leave the operation incomplete. Up 
 till 3 years ago 1 finished at any cost every 
 operation that I began, and this naturally 
 made the statistics worse. In the last 3 
 years I have closed the wound in 12 cases, 
 and not one of the patients has died in 
 consequence of the incision. I attach very 
 little importance to figures in relation to a 
 method of operating. My opinion is as 
 follows. Granted that the operation is 
 well done, and that the patient does not 
 die within about 24 hours from loss of 
 blood or shock (which has occurred to 
 me only 4 times in 2i!2 cases), the result 
 depends upon whether sponges, fingers, in- 
 struments, secretions, and above all the 
 ligature threads, are clean. If this be so, 
 all get well. Three weeks ago I operated 
 on a carcinoma of the ovary which had 
 grown through small intestine and the 
 bladder. I cut away 8 centimetres of small 
 intestine, completed the enteroraphie ; then 
 I cut away the upper part of the bladder 
 and united it with 20 sutures. The re- 
 covery was as free from fever as in the 
 simplest case, and the patient was dis- 
 charged cured after 20 days.' 
 
 In the north of Europe, Dr. Skoldberg, 
 of Stockholm, deserves the credit of ]iro- 
 mulgating, by his example and writings, 
 the knowledge of the operation in Sweden. 
 Before bis death in 1872, he had performed 
 
 F 
 
66 
 
 OVARIAN AND ALLIED TUMOURS 
 
 30 operations, with a result of 26 recoveries 
 and 4 deaths. This success naturally had 
 a great influence in Sweden ; and Dr. 
 Howitz, of Copenhagen, and Professor 
 Nicolaysen, of Christiania, who both as- 
 sisted me many times, have done good 
 service Avith their Danish and Norwegian 
 countrymen. Writing December 26, 1884, 
 ProfcFSor Nicolaysen, of Christiania, says 
 that he has done 109 ovariotomies, about 
 two-thirds of all in Norway, which alto- 
 gether amount to 166 cases, with 61 deaths, 
 a mortality of 36'7. Of Professor Nico- 
 laysen's 109 cases, there were 35 deaths. 
 But since 1878, when he began to apply 
 full Listerism, the result of 74 cases has 
 been 57 recoveries and 17 deaths, a mor- 
 tality of 23 per cent. 
 
 In connection with the practice in 
 Christiania, Professor Nicolaysen makes 
 remarks to this effect : That the great mor- 
 tality among the early cases was princi- 
 pally due to the delay in seeking relief by 
 operation, as most of the patients had been 
 subjected to long-continued medical treat- 
 ment leading only to anaimia, adhesions, 
 and all the complications of old cases. 
 This has been in a measure changed of 
 late years, and the operations have taken 
 place at an earlier stage of the disease. At 
 the same time antiseptic precautions have 
 been adopted, the carbolic spray and dress- 
 ing being used. Professor Nicolaysen adds 
 that, ' after having used sulphurous acid 
 for cleansing the sponges, there has been 
 a remarkable reduction in the mortality.' 
 
 In Russia, the first ovariotomy was per- 
 formed at CharkofF by Professor Vanzetti 
 in 1846, and the second at Ilelsingtbrs 
 in 1849, by Professor Haartmann. Both 
 cases were unsuccessful. The first suc- 
 cessful case was performed by Professor 
 Krassowski, of St. Petersburg, in De- 
 cember 1862, and his results were after- 
 wards so satisfactory that, in 1868, he pub- 
 lished the well-known atlas of beautifully 
 coloured plates. His example has been 
 followed by many Russian surgeons. In 
 1882 there had been 302 ovariotomies re- 
 ported by 40 native surgeons in St. Peters- 
 burg and the various provinces of Russia. 
 No account is published of many of the 
 ovarioiomies done in Russia, ami the 
 nu'iiber is really much greater. All but 
 one of the ovarian cases which have come 
 to me from Russia recovered from the 
 operation. 
 
 In Italy the first successful ovariotomy 
 was performed by Professor Landi, of Pisa, 
 
 in September 1868 ; the second, by Pro- 
 fessor Peruzzi, of Lugo, in 1869 ; the third, 
 by Dr. Marzolo, of Padua, in July 1871. 
 
 Each succeeding year brings from Italy 
 news of greater numbers of operations and 
 of better results. 
 
 In the first 100 cases performed in 
 Italy, Peruzzi proved that the recoveries 
 were 37 and the deaths 63, while in the 
 second 100 these figures were rather 
 more than reversed, the recoveries being 
 64 and the deaths only 36. In the 
 third 100 there were 26 deaths, in the 
 fourth 21 ; but in the fifth, completed in 
 June 1884, the deaths were 23 ; and 
 while 18 years were required to com- 
 plete the first 100 (1859-77), the fifth 
 100 was completed in 13 months. 
 
 It has sometimes been said that the 
 first ovariotomy in Europe was done by 
 Emiliani, of Faenza, in 1815. It so hap- 
 pened that the tumour he removed was 
 preserved in the mus'-um at Bologna, and 
 in 1878 I arranged with Dr. Peruzzi that 
 it should be examined by Professor Ranvier. 
 Ranvier wrote with extreme caution, but 
 reported that in all his sections he only 
 observed fibrous tissue without any trace 
 of glandular structure. 
 
 The exact size and form of this tumour 
 
THE RISE AND PROGRESS OF OVARIOTOMY 
 
 67 
 
 are well represented in tlio woodcut on 
 the previous page. 
 
 I do not think tliis case can bo cited 
 as a case of ovariotomy in the sense in 
 which this operation has been regarded, 
 from its first performance by McDowell 
 to the present time. Emiliani, no doubt, 
 believed he had removed a ' scirrhous 
 ovary,' and it is certain that he removed 
 a fil:)rou3 tumour which is much more 
 like a uterine than an ovarian tumour. 
 The removal of such a tumoiir, however, 
 could have no more bearing upon the rise 
 of ovariotomy than the removal of a hernial 
 ovary from the inguinal canal. 
 
 It is not easy to obtain information as 
 to the number and result of cases of ova- 
 riotomy in Spain and Portugal, but tliere 
 is reason to believe that they are neither 
 so numerous nor so successful as in Italy. 
 
 In India, as early as 1860, ovariotomy 
 was performed successfully at Tan j ore 
 by a native surgeon. In Australia many 
 operators have emulated their English 
 brethren. In New Zealand, Dr. Mackin- 
 non was the pioneer of ovariotomy at our 
 antipodes. In Canada, the few cases which 
 have been published have been almost all 
 successful ; and there is already abundant 
 evidence that ovariotomy may be prac- 
 tised successfully under the most different 
 conditions and in the most opposite cli- 
 
 mates. One case was reported from Japan 
 in 1880. 
 
 It is impossible to give anything like 
 a full historical sketch of the progress 
 of ovariotomy in America within any rea- 
 sonable limits. The initiatory work of 
 McDoAvell has been already described. 
 Atlee stood next to myself in the number 
 of operations he performed. Kimball of 
 Lowell, Peaslee, Alarion Sims, Storer, and 
 many other American surgeons have main- 
 tained the reputation of their country in 
 this department of surgery. Works by 
 Atlee and Peaslee were published in 1872, 
 and their European brethren read with 
 great interest their account of their own 
 work and that of their countrymen. 
 
 In a work by Agnew, there is a table 
 compiled by Baum of 5,153 cases of ova- 
 riotomy, of which 3,651 recovered and 
 1,502 died = 29'13 mortality per cent. 
 Of these there were : 
 
 
 
 
 1 Mor 1 
 
 
 Cases 
 
 Ee- 
 covered 
 
 Died 
 
 tality 
 per 
 cent. 
 
 Single .... 
 
 4,9G9 
 
 3,5.31 
 
 1,438 1 28 94 | 
 
 Double .... 
 
 183 
 
 120 
 
 63 
 
 34-42 
 
 During pregnancy 
 
 21 
 
 17 
 
 4 
 
 19-05 
 
 Twice on same 
 
 
 
 
 
 patient . . . 
 
 15 
 
 12 
 
 3 
 
 20-00 
 
 But this table includes cases both of 
 American and European surgeons. 
 
 CHAPTER V 
 
 THE CONDITIONS AFFECTING THE OPERATION OF OVARIOTOMT 
 
 I MAY refer students interested in the 
 statistics of ovarian disease in England to 
 the 6th chapter of my work published in 
 1882. 
 
 The cases v^hich come under the 
 hands of the surgeon fall into two groups ; 
 patients who, with symptoms calling for 
 immediate action, ought to be given the 
 chance of a preliminary tapping; and 
 others who must without hesitation be 
 advised to submit to the more severe 
 ordeal of ovariotomy. 
 
 A woman with a single unilocular cyst 
 may suffer to such a degree from rapid 
 accumulation of fluid and distension that 
 she must be saved by some means from 
 the effect of mechanical j^^i-ssure. Once 
 assured that the cyst really is single. 
 
 tapping may be tried ; and in my opinion 
 it should be enforced by almost a refusal 
 to do ovariotomy until it had been tested. 
 But this advice as to tapping, and espe- 
 cially as to renewed tapping, as a means 
 of cure must be restricted absolutely, as I 
 have before stated, to cases in Avhich the 
 cyst is single and the contents clear and 
 non-albuminous. In all cases of multi- 
 locular cysts or dei-moid tumours, where 
 the abdominal distension is sufficient to 
 injure the general health or cause local 
 suffering, there must be no faltering, no 
 suggestion of alternatives or delay. Justice 
 to the patient demands a positive recom- 
 mendation of excision, and generally it 
 should be accompanied by a warning 
 against the danger of delay. Everyone 
 
 F 2 
 
68 
 
 OVARIAN AND ALLIED TUMOURS 
 
 ■who takes upon himself the responsibility 
 o£ such counsel should have a clear id(-a 
 ©f the base upon which it rests. And it 
 may be traced out summarily in this 
 form. The health has already deteriorated, 
 and though the tumour itself be neither 
 malignant, nor inflamed, nor suppurating, 
 nor the seat of haemorrhage, yet its mere 
 presence is the cause of the patient's 
 decline. To let things go from bad to 
 worse without doing anything, especially 
 as that worse is a certainty, would 
 be acting again^t the very first principles 
 of medical science. The presence of this 
 morbid growth in the body may give 
 rise to other diseases. It attaches itself 
 oftentimes to the intestines, mechanically 
 blocks the passage through them, or 
 causes fatal contractions, and, at the very 
 least, impairs their functions and hinders 
 the due assimilation of food. Its con- 
 tinuance allows time for the balance of 
 the action of the heart and lungs to be 
 deranged, and for structural changes to 
 take place, which if not immediately fatal 
 or sufficient to mar the operation, may 
 render recovery of health after ovario- 
 tomy slow or incomplete. 
 
 As time advances, the natural tendency 
 of the tumour to degenerative changes 
 finds scope for progress. Whatever its 
 tissues may be, they are never lastingly 
 normal, have a precarious parasitic exist- 
 ence, gain their supply of blood as it were 
 surreptitiously, and are easily thrown 
 into the condition of atrophic decay. The 
 expansion of the membranous compart- 
 ments obliterates the vessels, fatty and 
 other changes occur, and rupture is always 
 imminent. The contents too, whatever 
 they may have been at first, alter in their 
 character and become less and less benign. 
 And by too long waiting, sympathetic 
 morbid action may be set up in the cor- 
 responding organ, and thus make the 
 ablation of both imperative. 
 
 Time, too, gives the opportunity for 
 adhesions to form, for rupture or de- 
 structive peritonitis to occur. With some 
 tumours growing on a long pedicle twist- 
 ing may cause haemorrhage or gangrene 
 The contingency of conception and preg- 
 nancy is an avoidable complication. Still 
 it is no less to be thought of and made the 
 subject of warning. 
 
 Jn many cases ovariotomy may be per- 
 formed with a confident hope of a success- 
 ful result; in others the probabilities of 
 auccess or failure may be about equal, 
 
 while in some the hope of success is so 
 small, that most patients, who are told the 
 whole truth, prefer waiting for the natu- 
 ral termination of the disease to volun- 
 tarily placing their lives in immediate 
 peril. Some, however, would urge the 
 unwilling surgeon to operate against his 
 better judgment, and I have often yielded 
 to the solicitations of patients who, their 
 sufferings being great and death being in- 
 evitable at no distant period, have pre- 
 ferred running any risk rather than submit 
 to a continuation of suffering. In only 
 one case have I refused to operate when 
 pressed to do so by a patient capable of 
 appreciating the difficulties of the position. 
 In this case, a woman in the Samaritan 
 Hospital suffered, as I believed, from 
 malignant disease, involving the uterus 
 and both ovaries, and had a large 
 quantity of fluid free in the peritoneal 
 cavity. I removed this fluid, but refused 
 to do more, although the woman threat- 
 ened to commit suicide if I did not operate. 
 After her death, the correctness of the 
 diagnosis was fully borne out. I have 
 heard of some few cases where patients 
 whom I had dissuaded from the operation 
 have been encouraged by others to submit 
 to it; and, with one exception, every such 
 patient has died after the operation. The 
 exceptional case was a woman who had 
 been several times tapped, and who had 
 been advised both by Dr. Keith and by 
 me not to think of ovariotomy so long as 
 life could be made tolei-able by tappings. 
 Fifteen months after I saw her, the tumour 
 was removed by Dr. Graham, of Liver- 
 pool, Avho encountered and overcame the 
 pelvic and other adhesions which both Dr. 
 Keith and I had recognised, and obtained 
 the satisfaction of saving a life otherwise 
 inevitably lost. I have thought it neces- 
 sary to make this statement distinctly, 
 because it has been supposed that ova- 
 riotomy has been restricted to favourable 
 cases only, and that good results had been 
 obtained by refusing to operate upon any 
 but selected cases. Indeed, this was 
 known to be the case in the early days of 
 ovariotomy in this country. 
 
 Before going into the numerical exa- 
 mination of the question as to how far the 
 age and condition of the patient, the size 
 of the tumour, the existence of adhesions, 
 the length of the pedicle, have affected 
 the result in my whole practice, I think 
 we may conclude that this experience 
 has now been sufficient to warrant the 
 
CONDITIONS AFFECTING THE OPEEATION OF OVARIOTOMY 69 
 
 acceptance of some such rule as tlie 
 following : 
 
 The probable result of ovariotomy can 
 be estimated with far greater accuracy by 
 a knowledge of the general condition of the 
 patient than by the size and condition of 
 the tumour. 
 
 In other words, a large tumour, exten- 
 sively adherent, in a patient whose heart 
 and lungs, and digestive and eliminative 
 organs, are healthy, and whose mind is 
 well regulated, may be removed with a 
 far greater probability of success than a 
 small unattached cyst from a patient who 
 is anoemic or leuka^mic. whose heart is 
 feeble, whose assimilation and elimination 
 are imperfect, or whose mind is too readily 
 acted upon by either exciting or depress- 
 ing causes. I believe this to be the ex- 
 planation of the facts which have led some 
 superficial observers to assert that the 
 more advanced the disease the greater, and 
 the earlier the stage of the disease the 
 less, is the probability of recoverj'. I am 
 convinced that this reasoning is based on 
 the observation of a few exceptional cases 
 where small unattached tumours have been 
 removed with a fatal result i'rom unhealthy 
 or infected persons; or where large 
 attached tumours have been successfully 
 removed from persons who have otherwise 
 been constitutionally sound. Small un- 
 attached tumours in sti'ong healthy persons 
 have by no means given the best results. 
 It is possible to operate too early as well 
 as too late — to place a patient's life in 
 peril by operation before it is endangered 
 by the disease ; just as it is possible, on 
 the other hand, to delay operation until 
 the powers of life are so exhausted that 
 recovery after a severe operation is im- 
 possible. A strong man in full health, 
 with a limb crushed by a railway accident 
 or shattered by a bullet, bears amputation 
 worse than another man who, on account 
 of diseased knee-joint, has been confined 
 to his room lor weeks or months. So a 
 woman who has become accustomed to 
 the confinement of a sick-room, has lost 
 flesh, and has been brought by her suf- 
 fering to dread the operation less than 
 the disease, bears the removal of an 
 ovarian tumour, even though large and 
 adherent, better than one whose whole 
 course of life is suddenly changed from 
 the performance of ordinary active 
 duties to the enforced quiet and con- 
 finement in bed which necessarily follow 
 ovariotomy. 
 
 SIZE 
 
 The size of an ovarian tumour has 
 not, by itself, appeared to affect the 
 result ; but size and solidity together, 
 by affecting the length of the incision 
 necessary for the removal, appear to be 
 of some importance. If there be but 
 little solid or semi-solid substance present 
 — which is generally easily discovered 
 belbre operation — large adherent cysts 
 holding 50, CO, or 70 pounds of fluid 
 may be removed, after the contents of 
 the cyst have been evacuated, through 
 an opening only just large enough to 
 admit one of the operator's hands. The 
 result of such cases has been satisfactory; 
 but the mortality has been greater when, 
 longer incisions have been necessary. 
 The number of inches is a very imperfect 
 mode of judging of the length of incision. 
 In a small woman with a tumour of 
 moderate size, an incision of 8 or 10 
 inches would extend almost from sternum, 
 to pubes ; while in a large woman, 
 greatly distended by a large cyst, an 
 incision of this length may be made 
 below the umbilicus, and after the con- 
 traction of the abdominal wall, the cica- 
 trix may not be more than 3 or 4 
 inches long. In examining a case for 
 operation, it becomes important to judge 
 whether a cyst or tumour can be removed 
 by an incision which does not extend 
 above the umbilicus. If this can be 
 done, the probability of success is much 
 greater than when it becomes necessary 
 to extend the incision far above the 
 umbilicus. 
 
 ADHESIONS 
 
 Writing in 1872, I reported that in 
 296 cases out of the first 500 there were 
 no adhesions, or they were so slight as 
 to be almost unnoticed. Of these patients 
 237 recovered and 59 died, the mortality 
 being 19'93 per cent. In 204 cases, 
 adhesions were very extensive : of these 
 patients 136 recovered and 68 died — a 
 mortality of 33-33 per cent. This 
 would show that the mortality of cases 
 where there are considerable adhesions is 
 about 13 per cent, greater than in cases 
 where there are no, or only trifling, ad- 
 hesions. But a more careful examina- 
 tion of each case appears to confirm the 
 conclusion at which 1 arrived some years 
 ago, that adhesions to the abdominal wall, 
 or omentum only, have but little influence 
 
70 
 
 OVARIAN AND ALLIED TUJMOURS 
 
 upon the mortality, and that the import- 
 ance which has been attached to the 
 diagnosis of adhesions before operation 
 has been greatly and unnecessarily ex- 
 aggerated. At the same time the dia- 
 gnosis of adhesions within the pelvis is of 
 very great importance, as the attachments 
 to the bladder or rectum may be almost 
 inseparable withoiit great and immediate 
 danger to life. The same may be said of 
 attachments to the liver, stomach, spleen, 
 or around the brim of the pelvis, the 
 separation of which would endanger the 
 iliac vessels or the ureters. I formerly 
 believed that the closeness of the con- 
 nection between the uterus and the 
 ovarian tumour — in other words, the 
 length of the pedicle — was a grave 
 matter, as upon its extent depended the 
 possibility of keeping the end of the 
 secured pedicle outside the peritoneal 
 cavity, or the necessity for leaving it 
 within this cavity. But during the last 
 5 years, having quite abandoned the 
 extra-peritoneal treatment of the pedicle, 
 a short pedicle, or close connection be- 
 tween cyst and uterus, becomes important 
 in leading to greater difficulty in securing 
 bleeding vessels. But it also leads to the 
 advisability of uniting the peritoneal 
 edges of the divided pedicle, or separated 
 tumour, by suture, in order to avoid 
 dangers Avhich will be pointed out in the 
 chapter on the operation. Some of these 
 remarks, written in 1872, were intended to 
 convey the result of an impression made 
 by a general survey of the 1st 500 cases 
 reported, and by reminiscences of what 
 happened at and after the operations. But 
 the information obtained from a more 
 exact investigation of the 2nd 500 cases, 
 and embodied in the accompanying table, 
 does not correspond with that impression: 
 
 Table showing tiik Effect of Adhesions 
 UPON THE Kksi i/rs OF Operations in the 
 '2nd iiOO Cases of Ovauiotomy 
 
 
 
 '£ 
 
 
 &-.^. 
 
 
 
 •g 
 
 2 
 
 2 c 
 
 Adhesions 
 
 > 
 
 "Xl 
 
 3 u 
 
 
 « 
 
 o 
 
 ts 
 
 "- u 
 
 
 
 o 
 
 1) 
 
 o S 
 
 
 
 M 
 
 O 
 
 l^ft 
 
 None .... 
 
 212 
 
 18.3 
 
 29 
 
 1.3-07 
 
 Parietal .... 
 
 (Jl 
 
 .')() 
 
 11 
 
 18 
 
 Parietal aa^l omental 
 
 0.3 
 
 ol 
 
 12 
 
 19 
 
 Omental .... 
 
 C2 
 
 47 
 
 ]^) 
 
 24-19 
 
 Intestinal, pelvic & otliers 
 
 102 
 
 04 
 
 38 
 
 37-25 
 
 500 395 
 
 105 
 
 21 
 
 The general mortality after the opera- 
 tion is seen to have been reduced Irom 
 
 25"4 to 21 per cent. ; while the large 
 increase in the mortality among the bad 
 cases of visceral adhesion is noticeable. 
 This may be accounted for by the greater 
 boldness with which excisions were latterly 
 undertaken and carried to completion. 
 Many of the later operations finished, 
 would formerly have been refused as 
 hopeless, or abandoned after the first inci- 
 sion, and added to the tables of in- 
 complete cases or exploratory incisions. 
 But with regard to what have been 
 spoken of as ' slight ' adhesions — that is, 
 adhesions to the parietes and to the 
 fringes of the omentum — the table pre- 
 sents us with a mortality of 5 per cent, 
 in excess of that of the simple cases ; 
 while the deaths after separation of 
 omental adhesions are double, or nearly 
 so, those among the free cyst operations, 
 the relative percentages being 13-()7 
 for the non-adhesions and 24-19 for the 
 omental adhesions. 
 
 Now, when we take into account that, 
 according to my experience, nearly three- 
 fifths of the cases operated on have adhe- 
 sions of some kind, and that the mortality 
 of the group of adhesion cases, as a 
 whole, was double that of the simple 
 cases — 2G-o8 to 13"67- — it gives a serious 
 aspect to the general question of adhesions. 
 The death-rate of 37 '25 in bad cases of 
 visceral adhesion, found in one-fifth of the 
 total number, at a time when the general 
 mortality after my operations was rapidly 
 coming down to 10 per cent., speaks for 
 itself as to the gravity of the prognosis in 
 such cases. And the other fact shown by 
 this investigation of my 2nd 500 cases, 
 that even with the so-called trifling adhe- 
 sions — that is, cases in which the adhesions 
 were only parietal or partially omental — 
 the deaths were nearly one-half more 
 (18'54) than in the free cyst cases, and 
 that among the adhesions classed as omental 
 the mortality was nearly double (24-19), 
 corrects the impression that adhesions of 
 this kind wore not of much importance. 
 Their existence should not deter from the 
 operation, nor make anyone falter. But 
 these facts mark more strongly than ever 
 the importance of avoiding everything in 
 the early stages of the disease which may 
 produce adhesions, of not letting the time 
 for operating go by when the cyst is free, 
 and of giving a proportionally guarded 
 prognosis as to the probable result of 
 operation when extensive adhesions are 
 known to be present. 
 
CONDITIONS AFFECTING THE OPERATION OF OVARIOTOMY 71 
 
 AGE 
 
 The average age of 1,000 cases of 
 completed ovariotomy proves to be as 
 near as possible 39 years. 
 
 The small mortality shown in my 
 reports of operations upon persons under 
 the age of 25 and between 60 and 70 is 
 remarkable when compared Avith that of 
 the intermediate ages — 40 to 45 excepted. 
 The 127 young people under 25 years of 
 age went through the operation with a 
 mortality of 12-59 per cent. ; the 45 
 between 60 and 70 escaped with a loss 
 of 1 7*77 per cent.; while those between 
 25 and 60 died at the rate of 26-41 per 
 cent. From these I omit 118 of from 40 to 
 45, who were fortunate enough to have a 
 death-rate of only 16'94 per cent. One 
 ■of the two cases over 70 died. I have 
 not been able to make out what were the 
 influences acting so favourably upon the 
 40-45 cases. That it was not a mere 
 iiccident would appear from the fact that 
 the immunity at that age was not confined 
 to any part of the series, but was about 
 equal in the two five hundreds. 
 
 MORTALITY AT DIFFERENT AGES 
 
 In reference to this subject Dr. Ogle 
 wrote to me thus : * Among the 3,414 
 deaths ascribed in the 10 years, 1871-80, 
 either to ovarian dropsy or to ovariotomy, 
 were 2 of girls under 15 years of age, 
 and 7 of women over 85 years of age. 
 The greatest absolute number occurred 
 between the ages of 45 and 55, and next 
 to this came the decennia on either side 
 of this period of life.' But taking into 
 account the different numbers of women 
 living at each period, Dr. Ogle adds : ' It 
 appears that the time of life when this 
 disease is most fatal — that is, causes most 
 deaths in proportion to the number living 
 — is from 55 to 65, and the next fatal 
 periods are the decennia on either side of 
 this.' 
 
 CONJUGAL CONDITION 
 
 The mortality was nearly equal among 
 married and unmarried women at all ages, 
 in 1,000 patients. 
 
 SOCIAL CONDITION 
 
 The results of operations in hosjoital 
 and private practice are affected by many 
 other causes besides the social condition 
 of the patients. 
 
 Under favourable circumstances the 
 rate of death has been so nearly equal 
 
 in all classes of patients that it overturns 
 
 the belief formerly entertained by some 
 writers, that deaths have been chiefly 
 among poor women, and that this is not 
 accidental. My experience certainly 
 does not support the conclusion that ' the 
 social position of the patient has a good 
 deal to do with the result.' My hospital 
 patients were poor, though lew could 
 actually be ranked as paupers. 
 
 Many of the private operations have 
 been performed in the houses now common 
 in London, where it is intended that a 
 patient shall obtain the conjoint advan- 
 tages of an hospital and of home or 
 private apartments. There can be no 
 doubt of the advantages of such houses, 
 provided the management is good. But 
 they must always be open to the objection 
 of subjecting one patient, more or less, 
 to the influence of others in adjoining 
 rooms or in the same house. I am con- 
 vinced that some of the deaths, both in 
 hospital and in the nursing establish- 
 ments, have been due to the injurious 
 influence of other patients upon the sub- 
 ject of the operation; an influence which 
 would not have been felt in a private 
 house. Apart from all question of in- 
 fection, my belief is that, in the one 
 case, if any important peritonitis follow 
 the operation, the inflammation is almost 
 always local, not attended by much 
 effusion of serum, nor by elevation of 
 temperature or other signs of fever or 
 blood-poisoning ; Avhei'eas, under the 
 influence of other patients in the same 
 house the inflammation is diffused, is ac- 
 companied by the rapid effusion of a con- 
 siderable amount of fluid, Avith great 
 elevation of temperature and other indi- 
 cations of septicajmia. I am becoming 
 more and more doubtfuh if we ever see 
 this latter chain of symptoms, either in 
 hospital or in healthy houses, if the 
 patients are kept quite free from the 
 access, by contagion or infection, of the 
 poisonous material — solid, liquid, or gase- 
 ous — which acts as certainly as an inocu- 
 lated particle of small-pox or vaccine 
 virus, or as the inspiration of an infective 
 atmosphere in scarlatina, and from which 
 the patient is absolutely safe in the 
 absence of the poison. 
 
 INFLUENCE OF SEASON 
 
 The general result of my experience 
 is that seasons, as expressed by winter, 
 spring, summer, or autunm — or that hot 
 
iZ 
 
 OVARIAN AND ALLIED TUMOURS 
 
 or cold months, or any particular month — 
 have little or no influence upon the result 
 of ovariotomy; and with regard to any 
 exceptional atmospheric or climatic con- 
 ditions, all we can say is that this is a 
 case for ' Collective Investigation,' that 
 the combined action of many observers 
 in every variety of social, territorial, 
 climatic, and professional conditions, ex- 
 tending over adequate time and numbers, 
 must be brought to bear upon the sub- 
 ject before we can formulate the laws 
 which determine the results of season 
 upon our operations. 
 
 CONTRA- INDICATIONS 
 
 As a general rule, any existing disease 
 which in its natural course would prove 
 fatal to the patient, or would influence 
 her constitution in such a manner as to 
 render her recovery very unlikely, or 
 other serious surgical operations inad- 
 missible, should also forbid ovariotomy. 
 It ought not to be resorted to in indi- 
 vidvials suffering from cancer, far-ad- 
 A-anced tubercizlosis or scrofula, syphilis, 
 important diseases of the heart, or in 
 cases where this organ has been displaced 
 by the tumour, and at the same time has 
 been fixed in its abnormal site by ad- 
 hesions which would retain it in its 
 position even after the removal of the 
 ovary ; diseases of the brain and of the 
 nervous centres, of the liver, spleen, and 
 kidneys ; ulcers of the stomach and 
 diseases of the alimentary canal, which 
 permanently impair general nutrition ; 
 ascites in consequence of liver complaint, 
 of disease of the heart, or degeneration 
 of the kidneys. The mere presence of 
 albumen in the urine has often had undue 
 weight. It is often of no more impor- 
 tance than in pregnancy, and disappears 
 after the pressure of the tumour ceases. 
 Scurvy, anaemia, and other blood diseases, 
 hectic lever, great w^eakness and extreme 
 emaciation from advanced age or im- 
 paired nutrition, would lead, if not to 
 absolute prohibition, to a very un- 
 favourable opinion as to the probable 
 result. 
 
 But scarcely ever will the judgment 
 of the surgeon be so severely tested as in 
 estimating the value and importance of 
 
 many of the above-mentioned contra- 
 indications, whether any one is by itself 
 so serious as to preclude surgical inter- 
 ference, or is merely a consequence of 
 the local disease. This may be instanced 
 by one of my cases where all the sym- 
 ptoms of far-advanced tuberculosis were 
 present — cough, hectic fever, high tem- 
 perature, and rapid pulse- — -which all dis- 
 appeared after extirpation of the ovarian 
 tumour. The pulse fell from 108 to 88,. 
 the temperature from lOl'-i" F. to its 
 normal range; cough was no longer 
 troublesome. It may be added that the 
 cyst contained genuine tubercular de- 
 posits, was thin-walled, and very fragile. 
 
 The operation ought not to be per- 
 formed when the tumour is in an ad- 
 vanced stage of cancerous degeneration. 
 But so many instances of recovery after 
 extirpation of what was pronounced to be 
 cancer are well known, that there must 
 be more than bare suspicion to set aside 
 the operation. Cancer of the ovaries is- 
 supposed to occur most frequently after 
 the change of life ; but cases have been 
 mentioned, in another chapter, of this 
 disease in a young girl, and in middle- 
 aged women. Such tumours often form 
 extensive and intimate adhesions, taint 
 the surrounding tissues, and attack the 
 neighbouring organs, with which they 
 form at an advanced stage of the degene- 
 ration one confluent mass. In most cases, 
 their extirpation, if attempted, would 
 meet with insurmountable difficulties ; 
 and should the operation be terminated 
 and the patient recover from it, the 
 disease would sooner or later attack some 
 other part or organ. Ascites generally 
 accompanies malignant disease of the 
 ovaries, and both ovaries are usually 
 affected at the same time. 
 
 The presence of ascites need not 
 deter from the operation, provided it be 
 due to escape of fluid from the cyst, or is- 
 brought on by the mechanical irritation 
 of the peritoneum by the tumour. If, 
 however, it is caused by disease of heart, 
 liver, or kidneys, these conditions almost 
 always forbid the operation. The compli- 
 cation of pregnancy with ovarian disease, 
 and its be aring on ovariotomy, are treated 
 of in a subsequent chapter. 
 
CHAPTER VI 
 
 PREPARATION OF 
 
 A PATIENT FOR OVARIOTOMY ; DUTIES OF THE NURSE ; DESCRIPTION 
 OF NECESSARY INSTRUMENTS 
 
 It by no means follows that the state of 
 robust health is one so favourable for 
 operation as that of a patient more or 
 less accustomed to the quiet and habits of 
 a sick-room. And it is perhaps one of 
 the most difficult questions which the 
 surgeon has to determine, whether a 
 patient not yet broken down by the pro- 
 gress of the disease, is suffering enough 
 in general condition to warrant him in 
 recommending an operation necessarily 
 attended with serious risk to life. Every 
 case must be judged by its own pecu- 
 liarities ; not those only which relate to 
 the physical condition of the patient, but 
 the various moi-al, mental, and social 
 influences which have so constantly to be 
 considered in daily practice, and which so 
 materially affect the results of any opera- 
 tion. For instance, an unmarried girl 
 with ovarian disease is often so distressed 
 by the suspicions which her appearance 
 excites, that she must be relieved earlier 
 than a married woman of the same size 
 needs be ; and a girl engaged to be 
 married, and naturally unwilling to marry 
 as an invalid, may claim with good reason 
 earlier aid from surgery than one not so 
 pledged. The same would hold good 
 with a wife wishing to travel with her 
 Imsband, or to join him in some distant 
 part of the world. On the other hand, 
 there are iarnily circumstances which 
 would properly delay opeiation till the 
 last possible moment. Children may be 
 dependent on the annuity of the mother, 
 whose life should not be subject to the 
 additional risk of the operation until it is 
 imperatively called for by the severity of 
 her sufferings. In many cases such con- 
 siderations have guided me in operating 
 either eaidier or later than one would do 
 if only obliged to regard what was best 
 for the bodily welfare, and able altogether 
 to ignore the affections, interests, and cir- 
 cumstances of patients. 
 
 A condition which certainly requires 
 correction before the operation is under- 
 taken, is that common one where only a 
 small quantity o£ highly concentrated 
 urine, depositing mixed urates in abund- 
 ance, is passed. If ovariotomy be per- 
 
 formed on a patient in this condition, a 
 serious amount of kidney congestion, with 
 symptoms almost amounting to urasmic 
 fever, is almost certain to follow the- 
 operation. Before undertaking it, there- 
 fore, it may be necessary to gain time by 
 tapping. Whether or no this may be 
 necessary, warm baths or vapour baths, 
 to promote free cutaneous secretion, some- 
 thing to secure a free daily action of the 
 bowels, and some of the alkaline car- 
 bonates, largely diluted, will most likely 
 greatly improve the condition of the 
 patient. Nothing tends so rapidly to- 
 clear the urine as lithia. From 5 to 10 
 grains of the citrate or carbonate of lithia, 
 dissolved in a full proportion of simple 
 or aerated water, 2 or 3 times a day, 
 generally lead to a moi'e abundant secre- 
 tion of urine which is free from deposit. 
 Sometimes it is a good plan to combine 
 the carbonates of lithia, potash, and soda^ 
 and it may be desirable to give iron at 
 the same time. A draught of 5 grains 
 of tartrate of iron, 5 of carbonate of 
 lithia, and 10 each of the bicarbonates 
 of potash and soda, Avith a few drops of 
 chloric ether, 2 or 3 times a day, has 
 has often appeared to me to be of great 
 service. A course of perchloride of iron 
 before any serious surgical operation is 
 said so to alter the condition of the blood as 
 to make pyemic fever or septicaamia less 
 liable to occur. A change to the seaside 
 or country will assist the restorative action 
 of medicines ; and if the patient is brought 
 from the country it may be well to ar- 
 range for the performance of the opera- 
 tion before the influences of town life have 
 had time to prove injurious. 
 
 The place where the operation is per- 
 formed ought to be healthy, and there can 
 be no excuse for putting or leaving the 
 patient in an unhealthy house or district. 
 If she lives in a healthy part of the 
 country and can be treated there, it would 
 be positive cruelty to bring her to an 
 unhealthy part of town, or to expose her 
 to the influences of a lar";e general 
 hospital. Even in the same town, or in 
 the same district of large cities, better 
 results have been obtained in private 
 
74 
 
 OVAKIAN AND ALLIED TUMOURS 
 
 houses and in small hospitals, where the 
 patient occupies a room alone, than in 
 large general hospitals. It is well worthy 
 of remark that the periods of good and 
 indifferent results in the Samaritan Hos- 
 pital have corresponded with improve- 
 ments in its sanitary condition. After 
 emptying the hospital for a month or 
 more, and thoroughly cleansing, painting, 
 and lime-washing the wards, a period of 
 almost uninterrupted success has followed. 
 Then what was called 'a run o£ bad luck ' 
 set in, clearly attributable to crowding, 
 some neglect in purifying bedding, or to 
 contagion or infection. Another thorough 
 cleansing again led to better results. If 
 we could obtain all the favourable con- 
 ditions of a room in a private house, in a 
 healthy country situation, there can be 
 no doubt that the mortality would be 
 much smaller than the best results hither- 
 to attained in large towns. 
 
 The ward or room, whether in a small 
 hospital or in a private house, should be 
 well provided with means for keeping up 
 a continual and sufficient ventilation, 
 without exposing the patient to currents 
 of cold air, and the temperature should 
 be regulated by an open lire. In a build- 
 ing constructed lor tlie purpose, it would 
 seem to be easy to keej:) up a constant 
 curi-ent of fresh air, at any temperature 
 required, night and day; but what is 
 theoretically easy in warming and ven- 
 tilating has probably never yet been done 
 well. All unnecessary furniture should 
 be removed irom the room, particularly 
 dusty woollen curtains and carpets. Two 
 iron bedsteads should be provided, not 
 more than o feet G inches wide, so 
 that the patient can be reached equally 
 well from either side, and may be lifted 
 from one bed to the other. A horsehair 
 mattress is cooler and firmer than a feather 
 bed, and therefore preferable, and open 
 iron spring bedsteads are far safer than 
 the old sacking and wool or straw mattress 
 under the horsehair. The covering ought 
 to be light but warm ; and no one should 
 be allowed in the room but the patient 
 and her nurse. 
 
 The nurse has a very important in- 
 fluence on the result of ovariotomy. 
 Much depends on her regarding all the 
 essential precautions, and managing for 
 the comfort and encouragement of the 
 patient, up to the time of the operation; 
 and the after-treatment can be altogether 
 marred by any failure of discipline, or 
 
 neglect in fulfilling every little -point of 
 the duties entrusted to hen What is 
 especially Avanted in a nurse for this kind 
 of work is a calm, quick, decided way of 
 doing it ; an intelligent understanding of 
 its nature ; a readiness in comprehending 
 the instructions given ; punctuality and 
 exactness in carrying them out; and a 
 discriminating carefulness in observing 
 and reporting all that passes iinder her 
 notice, and that may be of importance to 
 the surgeon in judging of the progress or 
 regulating the treatment of the case. The 
 passive, confiding docility of women after 
 ovariotomy, who find themselves subject 
 to the good understanding which exists 
 between a competent nurse and the sur- 
 geon she is serving under, is in marked 
 contrast with the keen anxious watchful- 
 ness and feverish fidgetiness of others less 
 fortunate in their attendants, and the 
 progress towards convalescence is pro- 
 moted or retarded in such a way as to 
 make very clear how much the style of 
 nursing has to do with it. 
 
 No nurse shoidd be entrusted with the 
 care of a patient after ovariotomy unless 
 she is well able to use the female catheter 
 without uncovering the body and expos- 
 ing it to chill. She should use the 
 catheter every G or 8 hours, or as much 
 oftener as the patient may wish, and 
 should preserve the urine, but not in 
 the sick-room, for the examination of 
 the surgeon. She should also be well 
 practised in clearing the rectum by injec- 
 tions, and expert in giving medicine or 
 food by it when necessary. She should 
 know the danger of bed-sores, and the 
 mode of avoiding them. 
 
 Very few nurses can be entrusted with 
 the sponges. The surgeon should always 
 see tnat they are as pure as they possibly 
 can be made before every operation. The 
 nurse should cut several slips of adhesive 
 plaster, about 2 inches broad, and long 
 enough to more than half encircle the 
 body, and arrange a supply of thymol or 
 iodoform gauze, salicylic wool, and some 
 muslin bags filled with phenolised or 
 boracic cotton-Avool, such as those de- 
 vised by Mr. Gamgee. An india-rubber 
 bag filled with hot water should be ready 
 for use ; a flannel belt to pm round the 
 body, and some large safety pins to fasten 
 it. Some brandy, one or two pint bottles 
 of champagne, and some ice, must be 
 entrusted to her care. An enema bottle, 
 holding an ounce, with an elastic tube, a 
 
PREPARATION FOR OVARIOTOMY 
 
 75 
 
 minim measure, and some laudanum ; good fire in the room, and a plentiful 
 should be provided, so that in case of' supply of hot and cold water; and she 
 pain a dose of it may he injected into the i ought to see that all is in such readiness 
 rectum, A feeding-cup is also wanted, that, after the patient is in the room, it 
 with which nourishment may be given I may not be necessary to send for any- 
 without the patient rising. I tljing, or to open the door. With some 
 
 It is better that the temperature of , few unusually nervous patients it may be 
 the room should not be so high as was desirable to administer the anaesthetic in 
 formerly supposed indispensable, nor need another room, or in bed in the same 
 any attempt be made to charge the atmo- room, before they are placed on the table; 
 sphere Avith moisture. In my first paper but, as a rule, as soon as they have emptied 
 
 the bladder, patients may walk to the table 
 andari-ange themselves upon it, with some 
 little assistance, in the position desired by 
 the surgeon. The night-gown should be 
 pressed up towards the shoulders. In 
 order to have as few assistants as possible, 
 a broad strap should be carried over the 
 patient's knees, and around the table, and 
 
 on ovai'iotomy, I expressed my belief that 
 many of the symptoms, supposed to be 
 caused by the operation, were in reality 
 due to the confinement of the patient in 
 a hot close room filled with watery vapour, 
 and I showed that both patient and sur- 
 geon were much more comfortable in an 
 ordinary atmosphere. The temperature 
 of the room should not be below GU° 
 Fahrenheit, but it need not be raised to 
 an uncomfortable degree above this point. 
 The patient should wear her ordinary 
 night-dress, warm woollen stockings, and 
 a loose short flannel dressing-jacket. Any- 
 thing tight round the neck or body should 
 be removed. Even if the bowels have 
 acted on the morning of the day selected for 
 operation, the rectum should be thoroughly 
 cleared out by an injection of Avarm water. 
 A little good beef- tea, with dry toast, 
 will be enough for the morning meal, and 
 nothing should be eaten for 4 hours 
 before the anaesthetic is administered. I 
 find about 2 or 3 in the afternoon a 
 better time for operating than an early 
 morning hoiir. A patient Avho expects 
 to undergo an operation early in the 
 morning seldom sleeps Avell, or she awakes 
 wearied and depressed ; but if she is to I tightly fastened. Each hand should also 
 get up and does not expect her fate to j be securely fixed by a bandage to a leg of 
 
 be decided till the afternoon, she sleeps 
 better, and there is time for clearing the 
 bowels after breakfast. With a warm 
 bath the night before, the skin is in a 
 better state for perspiring. The abdo- 
 
 the table. The head should be laid in a 
 comfortable position on pillows; and, 
 except the abdomen and face, the body 
 should be covered Avith Avarm light 
 blankets or flannel. The abdomen should 
 
 men should be thoroughly cleansed with ' be covered by a waterproof sheet, Avith 
 
 soap and Av^ater. It is important that the 
 nurse should be instructed in the use of 
 the clinical registering thermometer, and 
 it is ahvays Avell to knoAV the morning 
 and evening temperature of a patient for 
 2 or 3 days before operation. 
 
 Tables on Avhich the patient is to lie 
 
 an openmg about 8 inches long and G 
 inches Avide in the middle ; the inner 
 surfoce spread Avith a coating of adhesive 
 plaster of about an inch in Avidth all 
 round the opening, so that it may adhere 
 to the skin, prevent any exposure of the 
 patient, and keep her body and clothing 
 
 for the operation, Avith foot-pans or pails : perfectly dry and clean, 
 beneath for the reception of the fluid, and : The draAving on the next page shoAVS 
 another table for the instruments, should , hoAv I am noAv in the habit of arrar^g- 
 be placed opposite a AvindoAv admitting ; ing tAvo tables near a AvindoAv, Avith the 
 a good light. The nurse should have a patient covered upon them ; a table for the 
 
76 
 
 OVARIAN AND ALLIED TUMOURS 
 
 instruments being to the right hand of the 
 operator. Steam spray apparatus may be 
 placed upon another table near the feet 
 of the patient to her left — supposing the 
 surgeon uses the spray. 
 
 The necessary instruments for a 
 simple case of ovariotomy are few : a 
 scalpel, to divide the abdominal Avail; a 
 director, to protect the cyst as this division 
 
 is completed ; a trocar, to empty the cyst ; 
 needles and silk, to secure the pedicle and 
 close the wound ; with forceps and liga- 
 tures, to secure any bleeding vessels. But 
 there is, perhaps, no surgical operation 
 where the surgeon may be so met by 
 difficulties where he least expected them, 
 and it so often happens that instruments 
 are wanted which would not be at hand 
 
 if only the instruments required for an 
 ordinary case were taken, that it is a safe 
 rule to take to every case a full supply of 
 instruments, to meet every emergency. 
 Cautery clamps and cauteries for cases 
 where the cautery is aj)jilicable, ligatures 
 and needles of different shapes and sizes 
 for cases where neither clamp nor cautery 
 is used, pressure forceps for temporarily 
 holding separated omentum or torn vas- 
 cular adhesions, and for securing arteries 
 by ligature or torsion, vulsella specially 
 adapted for holding large cysts, a chain 
 and wire ecraseur, drainage tubes of 
 glass, vulcanite, or india-rubber, and per- 
 chloride of iron should always accom- 
 pany the surgeon. Only the instruments 
 which the operator thinks likely to be 
 required need to be arranged on the table 
 
 to his right, the others in reserve should 
 be placed ready lor use in a drawer, or on 
 a tiay, out of the way, but close at hand. 
 All this having been done, and the table 
 with the instruments covered with a towel, 
 the light subdued, and no other persons 
 present than the operator, the adminis- 
 trator of the anajstlietic, and the nurse, 
 the patient m:iy be brought into the 
 room. 
 
 Before proceeding to describe the 
 various steps of the operation, a few lines 
 may be given to the consideration of the 
 anoisthetic, ar,d to an account of the most 
 inii)ortant instruments which I use. 
 
 In all my earlier operations chloroform 
 was the anaesthetic given. Vomiting 
 following the operation, and continuing 
 with the distressing persistency known. 
 
PREPARATION FOR OVARIOTOMY 
 
 77 
 
 as * chloroform sickness,' was very fre- 
 quently observed, in some cases led to 
 great danger, and even became a principal 
 cause of fatal results. I tried sulphuric 
 ether; but the quantity necessary, the 
 diffusion of the vapour, the irritating 
 cough it produced, and the difficulty of 
 inducing complete anaesthesia by it, in- 
 duced me to search for a better anaesthetic. 
 I tried a mixture of chloroform and ether 
 in different proportions, but soon became 
 aware that the patient was at first only 
 affected by the lighter vapour of the 
 ether, and was then subjected to the 
 action of chloroform just as she was least 
 able to bear it. The addition of alcohol 
 to the ether and chloroform made a mix- 
 ture which appeared to answer better ; 
 and I was trying this triple combination 
 when Dr. Richardson brought the bichlo- 
 ride of methylene before the profession. 
 
 An impression has prevailed that bi- 
 chloride of methylene, or chloromethyl, as 
 it may be more conveniently called, is 
 only useful for short operations, and that 
 it cannot be safely administered for more 
 than 1 or 2 minutes. But as my ex- 
 perience would show that this commonly 
 expressed opinion is the very reverse of 
 the truth, it seems to be my duty to make 
 known what I have seen of the use of 
 chloromethyl in general surgery. 
 
 The first surgical operation in which 
 chloromethyl was ever used was a case of 
 ovariotomy, which I performed in October 
 1867. The sleep produced was of the 
 simplest and gentlest character, and the 
 operation, which lasted 35 minutes, was 
 quite painless. 
 
 This was my 229th case of ovario- 
 tomy. I have now done ovariotomy 
 1,138 times; and, with the exception of 
 about 10, where, for some reason or other, 
 chloroform was used, chloromethyl was the 
 anaesthetic employed. In some 200 other 
 cases of gastrotomy, and in more than 500 
 operations of more or less severity — such 
 as herniotomy, amputation of the breast, 
 removal of mammary or other tumours, or 
 of hasmorrhoids, and plastic operations for 
 the cure of vaginal fistula or ruptured 
 perineum — chloromethyl has been admi- 
 nistered. In very few of these operations 
 was the condition of insensibility to pain 
 maintained for less than 5 minutes. In a 
 few, it was kept up from 45 minutes to an 
 hour or more ; and I should think the 
 average would be about 1 5 minutes. Yet 
 I have never been at all uneasy in any one 
 
 of these cases, either during the adminis- 
 tration of the anassthetic or from any sub- 
 sequent ill effects fairly referable to it. 
 Whereas, with chloroform I never felt quite 
 at ease ; and, although I never lost a patient 
 during operation, I have three times had 
 to resort to artificial respiration. I have 
 very often seen patients suffer so much 
 from chloroform-vomiting for many hours 
 after operation, that the result has been 
 imperilled. And in a few cases death has 
 been in some measure due to the vomiting. 
 It is quite true that chloromethyl is not 
 quite free from the disadvantage of causing 
 nausea and occasional sickness; but, in 
 my experience, this is almost the rule with 
 chloroform, whereas with chloromethyl it 
 is certainly exceptional. I think after this 
 evidence it must be admitted that the 
 anaasthetic employed is a good one. In 
 some cases less than 2 drachms was used, 
 and very rarely more than 6 drachms. A 
 patient may be kept in a state of perfect 
 unconsciousness throughout a prolonged 
 operation with methylene administered by 
 the apparatus devised by Dr. Junker. The 
 patient does not inhale the undiluted va- 
 pour of methylene, but air which seldom 
 contains more than 2 per cent, and never 
 more than 4 per cent, of the vapour. 
 The fluid itself can only be blown into 
 the face piece by a careless administrator. 
 Scarcely any of the vapour escapes into 
 the room ; neither the surgeon nor the 
 assistants are affected by it. A patient 
 very seldom becomes pale ; she sleeps 
 quietly, awakes quietly, is not often sick, 
 and seldom has much bronchial irritation 
 referable to the chloromethyl. Indeed, 
 she gains all the advantages of complete 
 ansesthesia with fewer drawbacks than by 
 the use of any other anaesthetic I know 
 of. 
 
 The trocar used in ovariotomy by all 
 the earlier operators was an ordinary trocar 
 of full size. The instrument, now suffi- 
 ciently well known and described as my 
 ovariotomy trocar, I have used for several 
 years past, and have been well satisfied 
 with it. 
 
 In 1871, Dr. Fitch made the outer tube 
 cutting, and protected it by pushing the 
 inner tube forward. He also lengthened 
 and curved the end of the canula upon 
 which the tube is fixed, enabling us to 
 use an ordin;iry india-rubber tube, without 
 fear of stopping the current by its bending. 
 Whether my old ovariotomy trocar or the 
 instrument with this modification be used 
 
•8 
 
 OVARIAN AND ALLIED TUMOURS 
 
 (as shown in the drawing on page 86), a 
 cyst when punctured, and partly empty, 
 is fixed on to the canula by the spring 
 hooks, so that trocar, ligature, and vul- 
 sellum are united in one instrument, and 
 a large cyst may be emptied an 1 withdrawn, 
 without any fear of its contents escaping. 
 
 As aids to the hooked trocar in draw- 
 ing out a cyst, or in holding a cyst which 
 
 has been opened, while the septa of inner 
 cysts are being broken up and the contents 
 brought out, hooked forceps, or vulsella of 
 different kinds, are often necessary. The 
 best of these instruments is that known 
 as Nelaton's vulsellum. It holds the cyst 
 very securely, does not slip nor tear the 
 cyst. The essential or grasping part of the 
 instrument is shown in the upper drawing. 
 
 The clamp which is used for temporary 
 compression of the pedicle when we intend 
 to trust to the cautery for stopping bleed- 
 intr from the divided vessels, is known as 
 the Cautery Clamp. The instrument was 
 devised by Clay, of Birmingham, to stop 
 bleeding from vessels in the omentum 
 separated from the cyst. It is to him we 
 are indebted for the principle of combining 
 compression and cauterisation in the sup- 
 pression of ha?morrhage. The cautery 
 clamp not only securely holds the pedicle, 
 but so firmly compx-esses the portion in- 
 cluded within the blades, that alone it 
 would be almost sufficient to control the 
 bleeding; but when the divided edge of 
 the pedicle is seared by the actual cautery, 
 the effect of compression is assisted by the 
 line of eschar at the cauterised part. The 
 blades of the clamp being heated by the 
 cautery, the compressed part of the pedicle 
 is also heated, the blood in its vessels is 
 coagulated, and when the clamp is removed 
 a thin band almost like wash-leather, with 
 the seared edge, becomes a very efficient 
 safeguard against bleeding. Baker Brown 
 was the first to apply it to the pedicle. 
 I and others modified the instrument by 
 making it broader, by adding a guard to 
 prevent slipping of the cautery, and an 
 ivory or talc shield to protect the soft 
 parts from the action of the heated clamp, 
 liut Dr. Keith, after many trials of this 
 and other clamps, finds the original 
 instrument of Baker Brown to be the 
 best. 
 
 The cauterising irons used by Baker 
 Brown were the ordinary conical irons, 
 
 with a sharp edge, used in firing joints. 
 With these instruments red hot, he divided 
 the pedicle, as shown in this cut, the tu- 
 mour being held up by an assistant. This 
 was a tedious and troublesome process ; 
 and I found that the same end was attained 
 by cutting away the cyst an inch or two 
 from the clamp, and then burning all the 
 tissue that projected beyond the sur- 
 face of the clamp. Flat irons answered 
 this purpose better than the conical ones. 
 The galvanic cautery answers equally 
 well, and would be generally preferred, 
 if it were possible always to secure 
 efficient battery action ; but as this is 
 uncertain, Paquelin's cautery has been 
 employed. Dr. Keith adheres to the 
 original form of conical iron heated in 
 the fire. I believe it is of very little 
 consequence which of the cauteries is 
 used, provided the clamp exerts sufficient 
 compressing force, and time is taken to 
 cauterise slowly, so that the pedicle is 
 subjected to the somewhat prolonged in- 
 fluence of heat. 
 
 The ordinary chain ecraseur has been 
 used successfully in dividing the pedicle. 
 I believe I was the first to adopt this prac- 
 tice, but although the case proved success- 
 ful, I was so fearful of secondary bleeding 
 that I have never repeated the experiment. 
 When the ecraseur is ust-d with wire, not 
 to divide the pedicle but simply to secure 
 it in a kind of clamp, a nut and screw 
 allow the handle to be removed. 
 
 I have in anotner chapter alluded to 
 cases which have occurred in my own 
 practice where, long before the operation, 
 
PREPARATION FOR 0^'ARIOTOMY 
 
 79 
 
 the pedicle had given way from twisting 
 by rotation of the tumour, and tlie cyst 
 had received its whole blood supply 
 tlu'ough omental vessels. There can be 
 no question, therefore, as to the feasibility 
 of tearing through a pedicle, or of twist- 
 ing off an ovarian tumour. Maisonneuve 
 was the first to practise this twisting in 
 ovariotomy; he twisted the cyst round 
 and round iintil the pedicle gave way. 
 Macleod, of Glasgow, improved upon this 
 practice, and Hilliard, the Glasgow surgical 
 instrument-maker, modified some of the 
 instruments used by veterinary surgeons 
 in castration, in order to hold the pedicle 
 securely with one hand while the cyst is 
 held and twisted with the other. Macleod 
 
 has had one successful case, and his example 
 has been followed with good results in 
 Leeds. It is possible that there may be 
 cases where this method may be preferable 
 to the ligature or the cautery, but I can 
 say nothing on this point firom personal 
 experience. 
 
 As bleeding vessels low down in the 
 pelvis may have to be found and secured 
 where, the patient lying opposite the light, 
 the pelvis is in deep shadow, the surgeon 
 should be provided with a hand mirror to 
 reflect light to the bottom of the pelvis. 
 On a clear day this gives quite light 
 enough, but in dark weather, or when 
 operating late in the day, a candle lamp, 
 with a reflecting concave mirror, is service- 
 
 able. Collin's lamp is handy, but too 
 smalh A policeman's ' bull's-eye,' or a 
 good carriage lamp, is generally to be 
 had, and by the use of accumulators a 
 good reflected electric light may now be 
 obtained. 
 
 With regard to the other instruments, 
 it can only be necessary to repeat, that 
 the surgeon should be prepared with 
 scalpels, a probe-pointed bistoury, a broad 
 Key's director, fine strong pure ligature 
 silk, straight needles, forceps, and scissors. 
 
 I have for many years used forceps 
 with long handles, which answer all the 
 purposes of ' bull- dogs,' as well as of 
 artery and torsion forceps. The catch at 
 the handles serves to fix the instrument, 
 and the short, roughened points stop 
 
 bleeding completely, and enable the sur- 
 geon to twist the vessel if he wishes. 
 
 The forceps of Pean and Ko^berle 
 are either curved or angular. But both 
 have the disadvantage of a space between 
 the blades, which admits of entancrle- 
 ment of one instrument Avith another, or 
 of the passage of omentum or other 
 structures. This was a fault in my own 
 earlier instruments. It has been com- 
 pletely corrected in the later instruments 
 without at all lessening the compressing 
 power exerted on the vessel. 
 
 The handles meet without leaving any 
 opening between them. The rings do not 
 admit the thumb and finger too far ; and 
 the end which compresses the vessel is so 
 bevelled, that, if it be desirable to apply 
 
80 
 
 OVARIAN AND ALLIED TUMOURS 
 
 a ligature, the silk will easily slip over tlie 
 forceps, and not tie the blades together. 
 Thus my instrument is not only useful in 
 forci-pressure and in torsion, but enables 
 the surgeon to dispense with any other 
 
 kind of artery-forceps if he wish to apply 
 a ligature. 
 
 The distal end of the larger forceps 
 which I use for holding the pedicle in 
 ovariotomy, or any mass of tissue in 
 
 other operations where the temporary 
 command of bleeding or oozing vessels is 
 urgent, made upon the same principle, is 
 here represented of its ordinary size. 
 The pressure in use is ascertained to be 
 in pounds avoirdupois : 
 
 Large forceps — 1^ in. fulcrum — object 
 1 millimetre : 
 
 First catch Secoml catcli Third catch Fourth catch 
 20-10 82-8 47-8 60-0 
 
 All the instruments in known numbers 
 are placed on a table near the feet of the 
 
 patient and the right hand of the operator, 
 in shallow dishes, filled with a 2 per cent, 
 solution of phenol. The smaller forceps 
 are more conveniently arranged in up- 
 right trays, to which they are returned 
 
 immediately after use. A certain given 
 number being taken and counted before 
 the operation is begun, should also be 
 carefully counted before the abdomen is 
 closed. 
 
 CHAPTER VII 
 
 THE OPERATION OF OVARIOTOMY 
 
 DIVISION OF THE ABDOMINAL WALL ; SITUATION AND LENGTH OF INCISION ; SEPARATION OF 
 THE CYST ; EMPTYING AND REMOVAL ; TREATMENT OF THE PEDICLE ; SPONGING OF 
 THE PERITONEUM ; CLOSURE OF THE WOUND 
 
 We shall now suppose that the instruments 
 have all been placed where the surgeon 
 can reach them without moving from his 
 post ; that the patient has been placed on 
 the tabic, secured there by the thigh strap 
 nnd the wristbands, covered by the ad- 
 hesive waterproof sheet, and broUL'ht 
 under the influence of the anaesthetic. 
 The surgeon, standing on the right side 
 of the patient, with his right hand to- 
 
 wards the light, has one assistant on his 
 left hand, and another facing him on the 
 left of the patient. Nurses, with sponges 
 and the necessary articles already enume- 
 rated, are also behind and to the left of 
 the patient, while the administrator of the 
 ana-'Sthetic stands at her head, as shown 
 on page 7G. All is ready for the first step 
 of the operation, and we have now to con- 
 sider the situation and length of — 
 
THE OPERATION OF OVARIOTOMY 
 
 81 
 
 THE INCISION OF THE ABDOMINAL WALL 
 
 In all my cases the linea alba has been 
 selected as the seat of incision, and in a 
 very large majority of the cases on record 
 other operators have selected the same 
 situation. In some few cases the incision 
 has been intentionally carried either to 
 the right or left of this line. One o£ the 
 linea3 serailimares has been occasionally, 
 though very rarely, selected ; and in some 
 few cases oblique or transverse incisions 
 have been made. Thus Dr. Atlee in one 
 successful case made an incision 17 inches 
 long, from the symphysis pubis to the 
 middle of the crest of the right ilium. 
 Blihring made an incision at the outer 
 border of the external obhque on the 
 right side from the false ribs to the crest 
 of the ilium. 
 
 In one of the earliest cases in England, 
 Mr. King made a vertical incision, 7 or 8 
 inches long, to the right of the umbilicus, 
 and another 4 inches long at right angles, 
 extending towards the spine. In this case 
 no tumour could be found, and the patient 
 recovered. 
 
 Haartmann made an incision, 6 inches 
 long, parallel with Poupart's ligament ; 
 and Dorsey a vertical incision 8 inches 
 long met by a transverse incision in the 
 left side 6 inches long. These are the 
 principal examples on record of oblique 
 or transverse incisions. Vertical incisions 
 to one or other side of the linea alba have 
 been less uncommon. 
 
 McDowell, in his 1st and 2nd cases, 
 made his incisions 9 inches long, 3 inches 
 from and parallel to the left rectus. In 
 his subsequent cases he seems to hare 
 selected the linea alba. 
 
 Some writers, as Hamilton, who de- 
 scribes his incision as 'corresponding to 
 the inner margin of the right rectus,' 
 merely express in other words division 
 of the linea alba. The object is to avoid 
 either of the recti muscles. The only 
 operator, so far as I know, who prefers 
 division of one of the muscles, is Storer, 
 of Boston, who says, ' I differ from most 
 operators in that I prefer making the sec- 
 tion in the track of a rectus muscle rather 
 than in the linea alba, being thus much 
 more certain, from the nature of the tissue 
 divided, of a primary reunion.' 
 
 As I do not believe it possible that a 
 divided and reunited muscle, even when 
 complete imion results, can form so firm, 
 unyielding, and perfect a portion o£ the 
 
 abdominal wall as the muscle in its normal 
 state — as 1 do not think that division of 
 the muscle can make union of the skin, 
 peritoneum, or cellular tissue more certain 
 or complete — and as I have never seen 
 want of union when the recti had been 
 carefully avoided, I always endeavour to 
 divide the linea alba accurately, without 
 opening the sheath of either rectus. 
 
 It is not often easy to do this, for gene- 
 rally either the weight o£ the tumour has 
 drawn the recti to one side, or the muscles 
 have been spread out over the surface 
 of the cyst. Anato?nicalh/, it appears a 
 matter of some importance not to opeu 
 the sheath ; but, although it is well to try 
 to hit the linea alba exactly, it does not 
 appear of much importance surgically if 
 one edge of the muscle be exposed, or if 
 a division be made through the muscle 
 parallel with the course of its fibres. If 
 the incision be extended above the um- 
 bilicus, it is better to carry it round to 
 the left side, because the round and 
 suspensory ligaments of the liver pass 
 diagonally upwards and backwards at- 
 tached to the sheath of the right rectus, 
 and might be wounded if the incision 
 were carried either directly through the 
 umbilicus or to the right. In some cases 
 a wound of the ligaments might not be of 
 consequence, but in others it might lead 
 to serious heemorrhage, as the embryonal 
 umbilical vein is not always entirely obli- 
 terated, but remains patent, and is some- 
 times of considerable size. 
 
 When the linea alba is chosen for the 
 incision the following structures are suc- 
 cessively divided : 
 
 1. The skin. 
 
 2. The subcutaneous areolar tissue, 
 with fat of varying thickness. 
 
 3. The interlaced fibres of the aponeu- 
 roses of the abdominal muscles constitut- 
 ing the linea alba. 
 
 4. Layers of the fascia transversalis 
 with more or less fat. The uppermost 
 layer adheres closely to the linea alba. 
 The deepest layer is only very loosely 
 connected with the peritoneum. 
 
 5. The peritoneum. 
 
 But this normal arrangement is often 
 much modified. When there is muck 
 oedema of the abdominal wall the different 
 layers may be widely separated, and appear 
 as if increased in number; or they may be 
 agglutinated together by previous inflam- 
 matory processes; and the recti muscles 
 I are otten carried so much to one side by 
 
 Q 
 
82 
 
 OVARIAN AND ALLIED TUMOURS 
 
 the tumour that it is almost impossible to 
 avoid exposure or division of some of 
 their fibres. 
 
 The anatomical question may, perhaps, 
 be studied by the assistance of the ac- 
 companying diagrams, which show the 
 structures necessarily divided if the ab- 
 dominal wall be cut through — 
 
 1. AloD"; the linea alba. 
 
 2. Through one of the recti muscles, 
 and 
 
 3. Along one of the linese semihmares. 
 The effect of division in the upper and 
 
 lower part of the linea alba is also shown. 
 Let diagram (No. 1) represent the 
 layers just enumerated as divided, when 
 an incision is made through the anterior 
 abdominal Avail at the linea alba. 
 
 No. 1. 
 
 a. Umbilicus. 
 
 b. Skin. 
 
 c. Linea alba. 
 
 d. Symphysis. 
 
 e. Peritoneum. 
 
 /. Superficial layer of areolar tissue. 
 
 g. Deep layer of areolar tissue. 
 
 /i. Areolar tissue ricli in fat, or perimysium internum. 
 
 The following diagram (No. 2) will j on either side of the linea alba through 
 then show how many additional layers one of the recti muscles, 
 must be divided if the incision be carried | The diagram (No. 3) shows the layers 
 
 No. 2. 
 
 o. Umbilicus. 
 
 b. Skin. 
 
 c. The rectus muscle with its inserip- 
 
 tiones tendinea3. 
 
 d. Symphysis jjubis. 
 
 e. I'l'ritomuin. 
 
 f. Superficial layer of areolar 1 issue. 
 (J. Deep layer of areolar tissue. 
 
 divided if the incision be made along one 
 of the linea; semilunares. 
 
 All of the structures which make 
 up the anterior al)dominal wall, and are 
 arranged in the layers represented in the 
 preceding diagrams, arc of some interest 
 to the surffcon. 
 
 A. Perimysium internum. 
 /. Aponeurosis of e.\tcrn.^l oblirjue 
 
 muscle. 
 k. Aponeurosis of internal oblique 
 
 muscle. 
 /. Ajjoneurosisoftransversalis muscle. 
 m. Fascia transvcrsalis. 
 
 1. 21ie integument is thinner and more 
 sensitive between the sternum and the 
 umbilicus than in other regions. Around 
 the umbilicus it is not movable, being 
 firmly connected with the aponeurotic ring 
 by cellular tissue which contains no fat. 
 But when fluid, ovarian or ascitic, is free 
 
THE OPERATION OF OVARIOTOMY 
 
 83 
 
 in the peritoneal cavity, it often pasf^es 
 through the ring, and distends the integu- 
 ments into the sembhincc of an umbilical 
 hernia. Below the umbilicus the integu- 
 ment is very often found ojderaatous, and 
 any linese albicantes present then become 
 very prominent ; this condition does not 
 seem to interfere with union of the in- 
 cision by first intention. 
 
 No. 3. 
 
 a. Crest of the ilium. 
 
 b. Skin. 
 
 e. Peritoneum. 
 
 J'. Superficial layer of areolar tissue. 
 p. Fascia superticialis. 
 /). Perimysium internum. 
 i. Aponeurosis of external oblique muscle. 
 /;. Aponeurosis of internal oblique muscle. 
 /. Aponeurosis of the transversalis muscle. 
 m. Fascia transversalis. 
 
 2. The subcutaneous areolar tissue in 
 some parts of the abdominal wall presents 
 two distinct and separate layers. The 
 superficial layer is rich in fat-cells, and 
 contains the superficial blood-vessels. The 
 deeper layer has more the character of a 
 fibrous fascia, and is the proper fascia 
 superficialis. This separation is most 
 apparent in the hypogastric and inguinal 
 regions, and is more easily demonstrated 
 in old than in young persons. Of the 
 blood-vessels which ramify in the cellular 
 tissue, only the external epigastric artery 
 and vein are of praatical interest. The 
 artery, or one of its larger branches, is 
 more likely to be divided Avhen the in- 
 cision is along one of the line£B semilunares, 
 or through one of the recti muscles, than 
 Vvhen the linea alba is divided. But it 
 can be readily tied before the peritoneum 
 is opened. The external epigastric veins 
 are frequently enlarged or varicose when 
 tumours obstruct the current of blood along 
 the inferior vena cava. In some rare cases 
 a subcutaneous vein communicatesthrov.crh 
 
 the umbilical ring with the pervious um- 
 bilical vein. A slight deviation in the line 
 of incision will often enable tlie surgeon 
 to avoid enlarged veins ; and if this cannot 
 be done, it is advisable to stop, by i)ressure 
 forceps, the current of blood througli the 
 vein before it is divided. In this way, 
 what might bo otherwise a serious loss of 
 blood is jn-evented. It is not often neces- 
 sary to use a ligature after the forceps are 
 removed. 
 
 3. 27ie sheaths of the recti, complete 
 anteriorly, incomplete posteriorly from 
 about 2 inches below the umbilicus, formed 
 by the aponeuroses of the flat abdominal 
 muscles, and terminating in the linea alba, 
 hardly require more tlianapassingmention. 
 But if much disturbed during the first 
 incision, abscess is Ycry likely to delay 
 healing. 
 
 4. The recti and pyramidales muscles 
 are almost always seen, and one or other 
 may or may not be divided in ovariotomy. 
 When the recti are unusually broad near 
 tha pubes, the pyramidales may be absent. 
 When the recti are narrow below, the 
 pj'ramidales lying in front of the recti, and 
 inclosed in the sheath, are inserted into 
 the inner border o£ the sheath, half-way 
 between the pubes and the umbilicus, or 
 even higher. 
 
 5. The fibres of the flat abdominal 
 muscles cross each other in different di- 
 rections, embrace the recti muscles, and 
 conjoin on the linea alba, forming a ten- 
 dinous band, which is very strong at the 
 pubic end, and broader and weaker at the 
 sternal end. The fibres of the aponeurosis 
 on one side continue across the linea alba, 
 and interlace with fibres coming from the 
 opposite side, forming meshes which in 
 the normal state are very small, only giving 
 passage to nerves and vessels ; but which, 
 after great distension of the abdominal 
 wall, form apertures through which small 
 masses of fat may escape from beneath, 
 forming what have been called Hernias 
 adiposag, and often leading an inexperi- 
 enced ovariotomist to think that he has 
 opened the peritoneal cavity, and exposed 
 the omentum. 
 
 6. The umbilicus is merely one of 
 these openings in the linea alba ; but the 
 occasional permeability of the embryonal 
 umbilical vein must be borne in mind, as 
 well as the fact that the urachus may 
 also remain permeable, and urine escape 
 from the bladder through it at the umbi- 
 licus. I have never seen this in the 
 
 o 2 
 
84 
 
 OVARIAN AND ALLIED TUMOURS 
 
 adult; but in one case of ovariotomy I 
 found the urachus, though closed at both 
 endr, open for the whole length of my 
 incision in the abdominal Avail, and filled 
 by small urinary concretions. Usually it 
 is obliterated, and forms the vesico- 
 umbilical ligament running wp along the 
 linea alba from the bladder to the 
 ■umbilicus. 
 
 7. The deep fascia, or the layer of 
 areolar tissue between the iasoia trans- 
 versalis and the peritoneum, is very elastic, 
 and only loosely adherent, so that it is easy 
 to separate the peritoneum to a consider- 
 able extent without opening it. Indeed, 
 if fluid be free in the peritoneal cavity, 
 the membrane bulges up, like a bluish 
 thin-walled cyst, as soon as the deep fascia 
 is divided. 
 
 8. The peritoneum. It must be re- 
 
 membered that the obliterated umbilical 
 vessels and urachus, passing from the 
 fundus of the bladder to the umbilicus, 
 are covered by the parietal peritoneum. 
 The inferior epigastric arteries ascending 
 obliquely from Poupart's ligament to the 
 posterior surfixce of each rectus muscle, 
 also lie between the peritoneum and the 
 integument. The fold from the umbilicus 
 forming the suspensory ligament of the 
 liver has been already alluded to. It is 
 with the later steps of the operation that 
 the peritoneum and its reflections have 
 the most important relations. In con- 
 nection with the first incision it is only 
 necessary to add that it must be useless 
 to carry this incision nearer to the sym- 
 physis pubis than the reflection of the peri- 
 toneum from the anterior abdominal wall 
 to the bladder; and it is a safe rule to 
 
 stop short of this point, ai:id not carry the 
 lower end of the incision nearer than 2 
 inches from the symphysis pubis. 
 
 As a rule, the abdomen is tense, and 
 the incision is made with an ordinary 
 scalpel held in the first position, as shown 
 in this drawing. If the operation is per- 
 formed soon alter tapping, and the abdo- 
 minal walls are very lax, it is convenient 
 to mark, with ink or chalk, the exact line 
 and extent of the incision intended to be 
 made, and then, holding up a fold of in- 
 tegument, to transfix with rather a long 
 bistoury, and complete the incisifin of the 
 skin with one stroke of the knife. The 
 linea alba and any fat behind the recti 
 muscles may then be carefully divided in 
 the usual way, until the peritoneum is 
 reached. A point also which ought not 
 to be forgotten at this stage of the opera- 
 tion is the possible expansion of the blad- 
 
 der, behind the abdominal wall, by the 
 pressure of the tumour. It is sometimes 
 found flattened, and extending above the 
 umbilicus, covering a space as much as 8 
 to 9 inches long, and as much wide. I 
 gather from the ' Transactions of the 
 American Gynecological Society,' 1881, 
 tliat 22 cases had been recorded in 
 which the bladder had been accidentally 
 o])ened, of which 14 were known to have 
 died. 
 
 If there is any fluid free in the peri- 
 toneal cavity, the peritoneum bulges 
 into the deep gaj) made by the incision, 
 looking like a dark thin-walled cyst, and 
 it has oi'ten been mistaken for a cyst; 
 extensive separation has been made of 
 .supposed adhesions, while the operator 
 was really stripping the peritoneum from 
 the abdominal wall. When the peritoneum 
 bulges as just described, it should always 
 
THE Oi'ERATIOX OF OVArJOTOMY 
 
 85 
 
 be opened, and the fluid allowed to escape, 
 which may be done without wetting the 
 patient or its running over the floor, if the 
 waterproof apron is so held as to direct 
 the fluid into the foot-pan under the 
 table. Even if the biilging membrane 
 were not the peritoneum, but a thin- 
 walled adherent cyst, no liarm could be 
 done by this puncture, as it is certainly 
 a good plan to empty the cyst belbre 
 separating the adhei^ions. AVhen there is 
 no fluid free in the peritoneal cavity, and 
 an ovarian C3^st is not adherent, it is 
 necessary to divide the peritoneum very 
 carefully, or the cyst might be punctured 
 and its contents discharged into the peri- 
 toneal cavity. The peritoneum should 
 
 be raised with a hook or forceps, the 
 double sharp hook of Adams answering 
 
 the purpose perhaps better than any 
 oilier instrument. The membrane is then 
 divided by one or two horizontal touches 
 of the knife, as shown in the next draw- 
 ing, and an opening made large enough 
 to admit the insertion of a broad director. 
 The instrument known as Key's hernia 
 director is that which I prefer. The end 
 is rounded in imitation of a finger-nail ; 
 the groove does not extend within half an 
 inch of the point, and far greater safety 
 from the danger of wounding overlapping 
 intestine is thus attained than by the use 
 of the ordinary narrow directors, where 
 the groove runs quite to the end. Upon 
 this director a blunt-pointed bistoury is 
 passed, and the peritoneum divided to the 
 full extent of the incision in the akin. 
 
 On inquiring as to the different 
 lengths of incision in 1,000 cases, and 
 comparing the mortality per cent, with 
 incisions above and below 6 inches, 
 there was found at all stages of my pro- 
 
 gress the same difference of about 17 
 per cent, of deaths between the long 
 incisions and the short incisions. The 
 length of the incision, however, is little 
 else than an indication of the gravity of 
 the case, as it cannot be supposed that 
 2 or 3 inches more of simple division of 
 the parietes of the abdomen would much 
 augment the danger. 
 
 The smooth pearly aspect of most 
 ovarian tumours is sufficiently character- 
 istic for immediate recognition, and free 
 movement of the cyst is often visible. 
 But, when a cyst is adherent, it is often 
 extremely difficult to find out the exact 
 limits or boundary between cyst and 
 peritoneum, and, rather than make any 
 improper or dangerous separation, it is 
 better to extend the incision upwards and 
 downwards until some point is reached 
 where the cyst is not adherent. From 
 that point separation of adhesions may be 
 commenced. When there is much fat 
 
 in the abdominal wall, either in front of 
 or behind the recti muscles, this should 
 be divided by as clean a cut as possible, 
 going through nearly the whole thickness 
 of fat by one stroke of the knife ; for, if 
 the fat be much disturbed, troublesome 
 suppuration about the wound is very 
 likely to occur. During the progress of 
 the incision bleeding may be tolerably 
 free, but very often scarcely any blood 
 is lost ; and, as soon as the incision has 
 reached the peritoneum, the wound should 
 be carefully cleansed from the blood by 
 soft linen or sponges. Any A'essel seen 
 to bleed should be conipi-essedby pressure- 
 forceps. It is important to stop all bleed- 
 ing from the wound before the peritoneum 
 is opened. It is seldom that any large 
 vessel is divided, but if the compression 
 of the forceps or torsion does not at once 
 .stop bleeding, one or more ligatures may 
 be used and both ends may be cut off 
 short close to the knot. 
 
86 
 
 OVARIAN AND ALLIED TUMOURS 
 
 SEPARATION OF THE CYST 
 
 I have j ust said that if a cyst is so closely 
 adherent that it is difficult to ascertain its 
 exact bonndarie?, it is better to empty it 
 before attempting to separate it, than to 
 run any risk either of separating the 
 peritoneum from the abdominal wall, or 
 of so rupturing the cyst that its contents 
 
 might escape into the peritoneal cavity. 
 And adhesions to the intestine or omentum, 
 especially those at the posf-erior part of 
 the cyst, are also better left until the cyst 
 is emptied and drawn out; the separa- 
 tion being completed when the parts to 
 be separated are in full view. When 
 
 adhesions are loose, or not extensive, and 
 the cyst has been distinctly made out 
 after the division of the peritoneum, thead- 
 hesions may generally be easily separated 
 by one or two fingers, or by inserting the 
 whole hand between the cyst and the 
 abdominal wall — the palmar surface next 
 the tumour, and the fingers curved to 
 adapt the shape of the hand to the con- 
 vexity of the cyst. Sometimes extensive 
 adhesions yield before a very slight force, 
 but very considerable effort is occasionally 
 required to break them down. Adhesions 
 are very rarely so firm that it becomes 
 necessary to complete their separation by 
 knife or scissors ; when this is the case, it 
 is better to cut away some small portion 
 of the cyst and leave it adhering to the 
 intestine or other viscus, than to do any 
 damage by attempting to take away 
 every fragment of the cyst. I have, 
 however, very rarely done this ; as, aiter 
 the cyst has been separated from the 
 abdominal wall, emptied and drawn out 
 with the adhering portions of intestine 
 and omentum, I have almost always 
 been able to make complete separation, 
 although great care has often been neces- 
 sary to avoid injury to the intestine. I 
 have twice opened intestine when separat- 
 ing adhesions, but accurate adaptation of 
 the peritoneal coat by suture has pre- 
 
 vented any mischief. In one case I re- 
 moved about 3 inches of diseased and 
 adlierent intestine, and obtained complete 
 union of the ofien ends by 2 rovvs of 
 suture through the peritoneal coat only. 
 Occasionally, instead of separating ad- 
 hering omentum, it is better to divide j 
 it at some unattached point, after the 
 application of a ligature or pressure- | 
 Ibrceps, allowing the adhering portion to 
 be removed with the cyst. The per- 
 manent suppression of bleeding from i 
 
 separated omentum or parietal adhesions 
 is left until after the emptying of the 
 cyst, securing the pedicle, and cutting 
 away the tumour. 
 
 EMPTYING AND REMOVAL OF CYST 
 
 When the tumour is found fi-ee from 
 adhesions, or after the separation of slight 
 adhesions, the next step is to empty the 
 cyst. Tlie syphon trocar with spring- 
 hooks, held in the right hand, should be 
 
THE OPERATION OF OVARIOTOMY 
 
 87 
 
 pushed into the most prominent part of 
 the cyst, if this appear to be simple ; if 
 muhilocular, into that chamber which is 
 likely to contain the largest quantity of 
 fluid. The point is to be drawn within 
 the canula by means of the thumb-piece. 
 After a portion of the fluid has been 
 drained olF, and the cyst has become more 
 flaccid, it is drawn higher up over the 
 canula, and fixed between the prongs of 
 the spring-hooks, which, if properly ad- 
 justed, will hold the cyst-wall tightly 
 around the canula. After the first cavity 
 has been emptied, a second, a third, and 
 more if necessary, may be tapped suc- 
 cessively without removing the canula 
 from its hold, merely by pushing the 
 trocar forward and thrusting it through 
 the septum which seimrates the emptied 
 from the adjacent full cavity. In this 
 manner the whole tumour may be emp- I 
 tied of its fluid contents, and its bulk so I 
 
 reduced tliat it may be drawn through the 
 abdominal opening without undue force. 
 In a case where there are several cysts 
 which cannot be tapped one through the 
 other, they must be emptied singly, either 
 by tlie same trocar or by another. Great 
 care must be taken, if the same trocar be 
 used, not to perforate the main cyst Avail, 
 lest some fluid should escape into the 
 abdominal cavity. 
 
 Having succeeded in reducing suffi- 
 ciently the size of the tumour, the surgeon 
 then draAvs it through the incision, at the 
 same time breaking down any adhesions 
 Avhich have not been separated before. 
 The assistant opposite to the operator noAv 
 places his hands on either side of the 
 incision, and prevents the prolapse of the 
 viscera by carefully keeping the edges of 
 the incision in close approximation. He 
 does this best by placing the middle finger 
 of his right hand inside the abdomen. 
 
 hooking xip the abdcminal wall, and then, 
 by the thumb on one side of the opening 
 and the forefinger on the other side, he 
 holds the .edges of the opening close to- 
 gether. And he should not alloAV his 
 attention to be diverted from this very 
 important part of his duty. The assistant 
 at the operator's left hand supports the 
 cyst until it is completely separated, and 
 then receives it in a toAvel or basin. No 
 traction Avhatever is permitted, and the 
 greatest precaution ought to be observed 
 in this respect Avhen the pedicle is short, and 
 when there remain undivided adhesions. 
 
 In order to lessen the weight of the 
 tumour, cysts Avhich had not been emptied 
 before may be punctured, and secondary 
 cysts, if the sejjta are thin, may be broken 
 down by the hand, as shoAvn in next 
 column. Great care ought to be taken 
 that nothing gravitates into the abdominal 
 cavity. 
 
 But it Avill not be always possible to 
 reduce the bulk of the timiour sufficiently 
 to bring it through the original incision. 
 
 Tumours are sometimes met with Avhich 
 consist of solid or semi-solid unyielding 
 masses, or they are divided by trabecule 
 into small cavities filled Avith viscid, 
 colloid substance, Avhich cannot be broken 
 
 doAvn, and Avill not pass through the 
 canula. It Avill therefore become neces- 
 sary to enlarge the incision upAvards. 
 This is less dangerous than any attempt 
 at squeezing a large tumour through a 
 narrow outlet ; either the cyst may burst, 
 
88 
 
 OVAKIAN AND ALLIED TUMOURS 
 
 and its contents escape into the abdominal 
 cavity, or the edges of the wound are so 
 bruised that union by first intention might 
 be prevented, or the peritoneum so in- 
 jured that i'atal peritonitis or gangrene | 
 may result. ] 
 
 In a few of my earliest cases I followed 
 the practice of previous operators of hav- 
 ing flannels, wrung out of water at 96^, 
 carefully wrapped round the cyst or any 
 intestine that escaped, and to protect the 
 peritoneal cavity. But I discontinued 
 this practice, finding that it was impossible 
 to prevent small filaments of wool separat- 
 ing from the flannel and adhering to the 
 peritoneum. Then I used soit linen 
 towels, but for many years past only soft 
 sponges, although towels Avetted with 
 warm carbolised water are often useful to 
 cover a large tumour, and protect the 
 intestines. As the cyst is drawn through 
 the opening, a thin flat sponge, G or 8 
 inches in length and about 4 in breadth, 
 should be pass-ed inwards and left between 
 the intestines and the open abdominal 
 •wall. This serves the double purpose of 
 preventing escape of intestines, and pro- 
 tecting the cavity from the entrance of 
 anything from outside, or from cooling 
 when spray is used. 
 
 TREATMENT OF THE PEDICLE 
 
 The cyst or tumour having been 
 drawn out of the abdomen, any omen- 
 tum or intestine adhering to its peritoneal 
 coat separated, and any bleeding vessel 
 secured, the intestines and peritoneal 
 cavity protected as just described by a 
 flat sponge, tl.-e next step is to secure the 
 j>edicle. This has been done in different 
 ways, def;cribed as the intra-peritoneal 
 and the extra-peritoneal methods. 
 
 The older operators, McDowell and 
 Clay especially, adopted a plan Avhich 
 may be considered a combination of both 
 methods. The pedicle was tied, the 
 tumour cut away, and the pedicle was 
 left low down in the abdominal cavity, 
 surrounded by the ligature, while the ends 
 of the ligature were brought out between 
 the edges of the wound. Half an inch to 
 an inch of the lower angle of the wound 
 was left unclfised to admit of the passage 
 of the ligature, as an outlet for dis- 
 charges, and for the removal of the liga- 
 tures and of the tissues strangulated by 
 them. 
 
 The intra-peritoneal method was ori- 
 
 ginated, in 1822, by Nathan Smith, who 
 tied two arteries in the omentum with 
 strips of leather from a kid glove. He 
 also tied two arteries in the pedicle with 
 leather ligatures, and after removal of the 
 tumour, cut off the ends of the ligatures 
 short, and left them within the peritoneal 
 ca\ity, closing up the wound completely. 
 He was followed by Kogers, of New York, 
 Avho, in 1830, also tied some large vessels, 
 cut off the ligatures ' close to the knot, 
 and left them to absorption.' In Enfjland 
 this method was revived by Dr. Tyler 
 Smith, and was followed by many ope- 
 rators. After several years' preference of 
 the extra-peritoneal method, it has again 
 come into favour since the adoption of the 
 antiseptic system. 
 
 The other intra-peritoneal methods 
 include the use of the cautery, the ecia- 
 seur, the twisting off of the tumour, 
 torsion of its ve.ssels, or the separate liga- 
 ture of the vessels of the pedicle only or 
 of the pedicle itself. In cases where 
 there is no pedicle and the cyst has to be 
 enucleated from between the layers of the 
 broad ligament, ligatures of bleeding ves- 
 sels, or of parts of the broad ligament, 
 have almost compelled the adoption of the 
 intra-peritoneal method, since the danger 
 of leaving the ends of the ligature passing 
 outwards has been understood. 
 
 In the extra- peritoneal method, instead 
 of shutting up the pedicle and ligature, 
 or the eschar made by the cautery, within 
 the peritoneal cavity, the pedicle and the 
 clamp or ligature securing it are carefully 
 fixed outside the closed wound. 
 
 I continued to folloAv, though not 
 exclusively, the extra-peritoneal treatn)ent 
 of the pedicle for twenty years. The 
 clamp was put on for the last time in case 
 910, August, 1878. I generally used the 
 clamp alone, sometimes combined with the 
 ! ligature, and in a small number of cases 
 I was obliged to make a pin and ligature 
 serve as a clamp. My extra-peritoneal 
 treatment compri-sed in all G91 cases out 
 of the 1,000 upon which the calculations 
 in this book are founded. The mortality in 
 the entire group — including the greater 
 mortality of the earlier years — was 20 2 
 percent. I used the clamp alone 023 times, 
 losing 20*22 per cent. The clamp and 
 ligature combined were attended with a loss 
 of 30-Gl per cent., and when the pin and 
 ligature wore employed the deaths went 
 up to 35 "23 per cent. The bad nature of 
 the cases was the cause of the combination, 
 
THE OPERATION OF OVARIOTOMY 
 
 89 
 
 and accounts for the great mortality. But 
 the clamp alone furnished me with a 
 lower rate of mortality, 20*22 per cent., 
 than the aggregate of the 1,000 cases, 
 23"2 per cent., and the results from it were 
 more favourable than those of any other 
 kind of treatment, except that by the 
 cautery. It contrasted well with the 
 ligature, especially during the early years, 
 when the returned ligature caused me a 
 mortality of 49"12 per cent., though ulti- 
 mately this came down to 20' 19 percent., 
 as near as possible the same as the clamp. 
 When I looked into the question of mor- 
 tality among my first 500 cases, and Ibund 
 that the clamp gave me a mortality of 
 5 per cent, less than that of the mortality 
 of the whole series, and that the ligature 
 raised the death-rate 19 jier cent, above 
 that of the clamp, I felt that I had full 
 justification in persevering with the extra- 
 peritoneal treatment. In the second series 
 of 500 cases the clamp mortality was 
 again below that of the general mortality, 
 and within a fraction the same as that of 
 the cases in which the ligature was used, 
 by this time down to 20*19. Even during 
 the last two years of my hospital practice, 
 1876-1877, when the diminution in the 
 rate of mortality from 21 to 10 per cent. 
 
 took place, I was using the clamp in more 
 than two-thirds of the cases. These 
 results prove that I was not wrong in 
 acting as I did; and that, judging by all 
 the evidence forthcoming at the time, 
 except that witli regard to the cautery, 
 the clamp extra-peritoneal treatment of 
 the pedicle was better than any other I 
 had adopted. Upon the whole, it is 
 questionable whether, if I had at an early 
 period given up the clamp and worked 
 my way with the ligature through all the 
 difficult problems presented by the novel 
 conditions of the cases as they successively 
 came under treatment, the result would 
 have been better, or even so good. At 
 any rate, such treatment was at one with 
 the accepted doctrines of the day about 
 the pedicle, which, some contend, still 
 hold good in reference to the stumps of 
 uterine tumours; and it had compensa- 
 tions for some of the evils which, so long 
 as the question of contagion was over- 
 looked, attended the use of the ligature. 
 
 Although the clamp is now almost 
 disused, it is so simple, safe, and rapid a 
 mode of dealing with the pedicle for an 
 inexperienced operator, that it is well to 
 repeat the directions for its use given in 
 my edition of 1872. 
 
 The next drawings were made when 
 I was actually applying the form of clamp 
 which I last used. The tumour was held 
 up by one of the assistants, the clamp 
 passed round the pedicle, as shoAvn in the 
 above drawing, and one hand is shown 
 pressing the blades of the clamp together 
 
 by the forceps, which should be held very 
 firm while the screw which fixes the 
 clamp is being tightened by the other 
 hand, as shown in the next woodcut. 
 After the tumour has been cut away, it is 
 sometimes necessary to tighten the clamp 
 or the screw still further. The assistant 
 
90 
 
 OVARIAN AND ALLIED TUMOUES 
 
 keeps the abdominal wall closed around 
 the pedicle, as shown in the same drawing, 
 also from the life ; while the surgeon, 
 holding the clamp-forceps with his left 
 hand, fastens the screw with his right, 
 assisted by the needle-holder. 
 
 It Avould seem unnecessary to add 
 that the surgeon should be careful not to 
 enclose anything but the pedicle in the 
 clamp, but the fact that cases are on 
 record where a portion of the bladder has 
 been squeezed.^ and where one ureter has 
 
 been strangulated, and that I have myself 
 seen a strij) of omentum several times, 
 and a coil of intestine once, very narroAvIy 
 escape constriction, shows that the caution 
 is not uncalled for. 
 
 The pedicle with the clamp should be 
 fixed as near to the lower end of the in- 
 cision as can be done without traction, 
 and the edges of the wound are brought 
 in contact around it. 
 
 Any superfluous portion of the pedicle 
 protruding beyond the clamp is cut off, 
 but not quite close to the clamp, for this 
 would lead to the danger of the pedicle, 
 as it shrinks, sinking or being drawn in- 
 wards. It is as well to leave about a 
 quarter of an inch protrudmg beyond the 
 clamp, and this should be touched with 
 solid perchloride of iron, by which the 
 tissue is tanned until it becomes quite 
 dry and is preserved from decomposition. 
 
 Those Avho exclusively follow the 
 intra-peritoncal method, and either use 
 the cautery or return the ligature and 
 close the Avound, appear to have been 
 influenced ' by objections to the extra- 
 peritoneal method which seem to me to 
 be either groundless or trivial. AVhen 
 the pedicle is held outside the wound by 
 a clamp or in any other way, the pull 
 upon the uterus or broad ligament is said 
 to be very painful ; but 1 have seen a 
 good deal of pull with very little pain, 
 and much more severe pain in cases 
 where the ligature was used than I ever 
 saw in clamp cases. So with sickness : 
 I have seen as much or more after the 
 
 ligature or cautery, as I ever saw after 
 the clamp. It is said to set up fetid 
 discharge and poison the wound or the 
 patient ; and so it does if proper care be 
 not taken. But if the strangulated part 
 of the pedicle which projects beyond the 
 clamp be well saturated with perchloride 
 of iron, the slough is tanned ; it becomes 
 as hard and dry as a piece of leather, and 
 there is an end to that objection. It is 
 said to cause suppuration about the 
 wound ; but this, again, I have seen both 
 after the ligature and cautery. I never 
 saw more profuse suppuration of the 
 stitches than in one case where I divided 
 the pedicle with the ecraseur, and closed 
 the wound Avith platinum-wire sutures. 
 Then, after the wound is closed, it is said 
 to lead to a reopening each month, and aa 
 escape of some menstrual fluid. And 
 this is true in seme — perhaps in nearly a 
 third — of the cases. But if the patient 
 be prepared for it, it is not of the slightest 
 consequence. The Fallopian tube almost 
 always contracts completely after a few 
 months, and there is no further escape. 
 I can only recollect two cases where it 
 has continued up to the date of the last 
 report from the patient, and then it 
 caused but slight inconvenience. As to 
 any fancied impediment to the increase of 
 the uterus in pregnancy, and to its con- 
 traction during labour, from the adhesion 
 of the tube to the cicatrix, I can say that 
 many women have had 1 child, some 
 2, some 3, and others as many as G 
 or 7 children ; and in no case has 
 
THE OPERATION OF OVAiaOTOMY 
 
 91 
 
 any unusual suffering been referred to 
 the adhesion of the pedicle to the ab- 
 dominal wall. One real objection to the 
 clamp is that it may possibly pull on 
 intestine, or a tense pedicle may strangu- 
 late intestine. But this objection is of 
 little weight if the use of the clamp is 
 restricted to cases where the pedicle is so 
 long that tliere is not much drag on the 
 clamp. Where, however, we have a 
 broad, thick, short pedicle, or a broad 
 connection between uterus and cyst 
 rather than a distinct pedicle, Ave have 
 the choice between one or other of the 
 intra-peritoneal methods; and since the 
 great success which has attended the 
 combination of antiseptic ovariotomy and 
 the complete intra-peritoneal treatment 
 of the pedicle, the extra-peritoneal method 
 
 may be considered as almost abandoned, 
 and we have to choose between the liga- 
 ture and the cautery. 
 
 In ligaturing the pedicle of an ovarian 
 tumour, it is never safe to trust to a 
 ligature which does not transfix the 
 pedicle, unless this be very long and 
 slender. Many cases are on record 
 where, after cutting away the tumour, a 
 simple encircling ligature has slipped off, 
 and dangerous or iatal bleeding has fol- 
 lowed. It should be a rule, therefore, 
 always to transfix a pedicle, and, accord- 
 ing to its size, to tie it in two or more 
 portions, before the cyst is cut aAvay. A 
 long ordinary needle double-threaded, 
 or a long blunt-pointed, straight or curved 
 needle on a handle, may be used. The 
 latter is saier and more convenient if 
 
 the pedicle cannot easily be brought 
 Avell outside the abdomen. Both threads 
 having been carried through the same 
 puncture, one is tied above and one below 
 the Fallopian tube, as shown in the 
 sketch, a second turn having been given 
 to the first loop to prevent slipping when 
 the second turn securing the knot is 
 made. For additional security a separate 
 ligature may be tied between the two 
 first passed and the uterus. Mr. Bryant 
 and some other operators think it im- 
 portant that one loop should be laced 
 within the other, as shown in the lower 
 sketch. But I rather avoid this, as it is 
 possible that by so tying the second knot 
 the first may be loosened. Supposing a 
 clamp or pressure-forceps to have been 
 first applied, the cyst cut away, and the 
 pedicle then transfixed and tied between 
 
 the forceps and the uterus, the clamp 
 must be loosened or the forceps removed 
 before the ligatures are tightened. If 
 this is not done, the knot cannot be tied 
 so tight as to be secure after the clamp 
 is removed. As the clamp is taken off, 
 the tissues compressed by it retract, and 
 are apt to slip from under the ligature. 
 This can only be avoided by tightening 
 the ligature simultaneously with the 
 loosening of the clamp or removal of the 
 forceps. Mr. Doran's observations lead 
 him to the conclusion that ' it is much 
 more dangerous to draw the ligatures a 
 little too firmly, than to leave them some- 
 what looser than is strictly advisable ; * 
 and Mr. Thornton considers the presence 
 of blood-clot on the cut surface of the 
 stump ' as the pei'fect condition to aim at 
 in the treatment of the ovarian pedicle 
 
92 
 
 OVARIAX AND ALLIED TUMOURS 
 
 by ligature. This cap of blood-clot shows 
 that the ligatures, while tight enough to 
 prevent serious haemorrhage, were not so 
 tight as to cut off all supply from the 
 distal portion of the stump.' I differ 
 entirely both from Mr. Doran and Mr. 
 Thornton, and — fearing that a loose ligature 
 will become looser as the included tissue 
 shrinks, that bleeding would be probable, 
 and that unless a ligature sinks deeply 
 into, or forms a deep groove in the 
 pedicle, the surfaces of peritoneum on 
 either side of it are less likely to unite, 
 cover up the silk, and maintain the 
 vitality of the stump — I alway.s tie the 
 ligature as tightly as I can. 
 
 If it be desired only to tie the vessels, 
 this may be done by feeling the arteries, 
 and carrying a ligature round them 
 through the pedicle before the cyst is cut 
 away ; or, after the application of forceps 
 and removal of the cyst, holding the 
 pedicle carefully as the forceps are re- 
 moved, and tying any vessel Avhich bleeds. 
 The great objection to this plan is, that 
 there is often much loo.se cellular tissue, 
 rich in small veins, which go on oozing 
 after all the larger vessels have been tied. 
 Whichever may be the plan preferred, the 
 important question arises : Shall the ends 1 
 of the ligatures be cut off, and the wound 
 closed ? or shall they be left hanging out | 
 through a part of the wound, purposely 
 left open for their passage, and that of the 
 slough they embrace when it separates? 
 Dr. Clay, of Manchester, advocated this 
 latter practice. In its favour, it has been 
 taid, that it is a method applicable in all 
 cases ; that it secures an oiuiet for serum 
 from the peritoneal cavity ; and that, after 
 the separation of tlie ligature and slough, 
 no foreign body is left within the patient. 
 But it seems to me that the ligature- 
 threads act as a sort of seton in the peri- 
 toneal cavity, excite the formation of the 
 serum for which they are said to provide 
 the outlet, and counteract antiseptic pre- 
 cautions. Having tried both methods, 
 the results very soon led me to discontinue 
 this practice, and to drain by a glass tut)e 
 rather than by the ends of a ligature. On 
 this question of drainage 1 sliall have more 
 to say hereafter. One objection is, that 
 even if the patient recover, there is a great 
 liability to ventral hernia. The cicatrix 
 remains weak at the spot where tlie tube 
 or ligatures passed out, and it yields before 
 the pressure outwards of the viscera. I 
 have seen this in nearly every case where 
 
 I adopted this plan. ' In several it followed 
 the clamp, and in some, but in smaller 
 proportion, where the complete intra-peri- 
 toneal method was practised, and I have 
 come to the conclusion that if we use one 
 or more ligatures, it is better to cut off 
 the ends short, and close up the wound 
 completely. "Wire has been used for the 
 ligature, but it seems an irrational practice. 
 Silk, if pure, is an animal substance ; and 
 experiment proves that it may be ab- 
 sorbed. Wire cannot be absorbed, and 
 must be more or less of a mechanical 
 irritant. I tried wire on one side and 
 silk on the other side of a sheep on 
 which Professor Gamgee operated ibr 
 me, and the superiority of the silk Avas 
 manifest. What we have to look to is 
 the effect on the tissues strangulated, 
 rather than the material by which the 
 strann'ulation is effected. Catgut has been 
 used, but I know of nothing to show that 
 it is superior to carbolised silk. Professor 
 Billroth thinks it necessary to boil the 
 silk in a 5 per cent, solution of carbolic 
 acid, and there is no objection to do this. 
 His results certainly improved after using 
 boiled silk. 
 
 Supposing there is no true pedicle — 
 that the cyst is more or less completely 
 encapsuled in a layer of broad ligament, 
 or an expansion of the peritoneimi — this 
 capstile may be divided, and the cyst shelled 
 out of it, or the base of the cyst with its 
 enveloping capsule may be transfixed and 
 tied in two or more portions before cyst 
 and covering are cut away. This is what 
 many operators have termed a very short 
 broad pedicle. In some cases the Fal- 
 lopian tube, more or less elongated, is so 
 closely attached to the capsule that it is 
 better to include it in the ligatures, and 
 cut away all the attached part. In others 
 it is imaltei-ed, and quite iree from the 
 capsule. Then it is better not to interfere 
 with it. The ovary also may be either 
 free or attached. If normal and free, this 
 also is better left undisturbed; but if 
 closely attached, or, as it sometimes is, 
 stretched into a cordiike or flattened 
 outer layer of the cyst wall and capsule, 
 its removal is almost inevitaVjle. In case 
 of doubt it is better to remove than to 
 leave it, even if separation is not difli- 
 cult. 
 
 If, after enucleating a cyst, any con- 
 sidcral)Ic part ot the capsule remain, and 
 especially if any oozingof blcod continties 
 from the inner surliice, all the loose part 
 
THE OPERATION OF OVARIOTOMY 
 
 93 
 
 of the capsule should be drawn up, its 
 base transfixed and tied, and tho capsule 
 cut away. In the very rare cases where 
 a cyst cannot be enucleated from the 
 capsule or broad ligament, or from the 
 retro-peritoneal attachments, we must 
 either be content with removing the fluid 
 contents and closing the abdominal cavity, 
 or employ drainage. The choice of the 
 two methods should be determined by the 
 character of the contents of the cyst. If 
 clear, watery fluid only, the safer practice 
 is to close the abdomen. But if colloid, 
 or purulent, or dermoid, drainage is cer- 
 tainly the preferable practice. 
 
 The question, what becomes of a 
 ligature, and of the tissues strangulated 
 by it, when closed up in the peritoneal 
 cavity, is a very important one. It is 
 certain that the changes differ Avidely 
 from those which follow the use of the 
 ligature when the ends are left to pass out 
 through the partially closed wound. In 
 this case they lead to free discharge of 
 serum or pus, until the separation of the 
 ligature and the slough. Whatever may 
 be the material of the ligature, the tissues 
 strangulated by it come away after a 
 process of suppuration ; and if anything 
 like what goes on outside the body when 
 one of the extra- peritoneal methods is 
 adopted, or when the wound is left open 
 for the ligatures, went on when the wound 
 is closed, no patient could survive the 
 process. She would certainly be poisoned 
 by absorption of the fetid products of the 
 decomposing stump. A very different 
 series of changes must go on when the 
 wound is closed and access of air shut off. 
 Experience shows that patients survive 
 the process; and examination of those 
 who have died has shown that a pedicle 
 secured by a silk ligature has been found 
 some days afterwards, either, first, sur- 
 rounded by coils of adhering intestine ; 
 second, as the centre of a purulent cavity ; 
 third, very little altered, with the lisature 
 deeply imbedded Avithin it ; and fourth, 
 completely dead or gangrenous. All these 
 different conditions I have actually seen 
 accompanied by more or less evidence of 
 peritonitis, and depending more, I believe, 
 on the general health of the patient and 
 the conditions in which she was placed, 
 than upon any difference in the material 
 of the ligature or the mode of its applica- 
 tion. I must now, of course, add that 
 among the conditions in which the patient 
 is placed, we attach paramount importance 
 
 to the presence or absence of infective or 
 putrefying mattei-. 
 
 Our knowledge of this subject has 
 been greatly increased by the report of 
 the experiments of Spiegelberg and Wal- 
 deyer. Their experiments were arranged 
 in two series : 1. Excision of portions of 
 the horns of the uterus of bitches, leaving 
 the ligatures in the peritoneal cavity; 
 and 2. Removal of portions of the uterus 
 by the galvanic cautery. The conclusions 
 of the experimenters are that small foreign 
 bodies may be left in the peritoneal cavity 
 Avithout danger, and that strangulated and 
 cauterised tissues do not become gan- 
 grenous, and are not injurious to neigh- 
 laouring parts, provided only that the 
 abdominal cavity is perfectly closed. 
 
 As to the ligatures, they show that they 
 are absorbed after their fibres have been 
 separated and disintegrated by the ingrowth 
 of cells from neighbouring parts. They 
 are generally encapsuled, but may some- 
 times be found free in the peritoneal 
 cavity or in cystic cavities of ihe stump. 
 The divided surfaces adhere to some ad- 
 jacent structures and form vascular com- 
 munications without any trace of gangrene. 
 New cells spring up from the tissues around 
 and unite with the granulations of the cut 
 surfaces. There is no trace of gangrene 
 in the ligatured part, and new cell forma- 
 tions enclose the ligature. 
 
 The vessels of cauterised parts are 
 blocked by clot, and the dead tissue is en- 
 capsuled by growth of new cells. In 14 
 or 21 days the cauterised surfaces are 
 covered over by new tissue formed from 
 the cells supplied by the surrounding 
 structures. 
 
 Maslowsky corroborated the observa- 
 tions of the German experimenters, and 
 showed that the eschar from cauterisation 
 is first covered by effused fibrine, and 
 afterwards united by membrane with sur- 
 rounding organs. The white corpuscles 
 participate in the formation of the new 
 membrane, in which capillaries may be 
 found as soon as the 4th or 5th day. 
 
 In some respects the experiments are 
 satisfactory, as they tell us what really does 
 take place when a ligature or an eschar 
 is shut up in the peritoneal cavity ; and 
 we may resort to the cautery or the 
 ligature with a pretty accurate idea of the 
 process of repair and of the dangers which 
 may attend this process. 
 
 Doran, in two papers in the loth 
 and 14:th volumes of ' St, Bartholomew's 
 
94 
 
 OVARIAN AND ALLIED TUMOURS 
 
 Hospital Reports,' gives the results of 
 his own observations of 10 cases where 
 he examined the ligature and pedicle at 
 various periods after ovariotomy ; all 
 proving that the tied or strangulated 
 stump is not killed, but that ' a communi- 
 cation between the distal and proximal 
 parts of the stump is established by in- 
 flammatory plastic effusion, and the liga- 
 ture is unravelled by granulation-cells 
 insinuating themselves between its fibres.' 
 He also shows that the distal part of the 
 stump may soon form an intimate adhesion 
 with the neighbouring broad ligament. 
 
 It must not be forgotten that even 
 in healthy dogs and rabbits Avhere the 
 ligature or the cautery was considered by 
 the German experimenters to have been 
 most successful, adhesion of the tied or 
 cauterised part to the bladder, to intestine, 
 and to neighbouring folds of peritoneum, 
 has been the rule, just as in cases which I 
 have placed upon record where adhesion 
 of the tied or cauterised pedicle to intes- 
 tines has led to fatal strangulation. Even 
 if not fatal, such adhesions are more likely 
 to lead to obstruction of intestine more 
 or less serious and prolonged, and to be 
 permanently injurious, than the mere 
 adhesion of a pedicle to the abdominal 
 wall. 
 
 Acupressure was once applied success- 
 fully by Sir James Simpson. He secured 
 the pedicle by passing a long needle 
 through the abdominal wall, across the 
 pedicle, and out again. The pedicle was 
 thus compressed by the needle on the 
 outside of the abdominal wall in the left 
 iliac region. 
 
 Sir William Fergusson once tried this 
 plan, but was obliged to resort to the 
 ligature. I have never tried it myself, 
 though I have more than once found 
 acupressure useful in stopping bleeding 
 from vessels torn in separating adhesions. 
 
 The ecraseur has been used for the 
 compression and crushing of the pedicle 
 and separation of the tumour ; after which 
 the pedicle is dropped into the abdominal 
 cavity and the wound closed. Grave 
 objections, however, against this practice 
 are the possibility of hfemorrhage and its 
 dangers, and the difTiculty of finding and 
 securing the bleeding pedicle in the depth 
 of the abdominal cavity after having re- 
 opened the wound. This would be 
 especially difficult if haemorrhage occurred 
 after some lapse of time. I once used the 
 Ecraseur and successfully ; but I have not 
 
 ventured on it again, for fear that bleeding 
 might occur. This danger might be pre- 
 vented by tying a ligature below the 
 ecraseur chain, before separating the cyst 
 and dropping the pedicle into the abdomi- 
 nal cavity. But then it would be only a 
 modification of other methods of liga- 
 tures. 
 
 The cauterji alone Avould fail to stop 
 such large vessels as are fi'equently met 
 with in a pedicle. So might the crushing 
 which precedes the division by the ecraseur. 
 But the comhinalion of crushimj and the 
 cauterji is certainly efficacious in a con- 
 siderable proportion of cases. Clay, of 
 Birmingham, introduced the practice and 
 carried it out by his adhesion clamp and 
 hot irons, both for dividing adhesions and 
 omentum. The practice was extended to 
 the pedicle by Baker Brown, and has 
 since been used chiefly by Keith. It is 
 claimed for it that in most cases it effec- 
 tually stops hsemorrhage during the opera- 
 tion and prevents it afterwards, that it 
 leaves only a very thin layer of burnt 
 tissue at the end, and is followed only 
 by the changes described in a former 
 page. This method is of most value in 
 cases when the pedicle is broad, thick, and 
 short ; it does not answer well when large 
 vessels ramify in a thin membranous 
 pedicle. Notwithstanding the great ad- 
 vantage of the cautery, its use is attended 
 by serious drawbacks. Vessels not un- 
 frequently bleed on opening the blades of 
 the clamp, and a repetition of the whole 
 tedious proceeding, or the use of ligatures, 
 is necessary before the pedicle can be 
 returned into the abdomen with safety. 
 The instrument used for compressing the 
 pedicle and various cauteries, with the 
 mode of using them, have been described 
 in the last chapter. 
 
 When dividing the pedicle and sepa- 
 rating the cyst, the utmost care must be 
 taken to prevent any of the contents 
 entering the abdominal cavity. Shtmld 
 this happen notwithstanding all the pre- 
 cautions taken to avoid it, the cavity 
 must be carefully sponged and cleaned of 
 all extraneous substance with soft sponges 
 wrung out of Avarm carbolised water. 
 
 The omentum, the mesentery, and the 
 situations of the adhesions to the anterior 
 abdominal wall will often be found the 
 seat of haemorrhage, either from the 
 orifices of large vessels or from capillary 
 oozing. The bleeding must be stopped 
 by tying the vessels with ligatures, the 
 
THE OPERATION OF OVAEIOTOMY 
 
 95 
 
 ends of which are to be cut off close to 
 the knot, or by toi-sion, or by the pressure 
 of a needle passed across. 
 
 The following table shows the results 
 o£ my own trials of various modes of 
 dealing with the pedicle in 1,000 cases : 
 
 
 
 o 
 
 .a 
 
 3 o 
 
 
 
 497 
 
 126 
 
 P, ^ 
 
 Clamp .... 
 
 623 
 
 20-22 
 
 Tin and ligature acting 
 
 
 
 
 
 as clamp . 
 
 17 
 
 11 
 
 6 
 
 8.5-23 
 
 Clamp and ligature 
 
 49 
 
 .-54 
 
 15 
 
 30-61 
 
 Ligature returned 
 
 260 
 
 191 
 
 69 
 
 26-53 
 
 Ligature brought out . 
 
 14 
 
 6 
 
 8 
 
 ,57-14 
 
 Cautery 
 
 16 
 
 14 
 
 2 
 
 12-5 
 
 (Cautery and ligature . 
 
 14 
 
 10 
 
 4 
 
 28-57 
 
 ]''craseur and pin 
 
 2 
 
 2 
 
 
 
 
 
 Forceps and ligature . 
 
 1 
 
 
 
 1 
 
 100 
 
 No ligature — enuclea- 
 
 
 
 
 
 tion .... 
 
 o 
 
 3 
 
 
 
 
 
 Cyst wall sewed to 
 
 
 
 
 
 abdominal wall 
 
 1 
 
 1,000 
 
 
 
 1 
 
 100 
 
 768 
 
 232 
 
 23-2 
 
 As soon as the pedicle has been 
 secured, the tumour removed, and bleed- 
 ing vessels have been tied, the other ovary 
 should be examined. It is found by 
 grasping the fundus of the uterus, and 
 passing the hand downwards along the 
 tube and side of the uterus. The sur- 
 face may be irregular from recently 
 matured follicles, but these need not lead 
 to interference unless the ovary is two or 
 three times its normal size. If any 
 follicles are very large, they may be 
 punctured, and the clot they contain 
 squeezed out. If the ovary is hardened 
 or enlarged, it should be removed. When 
 the clamp was used the pedicle has some- 
 times been long enough to admit of the 
 application of two clamps outside the 
 abdominal wall with little more incon- 
 venience to the patient than one. In 
 other cases I have transfixed the pedicle 
 of the second tumour, tied it in two or 
 more portions, brought it outside, and 
 tied it to the clamp securing the first 
 pedicle. Recently I have always tied 
 bfith pedicles with silk, cutting off the 
 eiids short, just as when only one ovary 
 has been removed. 
 
 Besides examining the second ovary, 
 the state of the uterus should be ascer- 
 tained. It may be enlarged by pregnancy, 
 or by fibroid growths. In one case, after 
 completing ovariotomy, I also removed a 
 fibroid outgrowth ii-om the fundus uteri. 
 This patient died, and I think she would 
 
 have recovered if I had left the uterus 
 alone, as I have done in several cases 
 since, where the size of the growths was 
 insignificant. But when they have been 
 large enough to cause much inconveni- 
 ence, I have removed them at the same 
 time as the ovarian tumour. In one case 
 the patient recovered after removal of a 
 uterine tumour nearly as large as the 
 ovarian, and from another I successfully 
 removed a dermoid cyst of the left ovary, 
 and a fibroid outgrowth from tlie right 
 side of the uterus at the one operation. 
 
 SPONGING OF THE PERITONEUM 
 
 Before proceeding to close the wound, 
 the peritoneal cavity must be thoroughly 
 cleansed from any iluid or clot which it 
 may contain. A good deal of Iluid may 
 be pressed out, or scooped out by the 
 hand ; but complete cleansing can only 
 be attained by using many clean, soft 
 sponges in succession, passing them well 
 down behind and in front of the uterus, 
 along each flank in front of the kidneys, 
 and over the abdominal wall wherever 
 adhesions have been separated. Any 
 clot which may be seen or felt among the 
 coils of intestine or folds of omentum 
 must be removed. When I began to 
 insist upon the importance of this process, 
 Avhicli Worms described as la toilette du 
 pe'ritoinc, other operators said that it was 
 unnecessary or injurious ; that ovarian 
 fluid in the peritoneum was harmless ; or 
 that the time lost in removing it, and the 
 in-itation caused by the sponging, Avere 
 greater evils than a little fluid or blood 
 left in the cavity. Impressed by these 
 objections, I was in one case less careful 
 than usual in sponging away ovarian fluid. 
 A fatal result followed, and I have ever 
 since been extremely careful to remove 
 all by thorough sponging, and have been 
 Avell satisfied with the results. I have 
 regretted incomplete sponging, never that 
 I had been too careful. And it is con- 
 venient to insert a large, flat jjiece of 
 sponge just within the wound, and leave 
 it all the time that the sutures are being 
 passed. It catches any drops of blood 
 Avhich may follow the j^assage of the 
 needles, and if spray be used protects the 
 cavity from the cooling eff'tjct of the spray 
 or the entrance of carbolic acid. 
 
 CLOSURE OF THE WOUND 
 
 The next step will be to close the 
 wound. In my early cases I did this by 
 
96 
 
 OVArJAX AND ALLIED TUMOURS 
 
 passing hare-lip pins through the whole 
 thickness of the abdominal wall at inter- 
 vals of an inch. Each pin perforated the 
 skin about an inch, and the peritoneum 
 about half an inch, from the incision on 
 either side ; so that when the two op- 
 posed surfaces were pressed together upon 
 the pin, two layers of the peritoneum 
 were in contact with each other. But I 
 soon began to prefer sutures to pins, and 
 tried different materials for this purpose. 
 After repeated trials I found thin strong 
 Chinese silk superior to other materials 
 ibr closing the wound, as I had for tying 
 the pedicle. For some years I have 
 soaked the silk in a 5 per cent, solution 
 of carbolic acid before using it, and Bill- 
 roth's experience proves that it may be 
 safer to boil the silk. 
 
 The most convenient manner of ap- 
 plying the sutures is the following : Silk 
 about eighteen inches in length is threaded 
 at each end on a strong straight needle. 
 Each needle is introduced by a holder 
 from within outwards, through the peri- 
 toneum and the whole thickness of the 
 abdominal wall, at about one-third of an 
 inch from the cut edges of peritoneum 
 and skin on either side — pinching up 
 peritoneum and skin together, so that the 
 silk may be carried through both without 
 perforation of the recti muscles. The 
 ends of the sutures are held by the assist- 
 ant, who draws up the lips of the wound 
 until all the deep sutures have beea 
 applied. Then the lips of the wound 
 are held apart again, in order that the 
 operator may convince himself that no 
 
 further bleeding has taken place within 
 the abdominal cavity, which, if required, 
 has to be sponged again, and the protect- 
 ing sponge removed. Tliis done, the 
 sutures are tied, carefully adapting the 
 edges of the skin to each other with<nit 
 inversion or eversion, and the ends of the 
 threads are cut off. If the abdominal wall 
 is very thick, superficial sutures may be 
 required between the deep ones. If the 
 pedicle has been secured by the clamp, a 
 suture should be passed close to the latter, 
 in order to bring the lips of the Avound 
 so accurately around the pedicle that the 
 peritoneal cavity is perfectly closed. 
 
 DKESSING AND BANDAGE 
 
 After the closure of the wound, the 
 abdomen is carefully cleaned and dried, 
 
 the india-rubber cloth removed, and the 
 woimd covered with some non-irritatin" 
 antiseptic gauze, or salicylic or boracic 
 wool, and supported by long strips of 
 adhesive plaster. In many cases the false 
 ribs have been pressed outwards by the 
 tumour, and after its removal a 'deep 
 hollow is left. This must be filled up 
 with puds of cotton-wool. A flannel belt 
 is fastened around her abdomen by pins, 
 and the patient is then gently removed to 
 her bed. She is kept on her back, her 
 knees supported by a pillow, is covered 
 with light but warm blankets, and pro- 
 vided Avith hot-water bottles, if .she is at 
 all chilly. Tlie room is darkened, and she 
 is left alone witli her nurse. After ovari- 
 otomy and other serious operations, pa- 
 tients rally much more rapidly if the head 
 be kept wa-m, covered up with a shawl or 
 
ACCIDENTS DURING OVARIOTOMY 
 
 97 
 
 flannel. "When we reflect how tempera- | is well established may be very advan- 
 ture is lowered by cooling the head, it tageous. If reaction is slow, the head 
 is not difhcult to understand that warm- should not be raised by pillows, but kept 
 ing the head until reaction after shock I low. 
 
 CHAPTER VIII 
 
 ACCIDENTS DURING OVARIOTOJIY 
 
 Fainting is an accident which may happen 
 in any operation, and before the use of 
 aniEsthetics was not uncommon, I have, 
 however, never been embarrassed in my 
 ovariotomies by this condition. And 
 only in one case has the methylene 
 caused any trouble. Then the pulse 
 became for a while imperceptible, and 
 we Avere obliged to give brandy. The 
 woman rallied. She had some thoracic 
 complication, and though the cyst only 
 contained about 16 pints of fluid, yet, as 
 the removal was very quickly over, it is 
 possible that the enfeebled heart and 
 lungs were unable to accommodate them- 
 selves to the sudden change of pressure. 
 
 Out of the 127 deaths which followed 
 my first 500 operations, 20 were put 
 down as the effect of exhaustion, and 
 none from haemorrhage ; while in the 
 second series of 105 deaths there were 
 only 8 from exhaustion and 2 from 
 haemorrhage. The probability is that 
 some of the first series of deaths were 
 also partly due to bleeding, but the fact 
 was not established by examination. The 
 deaths from exhaustion were mostly at 
 the end of 2 or 3 days, but in 1 as early 
 as 13 hoars. No case of collapse after 
 the operation happened in the second 
 series, but in the first there were 6 cases 
 — the time being fi:om 2 hours to about 
 40 hours. No death has ever occurred 
 during the operation either from shock 
 alone or the anaesthetic. 
 
 Thus out of the 232 deaths after 
 1,000 operations only 36 are immediately 
 attributable to shock and ha3morrhage, 
 a proportion lessened by increased ex- 
 perience. The remaining mortality o£ 
 196 w;is due to other causes; and, con- 
 sidering the large proportion of septic 
 disease which proved fatal during the 
 earlier years, was to a great extent 
 avoidable. The mortality of 3'6 per 
 cent, from shock and hemorrhage cor- 
 
 responds very nearly with the results of 
 Keith's practice, in which there are very 
 few deaths recorded as from secondary 
 causes ; while in my own experience in 
 private cases and since adopting Listerian 
 details, I have had only 3 immediate 
 deaths, 2 from cardiac embolism in about 
 20 hours, and one from hgemorrhage 
 almost immediately after the patient was 
 in bed. But this was not a case of ovari- 
 otomy only. It occurred since the com- 
 pletion of the 1,000 cases, and I unwisely, 
 after removing an ovarian tumour, at- 
 tempted to remove a cyst of the liver. 
 In one case of secondary bleeding which 
 came on shortly after the operation was 
 finished, I reopened the wound, put 
 another ligature on the pedicle in lieu of 
 the one which had slipped, and left the 
 patient not the worse for the accident. She 
 got rapidly well. In another case I feared 
 that the patient was dying of internal 
 bleeding, but the father and brother, both 
 medical men, were opposed to the reopen- 
 ing of the wound, and would not permit 
 an examination after death, so that I am 
 not quite sure how far my fear was well 
 founded. In 1882 secondary bleeding 
 occurred a few hours after operation on a 
 lady aged 62. I opened the wound, found 
 that the ligature had slipped, transfixed 
 and tied the pedicle, sponged out the 
 peritoneal cavity, and reclosed the wound 
 — assisted by Mr. Fuller of Piccadilly. 
 The patient did not seem much the worse 
 for the accident, but she died on the 5tli 
 day. 
 
 Burst cysts and suppurating cysts do 
 not seem to have lowered the success of 
 my operations. There have been 15 such 
 cases, 12 burst cysts and 3 sup[)urating 
 cysts, among my 1,000 operations, and 
 only 1 death resulted. My experience 
 of 139 cases since the 1,000 gives 6 cases 
 where the cysts had burst ; of these 3 re- 
 covered and 3 died. 
 
98 
 
 OVARIAN AND ALLIED TUMOUES 
 
 Injuries to viscera. — Several cases are 
 on record, and I have heard of others not 
 recorded, where the bladder has been 
 injured either in making the first in- 
 cision or in separating adhesions between 
 the cyst and the bladder. Should the 
 bladder be injured, the opening should 
 be very carefully closed by suture, and a 
 catheter maintained in the bladder for 
 several days. As a rule the effects Imve 
 not been serious, although in some cases 
 the urine has drained through the wound 
 for several days. In one case where I 
 had cut into a patent urachus from which 
 urine escaped, I closed the opening by 
 one of the sutures which closed the in- 
 cision in the abdominal wall, and no 
 inconvenience followed. In 1881 Pro- 
 fessor Billroth, in making a double ovario- 
 tomy, was obliged to resect part of the 
 bladder and some inches of small intestine 
 on account of adhesions between these 
 parts. And in another double ovai-iotomy, 
 done at the Salp^triere by Professor Pozzi 
 in December 1882, though all due precau- 
 tions had been taken to empty the bladder, 
 there was found, after opening the peri- 
 toneum, a layer of what appeared to be a 
 membranous expansion, the product of 
 Bome old inflammation. An incision of 
 at least 10 centimetres, corresponding 
 with that in the peritoneum, was made 
 through this. After removing the two 
 ovaries, and when preparing to close the 
 abdominal wound, the supposed mem- 
 brane, on being examined, proved to be 
 the bladder. It had in no way con- 
 tracted after the use of the catheter, and 
 the hand could be easily passed into it 
 through the wound. Professor Pozzi had 
 therefore to deal with a wound of both the 
 anterior and posterior coats. The posterior 
 one he closed completely with sutures. 
 That in front was partially sewn up, and 
 the opening left was made to correspond 
 exactly with a part of that in the 
 aV)dominal wall. A siphon-tube was 
 arranged to drain away the urine, and 
 the bladder was, from time to time, 
 washed out with a solution of boracic 
 acid. By the end of January the urine 
 began to pass naturally ; in March the 
 fistula Avas closed, and the woman entirely 
 recovered. 
 
 The rectum has been torn or divided 
 (luring the separation of adhesions, in some 
 cases with fatal consequences ; in otliers, 
 where accurate closing has been efrected 
 by suture, recovery has followed without 
 
 any ffecal fistula. In a patient on whom 
 I operated in July 1876, removing a 
 tumour of the right ovary, the left having 
 been removed 3 years before, the cyst 
 was drawn out with a coil of adherent 
 intestine. This was carefully separated, 
 but not without a tear, leaving an open- 
 ing sufficiently large to admit one finger, 
 I inverted the edges of the opening so as 
 to bring two surfaces of the peritoneum 
 in apposition, united them by a continuous 
 silk suture, and the patient recovered 
 without any ill effect from the accident. 
 In another case operated on in the 
 Samaritan Hospital in June 1875, in re- 
 moving a malignant growth weighing 
 41 poiuids, I also detached and cut away 
 about 3 inches of small intestine, the coats 
 of which were involved in the disease. 
 The upper and lower ends of the gut were 
 brought together and united by peritoneal 
 suture, but the patient died on the 11th 
 day. Although some fa2cal fluid had 
 escaped from the wound in the abdominal 
 wall, the bowels had acted freely in a 
 natural manner, and it appeared that the 
 wound in the intestine had but little to 
 do with the fatal result. The practical 
 lesson from this is to be extremely careful 
 when separating adhesions between the 
 cyst and intestine, and if the intestine is 
 either accidentally wounded, or a diseased 
 portion is intentionally removed, the 
 union of the peritoneal edges by fine 
 sutures must be very accurately com- 
 pleted. 
 
 The liver has been injured during the 
 separation of adhesions. In one case, in 
 an insane patient under the care of Mr. 
 Archer, of St. John's Wood, I removed 
 some ounces of the lower edge and under 
 surface of both lobes of a large liver. I 
 had considerable trouble in stopping the 
 bleeding, and applied perchloride of iron 
 freely. The ovarian cyst for which I was 
 operating was a very large one, and the 
 patient in an extremely feeble condition 
 after repeated tappings, yet she recovered 
 rapidly and completely as in the most 
 simple case, is still alive, and has regained 
 her soundness of mind as well as body. 
 In one other case, already alluded to, I 
 lost a patient from hajmorrhage after 
 opening a cyst which projected from the 
 under surface of the liver, tl:e walls of 
 which poured out blood with extreme 
 rapidity in spite of all efforts to check it. 
 I have never met with a case in 
 which the spleen has been injured during 
 
ACCIDENTS DURING OVARIOTOMY 
 
 99 
 
 ovariotomy ; but an enlarged spleen has 
 been occasionally mistaken for an ovarian 
 tumour, and splenic cysts mistaken for 
 ovarian cysts have been removed more 
 than once. Should either of these mis- 
 takes be recognised after beginning an 
 operation, the surgeon must act exactly 
 as if he were doing splenotomy. 
 
 If a kidney should be unavoidably or 
 accidentally removed with, or instead of, 
 an ovarian tumour, as much care would 
 be called for in securing the blood-vessels 
 as in a case of nephrectomy planned be- 
 forehand. One or both ureters are known 
 to have been divided or tied accidentally. 
 In Simon's famous case, where a urinary 
 fistula remained after injury to the right 
 ureter, Simon removed the right kidney, 
 and I saw the Avoman some months after- 
 wards in excellent health. In a similar 
 case Nussbaum, instead of removing the 
 kidney, re-established communication be- 
 tween the kidney and the bladder. It is 
 remarkable that in cases of adhesions low 
 down in the pelvis the ureters should 
 escape injury so often as they do. I sus- 
 pect that their condition has been over- 
 looked in some post-mortem examina- 
 tions, and it is probable that in some of 
 the cases where suppression of urine has 
 been a prominent symptom, one or both 
 ureters may have been injured. I have 
 heard of one case where after death one 
 ureter was found tied. 
 
 After passing the sutures which are to 
 close the opening in the abdominal wall, 
 and before tying them, the sponges and 
 forceps should be counted. It is a good 
 plan to take a fixed number of sponges 
 and forceps to every operation. By for- 
 ceps I mean the torsion or pressure-for- 
 ceps, the use of which has been already 
 described. Of these I always take 12, of 
 sponges 20. If any other than the usual 
 fixed number be taken, some doubt is al- 
 most certain to arise when the nurse is 
 told to count the sponges. Very small 
 sponges are so easily lost, that it is ad- 
 visable not to use any which when wet 
 are smaller than an ordinary fist. Even 
 then it may not be easy to find one when 
 wet in the peritoneal cavity. It is a good 
 rule for the surgeon strictly to forbid either 
 of his assistants to put a sponge within 
 the abdominal cavity. JMo one should be 
 allowed to divide a sponge. One of my 
 f;-iends abroad writes that in one of his 
 i'atal cases a sponge was found in the peri- 
 toneal cavity. He had suspected that a 
 
 sponge might be within the abdomen at 
 the end of the operation, but could not 
 find it, and on counting the sponges the 
 number was complete. It afterwards ap- 
 peared that one had been torn into two 
 by one of the nurses. No one who has 
 not tried it can understand how difficult 
 it may be sometimes to find a lost sponge. 
 In my lectures as Hunterian Professor 
 at the Royal College of Surgeons in June 
 1878, I gave the following account of a 
 case in which I left a pair of forceps in 
 the abdomen. 'Not very long ago I 
 removed both ovaries, and a great many 
 forceps were used. After removing one 
 ovary and securing the pedicle, the other 
 ovary had to be removed. It had a very 
 short pedicle, and 5 or G of my torsion- 
 forceps were put on in order to secure the 
 bleeding vessels, while I was tying them 
 separately. I took off, as I thought, every 
 pair of forceps, closed the wound, and 
 everything seemed quite as it should be. 
 But about 2 hours after the operation 
 I received a message from a friend who 
 was putting up the instruments for me, to 
 say there was a pair of forceps missing. 
 We knew exactly the number of forceps. 
 If we had not known that, one pair 
 would not have been missed. This shows 
 how necessary it is always to know how 
 many forceps are taken. It was about 5 
 in the afternoon when I had this message : 
 ' There was a pair of forceps missing, pro- 
 bably they might be in the patient.' Ima- 
 gine the sort of feeling with which one 
 would receive that intimation. I at once 
 went to the patient. She seemed so well 
 that I did not like to disturb her. There 
 was some doubt where the forceps might 
 be, so I thought I would wait a little 
 longer. I waited till night; she still 
 seemed pretty well, and I thought I would 
 wait till the morning ; but in the morning 
 the nurse told me the lady had been very 
 restless. I then made a very careful 
 examination, by the vagina, and rectum, 
 and abdominal wall, to see if I could feel 
 the forceps, but there was nothing to be 
 felt at all. Still I was uneasy, and I 
 thought I had better open the wound. 
 So I gave her methylene, removed the 
 dressing, and took oat two stitches. I 
 put one finger in, but at first could not 
 feel the forceps. At last I found some- 
 thing hard, put another finger in, and 
 found the forceps wrapjDed up in the 
 omentum. From the way in which the 
 omentum had insinuated itself into the 
 
 H 2 
 
100 
 
 OVARIAN AND ALLIED TUMOURS 
 
 ring handles of the forceps, it was easy to 
 understand how difficult it was to find 
 and remove the instrument ; but I did it, 
 returned the omentum, closed the wound, 
 and the patient was none the worse. She 
 got well, and to this day does not know 
 that anything unusual occurred.' 
 
 I purposely avoid relating a case where 
 a pair of forceps was found in the bladder 
 of a patient a month after recovery from 
 ovariotomy, as the occurrence is still to me 
 inexplicable. It did impress upon me, how- 
 ever, what I had often before told others, 
 that the surgeon should take all the instru- 
 ments and sponges — not allow assistants or 
 nurses to supply either — and never to 
 
 neglect counting both. I ought to have 
 added that this should be done before 
 closing the wound, and thus avoid such 
 an unpleasant accident as happened to me 
 last year in a case, where I was operating 
 without either of my usual assistants. 
 The patient was in bed before the forceps 
 were counted. One pair was missed before 
 she had quite recovered from the anass- 
 thetic; a little more was given. I took 
 out two stitches, and found the forceps 
 without much difficulty. The patient 
 made a good recovery. I repeat the cau- 
 tion, always to count both sponges and 
 forceps before closing the opening in the 
 abdominal wall. 
 
 CHAPTER IX 
 
 ON THE REMOVAL OF BOTH OVARIES AT ONE GPEt^ATION 
 
 Some writers on ovarian disease have 
 asserted that the right ovary is much 
 more frequently diseased than the left, 
 and that coexisting disease of both ovaries 
 is extremely rare. But, on examining 
 the grounds for these assertions, we find 
 that they are principally based upon 
 examination of patients during life, or 
 patients who have not been submitted to 
 ovariotomy. 
 
 When we come to examine the result 
 of post-mortem examinations we find that, 
 as there is no anatomical or physiological 
 reason why the right ovary should be 
 more frequently affected than the left, so, 
 in fact, one ovary is found to be diseased 
 as oilen as the other. 
 
 Of 80 cases collected by West from 
 Scanzoni, Lee, and his own notes of 
 post-mortem examitiations, in 28 the 
 disease was on the right side, in 26 on the 
 left side, and in 26 both ovaries were 
 diseased — so that in about one-third of 
 the cases both ovaries were diseased. In 
 186.") Scanzoni again drew attention to 
 this subject in a paper 'On the Relation 
 of Disease of both Ovaries to the Ova- 
 riotomy Question.' He gives the result 
 of an examination of the reports of post- 
 mortem examinations for the previous 
 14 years by Virchow and Fiirster. 
 These records were examined with 
 the sole object of ascertaining in how 
 many cases one or l;)Oth ovaries were 
 
 diseased. In 99 cases of ovarian disease 
 it was found that in 48 one, and in 51 
 both ovaries were diseased — so that in 
 more than half the disease was on both 
 sides. The tendency to disease of both 
 ovaries appears to be greater before the 
 age of 50 than in older women. Of 52 
 women under 50, both ovaries were 
 diseased in 31 ; 1 ovary only iia 21 
 (59 per cent, to 40). Of 44 Avomen 
 above 50, both ovaries were diseased in 
 17 only, while 1 ovary was diseased in 
 27. Thus, imder 50, we had both ovaries 
 diseased in 59 per cent. ; above 50, only 
 in 38 per cent. 
 
 But it must be remembered that any 
 conclusion drawn from post-mortem exa- 
 minations would in all p'-obability differ 
 very widely from results observed in ova- 
 riotomy. The first series of facts shows 
 what may be expected when ovarian 
 disease has proceeded to its natural termi- 
 nation, or lias only been modified by pal- 
 liative treatment. The otlier series shows 
 what may be expected when the patient is 
 subjected to radical treatment before the 
 disease has advanced to its last stages. All 
 observation tends to the conclusion that 
 disease begins in one ovary and advances 
 to a considerable extent in that ovary be- 
 fore the other is affected, and that in about 
 half of the cases it proceeds even to its 
 fatal termination without any disease 
 occurring in the opposite ovary. 
 
THE REMOVAL OF BOTH OVARIES AT ONE OPERATION 101 
 
 If, then, in only about half of the 
 cases where ovarian disease has reached 
 its latest stage, disease of both ovaries is 
 found, we might expect that in earlier 
 stages of the disease both ovaries would 
 be much less frequently affected ; and so 
 far as my observation has gone, this is the 
 fact. In the 1,139 cases in which I have 
 performed ovariotomy I only removed 
 both ovaries in 102 cases. In a few other 
 cases the ovary not removed presented 
 some indications of disease in a very early 
 stage, but not sufficient to warrant its 
 removal. 
 
 It is not improbable that in some of 
 the earlier cases slight disease of the 
 opposite ovary may have been overlooked ; 
 but, making every reasonable allowance 
 for such error, it is not probable that both 
 ovaries will be found diseased in more 
 than about 10 per cent, of the patients. 
 
 As to the frequency with which, after 
 successful ovariotomy, the ovary not re- 
 moved, but examined and found healthy, 
 becomes diseased, 4 came under tny notice 
 up to the year 1872, and since then there 
 have been 10 others. 
 
 In my 2nd case, operated on in 
 1858, the patient remained well for 7 
 years. Then disease of the opposite 
 ovary appeared, so evidently of a malig- 
 nant character that no operation was 
 thought of, and soft cancer was found 
 after death. 
 
 In the ord case, also operated on in 
 1858, the patient died of peritoneal cancer 
 10 months after operation, and disease had 
 commenced in the remaining ovary, which 
 was enlarged to the size of an apple. 
 
 In my 43rd case, operated on in 
 18G2, disease of the opposite ovary came 
 on 2 years afterwards, and was treated 
 successfully by vaginal tapping and drain- 
 age. The patient remained well till 1872, 
 when Dr. Sadler, of Barnsley, had again 
 to give relief by vaginal tapping. She 
 died in 1874. 
 
 Other cases where disease occurred 
 in the ovary left at the first operation, 
 and led to a second ovariotomy on the 
 same patient, are mentioned in the next 
 chapter. 
 
 It has been already explained how, 
 afler removing one ovarian tumour, the 
 surgeon should examine the other ovary. 
 In the majority of cases it is healthy and 
 
 whether any cysts projecting from its 
 surface should be punctured and their 
 contents squeezed out, or whether it is 
 more prudent to be content with the re- 
 moval of one ovary, hoping that the other 
 will never need surgical interference, or 
 postponing that interference till after 
 recovery from the first operation. In 
 determining which practice to follow, the 
 age of the patient, her conjugal condition, 
 and the ease or difficulty with which the 
 second operation could be performed, are 
 the leading points for consideration, 
 
 I have little doubt that the removal of 
 the second ovary does add somewhat to 
 the danger of the operation. U we deduct 
 from the 1,000, 82 cases where both 
 ovaries were removed, this would reduce 
 the number of single operations to 918 
 and the deaths to 204, with a mortality 
 of 22-2 per cent. But as of the 82 cases 
 of double ovariotomy 28 died, the mor- 
 tality is 34-14 per cent., or more than 12 
 per cent, above that of the single cases. 
 Of 139 cases since the 1,000 both ovaries 
 were removed in 20 ; of these 7 died, a 
 very large mortality compared with that 
 where only 1 ovary was removed ; but 
 I should add that in 2 of the 7 fatal cases 
 uterine tumours were also removed, and 
 in 1 the death was caused by hsemorrhao-e 
 from a liver cyst. This is sufficient to 
 show that the surgeon should not remove 
 the second ovary without good reason. 
 I have several times been begged by 
 patients before the operation to remove 
 the second ovary, even if it were healthy 
 and the risk of the operation increased, in 
 order that they might be spared from the 
 possibility of being again subject to similar 
 disease ; and medical men have occasion- 
 ally supported this not unnatural wish of 
 the patient. I have always replied that 
 I should object to the removal of a healthy 
 organ if that removal endangered the 
 success of an operation which was clearly 
 necessary ; that the second ovary cannot be 
 removed without some additional risk; 
 that, as a rule, the removal of one ovary 
 Avould not be followed by disease of the 
 other; that the double operation would 
 necessarily render the woman sterile, and 
 that there might possibly be some conse- 
 quences of the removal of both ovaries 
 which would be objectionable if not di- 
 rectly prejudicial. For these reasons I 
 
 should not be disturbed. But occasionally | am of opinion that a healthy ovary should 
 it is more or less enlarged ; and it becomes not be removed from any woman at any 
 a question whether it should be removed, | age, unless Battey's operation has to be 
 
102 
 
 OVARIAN AND ALLIED TUMOURS 
 
 considered. This subject will be treated 
 in a subsequent chapter. 
 
 The amount of apparent disease in an 
 ovary Avhich would justify the removal of 
 the organ may vary with the age and con- 
 dition of the patient. In a woman past 
 the ao-e of child-bearing a sniidl amount 
 of apparent disease would justify removal 
 of the ovary, whereas a surgeon should 
 hesitate before he condemns a young 
 woman to permanent sterility. It has 
 been suggested that in every woman past 
 the age of child-bearing, if one ovary has 
 to be removed both should always be taken 
 away, to avoid the possibility of recur- 
 rence of disease calling for a second ova- 
 riotomy. But one would hardly be justi- 
 fied in adding anything to the risk of a 
 first operation on so small a probability as 
 there is of recurrence of non-malignant 
 disease on the other side. 
 
 Sometimes during an operation, after 
 removal of one ovary, some slight altera- 
 tion in the other may be observed, and 
 the question of removal of the second 
 ovary may arise. In many of my cases 
 this question has arisen. In my 112th 
 case of ovariotomy the left ovary was en- 
 
 larged to nearly double the normal size. 
 Two follicles, about the size of cherries, 
 were distended by clot. These I laid 
 open, turning out their contents. The 
 operation was peculiar on account of the 
 doubt as to the treatment of the left ovary. 
 I resolved not to remove it. This opera- 
 tion was performed in November 1864. 
 The patient recovered well, was married 
 in August 1865, and is now the mother 
 of 8 children. All the pregnancies and 
 labours were perfectly natural. 
 
 Of the 82 cases in which both ovaries 
 were removed at one operation, 20 were 50 
 years of age or more, 18 were between 
 40 and 50, and 31 were under 40 ; 43 
 were married, 36 single, and 3 Avere 
 widows. In 1 case there were 3 ovaries. 
 
 The chief point of practical importance 
 in double ovariotomy is the mode of deal- 
 ing with the pedicle. The results, before 
 adopting complete intra-peritoneal ligature 
 and antiseptic treatment, were strongly in 
 favour of the extra-peritoneal method of 
 dealing with both pedicles; but since 1878 
 I have always treated both pedicles by 
 the ligature, which has been returned and 
 left within the abdominal cavity. 
 
 CHAPTER X 
 
 ON OVAHIOTOMY PERFORMED TWICE ON THE SAME PATIENT 
 
 The first patient upon whom I performed 
 ovariotomy, one ovary having been pre- 
 viously removed, had been operated on 
 by Baker Brown G months before she 
 consulted me on account of a recurrence 
 of the disease. The paper in which I 
 described this case was read beibre the 
 Medical and Chirurgical Society in June 
 1863. 
 
 My next case is the first in which 
 ovariotomy was twice successfully per- 
 formed upon the same patient by the same 
 surgeon. 
 
 1 perfonned the first operation in the 
 Samaritan Hospital on February 15, 
 1865, The patient was an immarried 
 schoolmistress, aged 24, She was feeble, 
 and had a strumous appearance. The 
 whole abdomen was occupied by an 
 irregular tumour, in some parts of which 
 fluctuation was perceptible. There was 
 
 nothing imusual in the operation. The 
 pedicle was 3 to 4 inches in length, 
 extending from the left side of a long 
 thin utervis; it was secured in a small 
 clamp, and left outside without trac- 
 tion. The right ovary Avas felt to be 
 healthy. About 22 pints of fiuid were 
 evacuated, and the more solid re- 
 mainder of the tumour weighed about 
 7 pounds. The patient rallied well, and 
 left the hospiUd 4 weeks after the opera- 
 tion. 
 
 The patient remained Avell for more 
 than a year after the first operation. In 
 August 1866, I found a semi-solid tu- 
 mour of the right ovary, reaching up to 
 the false ribs on the right side, in the 
 centre to 2 inches above the umbilicus, 
 and extending towards the left side half 
 way between the umbilicus and anterior 
 superior spine of the ilium. The uterus 
 
OVARIOTOMY PERFORMED TWICE ON SAME PATIENT 
 
 103 
 
 was freely movable. As there wus no 
 cyst large enough to tap witli any liope of 
 affording even temporaiy relief, I pei-- 
 formed ovariotomy August 30, 18GG, 
 just 18^ months after the first opera- 
 tion. Bearing in mind the sIoav and 
 imperfect union in my former second 
 operation, when I made the incision very 
 near the cicatrix of the first operation, 
 I made it in this case 1^ inch to 
 the right of the cicatrix (which was 
 exactly in the middle line), and carried it 
 from 1 inch above the umbilical level 
 •downwards for 5 inches. Its lowest 
 point was about ^ an inch higher than 
 the level of the lowest point of the 
 ■cicatrix. A thin-walled compound cyst 
 was closely adherent all over its anterior 
 surface, but the adhesions yielded easily. 
 A broad thin pedicle extended about 2 
 inches from the right side of the uterus. 
 The uterus was in its normal position ; 
 but the pedicle of the tumour removed at 
 the first operation passed from the left side 
 of the uterus and adhered firmly to the 
 lower angle of the cicatrix in the middle 
 line of the abdominal wall. The pedicle 
 of the tumour about to be removed was 
 enclosed in a broad clamp, and the tumour 
 was cut away. Finding that there would 
 be considerable traction on the uterus and 
 broad ligament if the clamp were kept 
 OTitside, I applied the actual cautery and 
 burnt off the portion of cyst left above the 
 clamp. The pedicle was allowed to sink 
 into the pelvis. The wound was closed 
 by silk sutures. The jelly like substance 
 removed with the fragments of the broken- 
 up tumour, together measured 18 pints. 
 The tumour was a multilocular cyst, 
 with much tubercular deposit in the walls 
 and septa. 
 
 The progress of the patient after the 
 second operation was quite as satisfactory 
 as after the first. After the 2nd day 
 all unfavourable symptoms ceased, and 
 she returned to Lincolnshire 29 days after 
 the operation. 
 
 jNote added November 13, 18G6. — 
 * I have heard from her twice since her 
 return home. The last letter is dated 
 November 10, 1866. She says, " I think, 
 upon the whole, I feel as well as I did after 
 my first operation. My voice is stronger. 
 I can sing the upper notes with greater 
 facility than formerly. I can sing from 
 A up to C natural." I was curious to have 
 the range and power of the voice observed 
 after the removal of both ovaries, and it 
 
 could be done with unusual accuracy in 
 this case, as the patient is a teacher of 
 singing.' 
 
 In 1867 this patient went to reside 
 at Brighton, and iulfilled her duties as a 
 schoolmistress there for more than a year. 
 I heard of her more than once as being in 
 good health, but on June 30, 18GH, I 
 received a letter from Mr. Humphry, 
 stating that she had died two days before, 
 and adding, ' About a week before her 
 death I saw her for the first time, when 
 she had slight congestion at the bottom of 
 one lung. In two or three days this 
 subsided, but she seemed to get worse, 
 great prostration, some sickness, small, 
 quick pulse, restlessness of manner, and 
 some fulness of abdomen leading me to 
 fear some serious mischief about the seat 
 of the old disease. These increased, with 
 swelling of the left leg, which was painless, 
 as was the abdomen, and she quickly 
 sank. I found about a gallon of almost 
 clear serum in the abdomen. No general 
 adhesions. One pedicle adherent to lower 
 end of scar in the abdominal wall, and 
 adhesion between bowel and bladder. 
 Uterus very small and elongated, from 
 dragging to abdominal wall through 
 pedicle. Clot in left iliac vein. No other 
 sign of disease. I could only lay the 
 attack to cold.' 
 
 The next case where I performed 
 ovariotomy successfully twice on the same 
 patient was my 30 th case of ovariotomy. 
 The patient was single, 50 years of age. 
 She had been tapped 12 times, the quan- 
 tity increasing and the fluid becoming 
 thicker every time. The operation was 
 performed on December 17, 1861. The 
 pedicle was short, but was easily secured 
 by a clamp about 1 inch from the right 
 side of the uterus. On examining the 
 left ovary, it was found atrophied, but a 
 thin- walled single cyst, as large as an 
 orange, was observed close to the uterus, 
 within the folds of the left broad liga- 
 ment. This was laid open by an incision 
 and emptied. The wound was then 
 closed, with the stump of the pedicle at 
 the lower angle of the wound. The entire 
 weight of the tumour Avas nearly 40 
 pounds. The progress after the operation 
 was uninterrupted, and on December 31 
 the patient was convalescent. 
 
 For more than 5 years the result 
 was satisfactory. But in November 1867, 
 the patient returned with a cyst in the 
 abdomen of aboutthe size and shape o£ 
 
104 
 
 OVARL\N AND ALLIED TUMOUKS 
 
 the womb at the Gth or 7th month 
 of pregnancy. After tapping, and 2 
 months of restorative treatment, the cyst 
 being larger than before tapping, I per- 
 formed the second ovariotomy on Feb- 
 ruary 5, 18G8. I made the incision 
 parallel with the cicatrix over the linea 
 alba, but H inch to the left of it, 
 and extending about 1 inch lower. The 
 cyst on the left side was exposed and 
 tapped. The only adhesions were to a 
 piece of omentum, which also adhered to 
 the abdominal wall beneath the cicatrix 
 and to a coil of intestine. These ad- 
 hesions were easily separated. On with- 
 drawing the empty cyst and a group of 
 secondary cysts, the uterus was seen to be 
 held up near the lower end of the cicatrix 
 by the pedicle of the tumour removed in 
 1861. The cyst on the left side had a 
 broad attachment behind and to the left of 
 the uterus. There was not room to apply 
 a cautery clump without injury to the 
 uterus, and I accordingly cut away the 
 base of the cyst, tying all vessels which 
 bled as I went on, separating the ex- 
 tremity of the Fallopian ttibe from the 
 part of the cyst to which it adhered, and 
 leaving a small portion of cyst wall closely 
 adhering to the inner part of the tube 
 iind to the uterus. 
 
 The cyst weighed 15 ounces and 
 contained 7 pints of fluid. It was a 
 multilocular proliferous cyst with very 
 vascular walls. The woman went on 
 well, although nervous, feverish, and 
 subject to palpitation, afterwards ex- 
 plained by the discovery that she had a 
 large secret supply of brandy. Yet she 
 left 28 days after operation, on March 5, 
 18G8. She died just 8 months after the 
 second operation. There was no post- 
 mortem examination ; the registered cause 
 of death being ' aberration of mind and 
 voluntary abstinence from food.' I was 
 afterwards informed that she became 
 quite fleshy, and able to walk 3 or 4 
 miles, until she began obstinately to refuse 
 all food. 
 
 In one other case I went prepared to 
 perform ovariotomy upon a lady whose 
 right ovary I had previously removed ; 
 but I found the uterus and left ovary 
 quite healthy, and a very thin-walled cyst 
 attached only to the abdominal wall, as 
 if it had arisen at a spot where some 
 firm adhesions had been separated at 
 the first operation. I emptied the 
 cyst, laid it freely open, and saw the 
 
 patient several years afterwards in good 
 health. 
 
 My next case was an unmarried lady, 
 28 years of age. I performed the first 
 operation on June 11, 1862. On opening 
 the peritoneum, I found that the tumour 
 was quite closely attached to the right 
 side of the uterus ; there was nothing like 
 a pedicle. I accordingly passed the chain 
 of an ecraseur above the Fallopian tube 
 and below the round ligament, and 
 tightened it quite close to the uterus. I 
 then cut away the tumour, and afterwards 
 pared down the stump nearly to the tight 
 chain. I then loosened the chain ; there 
 was no bleeding. So the chain was re- 
 moved, the pelvis cleansed, the left ovary 
 found to be healthy, tvi^o small pedun- 
 culated cysts of the left broad ligament 
 twisted off, and the wound was closed by 
 two deep and four superficial sutures of 
 platinum wire. 
 
 The patient went out of town on 
 June 30, with the wound quite healed, 
 soon gained strength, Avas married in the 
 summer of 1863, and a fine strong child 
 was born in August 1861. The labour 
 was perfectly natural. 
 
 A second child was born in February 
 1866, and the patient again became preg- 
 nant early in 1867. Up to this time the 
 health had been very good, but then 
 disease reappeared, so that she required 
 tapping during the pregnancy. Another 
 tapping followed, and a solid sub- 
 stance of considerable size could be 
 felt on the left side. Towards the 
 latter end of May 1868 the distension 
 again rapidly advanced. The second 
 operation, for removal of the second 
 tumour, was undertaken on the 21st of 
 June, 1869. 
 
 The incision was made parallel with, 
 and ^ an inch to the left of, the 
 cicatrix of the first operation, extending 
 from the umbilicus to a point 2 inches 
 above the pubes. A little ascitic fluid 
 escaped on opening the peritoneum, and a 
 coil of intestine was seen, as well as a 
 large piece of omentum, which adhered to 
 the abdominal wall around the umbilical 
 ring. On introducing the hand, and 
 pressing the intestine and omentum up- 
 ward, I brought a tumour forward and 
 tapped a very thin transparent cyst. Two 
 or three pints of clear serum escaped, and 
 I then found a solid fibroid tumour to be 
 closely attached to the upper and back 
 part of the uterus. A coil of intestine 
 
OVARIOTOMY PERFOHMED TWICE ON SAME PATIENT 
 
 105 
 
 and a piece of omentum which adhered to 
 the tumour were separated from it, and 
 the tumour Avas drawn outward. Tlic 
 chain of an ccraseur was then passed 
 behind the uterus around the neck of the 
 tumour, avoiding the right ovary and 
 right Fallopian tube, which were healthy. 
 The chain was slowly tightened, and the 
 tumour pared away near the chain. One 
 omental vessel was tied, and the ligature 
 returned with the omentum. Some 
 stitches were then inserted to close the 
 upper part of the wound, the chain of the 
 ecraseur being occasionally tightened. 
 As it cut through there was iiree bleeding, 
 and some vessels were tied on the posterior 
 surface of the body of the uterus, and 
 close to the left Fallopian tube, which had 
 been divided. 
 
 The uterus was again examined, and 
 perchloride of iron was applied to part of 
 the surface where there was some oozing. 
 At length the wound was closed, the 
 sutures being passed so as to include the 
 opening at the umbilical ring, and two 
 others beside the cicatrix, where there 
 had been hernial protrusion. 
 
 There was some sickness during the 
 operation, and it continued aiterwards. 
 She soon began to show signs of failing 
 power, and died 66 hours after the 
 operation. 
 
 At the post-mortem examination some 
 of the small intestines were slightly ad- 
 herent from recent exudation of fibrine. 
 The uterus and other parts were sent to 
 Dr. Wilson Fox for examination, whose 
 report runs as follows : ' The tumour is, 
 I believe, a fibro-sarcoma, with a large 
 proportion of cells like organic muscular 
 iibres, but others are mere fibre cells. 
 Besides these, there are a great number 
 of round and oval-shaped nuclei. The 
 tumour has under the microscope a mi- 
 nutely lobed character ; i.e. it is traversed 
 by septa in all directions, and in the septa 
 the muscular fibres, and also the fibre 
 cells, are the most abundantly accumu- 
 lated. The section is everywhere opaque, 
 and glistening and firm ; a few stria2 of 
 fatty degeneration are seen in spots only. 
 Parts of the tumour are breaking up into 
 a reticular structure, in the meshes of 
 which a clear serous fluid is contained. 
 Various cysts, from the capacity of a large 
 walnut to that of a hazelnut, are also 
 scattered through it, in addition to the 
 larger ones opened before. As to whether 
 this tumour represents a sarcoma of the 
 
 ovary, I am not prepared to pronounce a 
 positive opinion ; but in some parts there 
 are little cavities with well-defined walls, 
 which look as if they might be the 
 remains of the Graafian follicles, but the 
 walls are completely chanced by the fibro- 
 plastic growth, and tlieir lining does not 
 show any remaining distinct traces of the 
 membrana granulosa. They appeared 
 empty, and two or three times the size of 
 the ordinary Graafian follicles. The 
 amount of muscular tissue present is not, 
 I think, enough to invalidate an ovarian 
 origin. The general character of the 
 tumour is unlike the fibroids of the uterus 
 which I have seen, but I have not made 
 these latter the objects of a sufficiently 
 comprehensive study to be able to speak 
 positively on this point. If the tumour 
 is ovarian, as I am inclined to think, 
 there Avould appear to be a double source 
 of cyst formation in it — one, the liquefac- 
 tion or breaking down into cavities, such 
 as is seen in the whole class of these 
 tumours, and the other, from enlarged 
 and altered Graafian follicles.' 
 
 During the operation, besides the 
 tumour, 1 found in the abdominal cavity 
 a free, sjjheroidal body, measiiring 2 
 inches in its long diameter, 1^ inch in 
 breadth, and | of an inch in thickness. 
 Its Aveight was 241 grains. It was semi- 
 elastic, of dark brownish-yellow colour, 
 and the surface was smooth and shining. 
 It consisted entirely of fat and cholesterine 
 crystals, and had an exceedingly delicate 
 investment of connective tissue, with 
 fascicles of nucleated fusiform cells and 
 elastic fibres. This body was evidently 
 one of the appendices epiploica3, which 
 had separated irom its pedicle, and had 
 remained some time free in the abdominal 
 cavity. 
 
 During the attendance in 1862, doubt 
 arose Avhether I had been right in de- 
 scribing the right ovary as having been 
 removed at the first operation ; and the 
 second operation not only justified the 
 doubt, but also suggested the question — 
 which even the examination of the tumour 
 by Dr. W. Fox did not solve — Avhether 
 the tumours in either operation were really 
 ovarian, or fibro-cystic, or fibro-sarcoma- 
 tous growths, originating in the uterua 
 and only involving the ovaries. A case 
 such as this, which not only shoAvs the 
 difficulties of diagnosis encountered in 
 the emergencies of practice, but proves 
 how perplexing, even in the deliberate 
 
106 
 
 OVARIAN AND ALLIED TUMOURS 
 
 investigations of the accomplished patho- 
 logist, some of the obscurer forms of 
 disease may become, should tend to 
 moderate any captiousness of criticism in 
 matters of practical surgery, and open up 
 the Avay to more minute and recondite 
 research into the origin and forma of 
 morbid changes. 
 
 To these 4 cases I have now to add 
 9 others, making 13 in which I have 
 removed an ovarian tumour from a 
 patient who had previously undergone the 
 operation. In 11 of these patients I 
 performed both the operations myself It 
 seems unnecessary to make a detailed re- 
 port of the cases, but it may be interest- 
 ing to give the dates of the first and 
 second operations. 
 
 Ko. 
 
 Date of 
 operations 
 
 Eesult 
 
 History or 
 cause of" death 
 
 1 
 
 Feb. 1873 
 June 1874 
 May 1870 
 June 1875 
 April 1873 
 Julv 1876 
 May 1869 
 July 1876 
 Oct. 1872 
 Nov. 1876 
 Dec. 1865 
 Dec. 1876 
 May 1S70 
 Feb. 1878 
 May 1875 
 June 1880 
 Aug. 1876 
 Nov. 1881 
 
 Recovered 
 Recovered 
 Recovered 
 Recovered 
 Recovered 
 Recovered 
 Recovered 
 Recovered 
 Recovered 
 
 JDiedAp r 
 
 ) Married 1876 
 J Well in 1881 
 1 Intestine torn 
 J Well in 1881 
 
 1 Well in 1881 
 1 Well in 1881 
 1 Well in 1881 
 ^ Well in 1881 
 1 Well in 1881 
 j Well in 1884 
 
 CHAPTER XI 
 
 ox THE TREATMENT OF PATIENTS AFTER OVARIOTOMY 
 
 The treatment of patients after ovariotomy 
 may be considered under three distinct 
 heads : first, the conditions imder which 
 the patient is placed, and the duties of the 
 nurse ; secondly, the medical treatment ; 
 and thirdly, the surgical treatment. 
 
 A large, lofty, quiet, airy room, neither 
 too hot nor too cold ; two comfortable, 
 small, clean iron bedsteads, with hair 
 mattresses, and light, warm bedding, so 
 that the patient may be lifted from one to 
 the other, and have a fresh bed every 
 day ; the personal linen so contrived that 
 it can be changed frequently without 
 much disturbance of the patient ; the 
 windows provided with shutters or blinds 
 disposed so as to admit only an agreeable 
 amount of light, or to maintain a soothing 
 twilight ; an open fire, wliich, with an 
 open window, secures a fitting tempera- 
 ture with natural ventilation ; a floor free 
 from all woollen covering and painted or 
 varnished to facilitate the removal of 
 everything that could prove offensive or 
 hurtful — these things together form a 
 combination of favourable conditions 
 which, imjjortant in general surgery and 
 in the treatment of every case of severe 
 illness, are imperatively necessary after 
 ovariotomy. It is in attention to minute 
 details, and by the observation of the ill- 
 effects which follow the neglect of any of 
 them, that the practitioner is taught their 
 
 importance, and learns how much of his 
 success depends upon careful and intelli- 
 gent obedience in those who are entrusted 
 with the care of the patient. 
 
 The duties of the nurse are to use the 
 catheter about every six hours, or oftener 
 if the patient desires it, in order to render 
 any movement or muscular eflfort in 
 emptying the bladder unnecessary. This 
 should be done for 3 or 4 days ; and it is 
 often longer before a patient is able to 
 dispense with the use of the catheter. A 
 silver catheter seems to irritate the urethra 
 and bladder less than an elastic instru- 
 ment. Certainly, troublesome catarrh of 
 the bladder is more frequently noticed 
 when an elastic catheter has been used, 
 probably because it is not so easily cleansed, 
 and some decomposing mucus is intro- 
 duced by it into the bladder. A silver 
 instrument is more easily cleansed. This 
 should be thoroughly done every time the 
 instrument is used, and it should be kept 
 in carbolised Avater. The nurse should 
 also be capable of injecting into the rectum, 
 either small quantities of food, or such 
 doses of some opiate as may be found 
 necessary to relieve pain. A succession 
 of small opiates, left to the discretion of 
 an intelligent nurse, with directions to 
 give only enough to keep the jiatient free 
 from severe pain, answer better than 
 larger doses administered at stated inter- 
 
TREATMENT OF PATIENTS AFTER OVARIOTOMY 
 
 107 
 
 vals. She should be ready to supply the 
 patient either with warm or cold drinks, 
 or with such light nourishment or stimu- 
 lants as may be directed. Stimulants, 
 such as brandy or champagne, must also 
 be left to the nurse, but with explicit 
 understanding that they are only to be 
 used when called for by faintness, or chil- 
 liness, or some sign of exhaustion. Very 
 little food is required during the first 
 3 days after the operation, but there 
 should always be at hand a supply of 
 some light nourishment, such as well- 
 made barley-water, toast and water, thin 
 gruel, water arrowroot, bread and milk, 
 chicken broth or beef tea. These the 
 patient may take almost as freely as 
 she pleases, provided she is not sick. 
 Should sickness be troublesome, a little 
 brandy in iced soda-water, or champagne 
 iced, will probably relieve it ; but it is 
 often only a sign of weakness, and is then 
 best met by enemas of beef-tea, either 
 with or without egg and brandy, thrown 
 into the rectum, in quantities of net more 
 than 2 ounces, at short intervals. Before 
 giving the injection, and at any time 
 when flatulence is distressing a patient, 
 the nurse should introduce an elastic 
 tube or the injection-pipe some 2 or 3 
 inches into the rectum, in order that flatus 
 may escape without straining effort, and 
 also to allow of the outflow of any pre- 
 viously injected and unabsorbed food. 
 The nurse should be able to note varia- 
 tions of the pulse, to take and record tem- 
 perature observations with the thermo- 
 meter, at stated hours, or on the occurrence 
 of any febrile symptoms. In cases of 
 drainage, a nurse who can be trusted to 
 attend to the cleanliness of the tube, to 
 draw off accumulations of fluid, or to in- 
 ject antiseptic solutions, is an exception- 
 ally good one. The nurse should watch 
 the urine of the patient, and should be 
 directed to give the patient every 2 or 3 
 hours some lithia water, or a mixture of 
 the citrates of potash and lithia, as soon 
 as it becomes scanty or concentrated, de- 
 positing urates on cooling. 
 
 Beyond this administration of lithia 
 and potash, and opiates in sufficient 
 quantity to relieve pain, medical treatmerd 
 may be said to consist in doing no harm, 
 provided the case go on without any 
 serious complication. But if peritonitis, 
 either of the sthenic or traumatic charac- 
 ter, or of the septic variety, occur, the 
 fever accompanying either form of in- | 
 
 flammation must be watched ; and if the 
 temperature of the body as shown by the 
 thermometer rises considerably above the 
 normal standard, means must be taken 
 with the object of lowering the tempera- 
 ture. Packing the arms and legs in wet 
 towels — even the cold bath — has been 
 occasionally used in cases of hyperpyrexia, 
 but generally iceing the head continuously 
 is far less disturbing to the patient, and 
 even more efficacious. I have tried the 
 cushions made of tubes for iced water, 
 introduced by Dr. Roberts, of Manchester, 
 and icebags for the neck, after Dr. Rich- 
 ardson — but prefer Mr. Thornton's ice- 
 cap for the head to any other arrangement. 
 Before antiseptics, the head Avas kept cool 
 for a day or two in about half the cases. 
 Since antiseptics, I have scarcely ever 
 found it necessary. 
 
 The bowels are kept quiet after the 
 operation ; and as long as the patient feels 
 comfortable, their action needs not be 
 brought on, even if they do not act for 
 10 days or more. I have known the 
 bowels to be 19 days without acting, and 
 then act naturally without any painful 
 effort. An enema of warm water or a 
 dose of castor oil will bring on their action 
 if not spontaneous. Hard faecal masses in 
 the rectum may cause tenesmus, keep up 
 a spurious diarrhoea, and thus render the 
 patient uncomfortable. Their presence 
 will be discovered by digital examination. 
 They should be broken up with the finger 
 or a spoon, and the bowels afterwards 
 cleared by injecting warm water. If 
 the first motion fatigues the patient and 
 renders her restless, it will be advisable 
 to have it followed by an opiate enema. 
 Vomiting is often a troublesome symptom, 
 less so when methylene has been used 
 than after chloroform. It is sometimes 
 relieved by giving small pieces of ice to 
 suck, or to swallow as ice pills; some- 
 times by draughts of hot water. But 
 this is sometimes dangerous by leading to 
 accumulations of large quantities of fluid 
 in the stomach. If this accumulation and 
 consequent faintness are observed, it may 
 be necessary to empty the stomach by the 
 stomach-pump. Of all medicines, I have 
 found 15-grain doses of bromide of potas- 
 sium in 2 ounces of water the most use- 
 ful. Next to that, 3 to 5 drops of prussic 
 acid. 
 
 Flatulence, often a very troublesome 
 symptom, may be relieved by passing the 
 elastic tube of an enema apparatus up 
 
108 
 
 OVAKIAX AND ALLIED TUMOURS 
 
 the rectum. An enema of 5 grains of 
 quinine in 1 ounce of water or beef-tea, 
 •with or -without a few drops of laudanum, 
 or ^ an ounce of port-wine, repeated 
 every 4 hours, has often relieved flatu- 
 lence by restoring the tone of the muscu- 
 lar coat of the intestines, and occasionally 
 Faradisation has proved useful in the 
 same way. A few drops of chloric ether 
 and salvolatile sometimes give relief, and 
 tincture of nux vomica has appeared to 
 be of use in some cases. 
 
 Surrjlcal treatment. — The various con- 
 ditions following ovariotomy which may 
 call for surgical treatment may be ar- 
 ranged in order, commencing Avith the 
 wound in the abdominal wall and the 
 separation of the pedicle ; next collec- 
 tions of serum, blood, or pus in some 
 part of the peritoneal cavity ; and thirdly 
 adhesions between the intestine and the 
 pedicle, or the abdominal Avail, leading 
 to intestinal obstri;ction. 
 
 Unless the abdominal wall is oedema- 
 tous, or the dressing is moistened, it is 
 better not to disturb the bandage or 
 plaster until the seventh day after opera- 
 tion. And then it is not necessary to 
 raise the plaster from the sides of the 
 abdomen : it should be raised and divided 
 with scissors 2 or 3 inches on one 
 side of the wound, then raised and di- 
 vided on the other side. In this way the 
 wound may be uncovered without dis- 
 turbing the patient. After removing the 
 gauze or wool, the plaster left on either 
 side is used as splints, and drawn together 
 by new plaster above and below the Avound 
 so as to take off all tension from the 
 Avound as the stitches are removed. As 
 a rule, union takes place without any 
 suppuration. Quite exceptionally a little 
 pus Avill exude from one or more of the 
 points of suture. This is not of much 
 consequence. Indeed, since antiseptics it 
 is very rare to see even a single drop of 
 pus. Three or four times, before the anti- 
 septic period, I have seen considerable 
 collections of pus in the abdominal Avail, 
 almost always in very fat patients. In 
 sucli cases care must be taken to avoid 
 any dressing Avhich Avould interfere Avith 
 the free escape of the pus. A pad of 
 boracic cotton sliould be placed over the 
 Avound, and support given by strips of 
 plaster, Avhich draw up the side pieces or 
 splints. Kceberle uses cotton threads 
 Eteeped in collodion with the same object. 
 
 In every case after removal of the 
 
 sutures, the abdomen should be supported 
 by adhesive plaster for at least a fortnight, 
 or until the Avound is firmly agglutinated. 
 Tympanites, hiccup, and vomiting might 
 separate the edges of a Avound Avhich had 
 united fairly Avell, if these edges Avere not 
 Avell supported. In a few cases I have 
 seen more or less reopening of the wound ; 
 in 2 the sutures Avere removed too 
 early, and the abdominal Avails Avere not 
 supported by plaster ; in other 2 cases 
 there Avas pyaemia or septicajmia, and the 
 plastic process Avas slow on account of the 
 state of the blood ; in other 2 cases the 
 accident was caused by violent cough on 
 the 7th or 8th day, and in one by 
 sneezing a day or two after tlie stitches 
 had been removed. These three patients 
 recovered, the septictemic cases died. I 
 have also seen other cases Avhere partial 
 reopening of the wound has appeared to 
 do good by admitting of the escape of 
 serum. In all, the stitches Avere replaced 
 as soon as I Avas aware of the occurrence. 
 In two cases there Avas escape of intestines 
 and some difficulty in replacing them, but 
 the accident scarcely retarded recovery. 
 
 Unless the pedicle is very short, if a 
 clamp has been used it lies across the 
 lower part of the Avound, Avithout any de- 
 pression of the abdominal wall, and the 
 patient is quite unconscious of its pre- 
 sence. Sometimes, Avith a very short 
 pedicle, the clamp and the integuments 
 have been drawn almost doAvn to the 
 sacrum, even then, Avithout much com- 
 plaint from the patient. There has some- 
 times been protrusion of the pedicle be- 
 hind the clamp, separating the lower 
 edges of the Avound. When this occurs, 
 the loAvest stitch should be removed, as 
 the protrusion is due to obstructed re- 
 turn of blood through the veins of the 
 pedicle. Two or three times the protru- 
 sion has been so great that I have passed 
 a pin through the pedicle behind the 
 clamp, tied a ligature beloAv the pin, and 
 cut away both clamp and pedicle ; but 
 this was seldom necessary, as the swelling 
 subsided soon alter the removal of the 
 compression caused by the too tight 
 stitch. The clamp and the portion of 
 pedicle compressed by it generally fell off 
 from the 7th to the 10th day, sometimes 
 as early as 3 or 4 days, and sometimes 
 not for 15 or more. It is important not 
 to remove the clamp too soon, especially 
 if the pedicle is short, as the newly 
 formed adhesions between the pedicle and 
 
TREATMENT OF TATIENTS AFTER OVARIOTOMY 
 
 109 
 
 the abdominal wall might give way, and 
 the pedicle sink into the peritoneal cavity, 
 possibly giving rise to septic peritonitis 
 and death, and probably leaving an open- 
 ing which, after healing of the skin, would 
 admit of the easy production of a ventral 
 hernia. But Avhen the clamp is only held 
 by a few shreds of dead tissue, it may be 
 removed. A little ulceration of integu- 
 ment from pressure of the clamp should 
 not lead to the premature removal of the 
 clamp, as this is of far less consequence 
 than the risk of removing the clamp too 
 soon. 
 
 The delay in the union at the lower 
 angle of the wound, where the remains of 
 the pedicle are fixed in clamp cases, may 
 protract the complete cicatrisation to the 
 3rd or 4th week, but this is of little con- 
 sequence, and need not interfere with 
 the movement of the patient. Where the 
 patient has been treated by one or other 
 of the intra-peritoneal methods, union by 
 the first intention along the whole length 
 of the incision is usually complete. 
 
 When bad symptoms follow ovariotomy 
 — pain, vomiting, fever with abdominal 
 distension — the surgeon should suspect 
 that some fluid, either serum, blood, or 
 pus, is collecting in the peritoneal cavity. 
 It may collect in such quantity as to give 
 rise to sensible fluctuation fi-om one side 
 of the abdomen to the other. Or, in 
 smaller quantity, it may gravitate to the 
 bottom of Douglas's space, and form a 
 tense swelling behind the uterus, easily 
 felt through the vagina, although there 
 may be no free fluid perceptible in the 
 abdominal cavity. If the pedicle has been 
 treated by the uncut ligature, the ends of 
 the ligature passing through the wound 
 then serve as drainage conductors, and a 
 very free discharge of fluid may go on for 
 several days. Koeberle prepares for drain- 
 age by introducing strong perforated glass 
 tubes, and, by the aid of a syringe fitted 
 to the tubes, he withdraws fiuid several 
 times daily. Peaslee advocated and 
 adopted with success this system of drain- 
 age, with the addition of repeated washings 
 out of the peritoneum with warm water 
 and disinfecting solutions. In a few bad 
 cases I have followed this practice, but 
 never with success. 
 
 In most of the cases reported by 
 Peaslee as treated with peritoneal injec- 
 tions, the pedicle was dealt with after the 
 oldest method : that is, it vvas transfixed, 
 each half was tied, and the ends of the 
 
 ligatures were allowed to hang out of the 
 wound. In one case, the ligatures were 
 brought out through a vaginal canula. 
 In all, the convalescence was very tedious, 
 and 3 had septicasmia. The most re- 
 markable of the whole, as regards the 
 treatment, was that in which loO injec- 
 tions were made into the peritoneal cavity 
 in 78 days. The last ligature came away, 
 and pus ceased to be secreted, on the 
 94th day after operation. 
 
 Whenever fluid can be detected by 
 vaginal examination in the neighbourhood 
 of the uterus it is usually in such quantity 
 that it must be removed. This is done 
 either by a straight or curved trocar, over 
 which an elastic catheter is fixed, instead 
 of a canula. Or, by a trocar still more 
 curved, a piece of drainage-tube may be 
 inserted and fastened, as shown in the 
 next cut. I introduced such a tube in 
 the following case, where it led to free 
 discharge, which was followed by complete 
 recovery. 
 
 I performed ovariotomy on a girl, 
 18 years of age, in the Samaritan Ho.s- 
 pital on June 13, 1864. Long and very 
 firm adhesions anteriorly and in the right 
 iliac fossa, and a very extensive surface 
 of adherent omentum, were separated 
 by the hand with some difficulty, and 
 a close adhesion to the fundus of the 
 bladder was separated by very careful 
 dissection. The ovary appeared normal, 
 while the tumour was attached to its 
 external angle by a narrow pedicle, about 
 1 inch in length. The ovary was, how- 
 ever, removed with the tumour. A small 
 pedicle was secured close to the uterus by 
 a silk ligature, which was cut off short 
 and returned. The stitches were removed 
 44 hours after operation, the wound being 
 perfectly united. On the 3rd day after 
 operation some sharp pain came on, which 
 became easier after a uterine discharge 
 like menstruation appeared. She con- 
 tinued doing well till the 9th day, when 
 she was found with dry tongue, dilated 
 pupils, flushed face, and drowsiness. I 
 examined by the vagina and rectum, and, 
 detecting fluid between them, made a 
 puncture by a trocar, and let out 5 
 ounces of dark bloody serum whicli had 
 a putrid ammoniacal odour. The pulse 
 sank from 112 to 95 and 92, but mucous 
 diarrhoea came on, and the typhoid condi- 
 tion was aggi-avated next day. A- the 
 discharge from the trocar puncture had 
 ceased, and examination detecte i fluid 
 
110 
 
 OVAEIAN AND ALLIED TUMOURS 
 
 still in the recto-vaginal space, I made 
 another opening into it, and evacuated 10 
 ounces of fluid still more putrid than 
 that of the day before, and containing 
 pus. I then carried on the trocar through 
 the opening made the day before, and 
 drew a drainage-tube through the canula 
 before withdrawing it. The tube was 
 then tied and left lixed, as shown in the 
 diagram. I took great care that it should 
 
 pass through the lowest point where the 
 peritoneum is reflected from the rectum 
 to the vagina. Very free discharge came 
 through the tube for several days, and 
 the general condition rapidly improved. 
 The tube was removed on July 1, and 
 convalescence was rapid. 
 
 The result of my experience is, that 
 the danger of puncture has been exagge- 
 rated ; that the benefit of the evacuation 
 of fluid is very marked ; and that any 
 danger arises from too early closing of the 
 opening, not from the opening having been 
 made. Where it is not easy to pass a 
 drainage-tube, or where it is desired to 
 use antiseptic injections as well as to drain, 
 it is better to leave a silver canula in 
 Douglas's pouch, and to keep it there by 
 the spring of double silver wire as shown 
 in the drawing at page 44. It passes out 
 througli the vagina, and injections may 
 easily be thrown through it. But this is 
 a troublesome detail of after-treatment 
 which has become extremely rare since 
 the adoption of antiseptics. 
 
 Tiie most alarming symptoms which 
 occur after ovariotomy are those which 
 depend upon oljstructed intestine. I 
 heard of one case which has never been 
 recorded, where a coil of intestine slipped 
 through one of the loops of wire used as 
 
 sutures for the wound, and was tightly 
 compressed when the wire was fastened. 
 In a published case, there is very little 
 doubt tliat a fa3cal fistula was caused by 
 perforation of intestine with the stitch 
 closing the wound. In one of my early 
 cases, a coil of intestine was compressed 
 between the pedicle and the abdominal 
 wall, and I have seen others since where 
 the same accident would have happened 
 if I had not been on my guard. After 
 the intra-peritoneal methods of dealing 
 with the pedicle by ligature and by cautery, 
 
 1 have seen fatal obstruction of the intes- 
 tine caused by adhesion of coils of intes- 
 tine around the divided end of the pedicle 
 at such sharp angles that the canal was 
 quite closed ; and 1 have seen adhesion of 
 intestine to a clamped pedicle lead in the 
 same way to obstruction. The following 
 case illustrates the course of the symptoms 
 when this dangerous complication pre- 
 sents itself: 
 
 A single woman, 35 years old, was ad- 
 mitted to hospital in March 1867. The 
 whole abdomen was filled by a multilo- 
 cular ovarian cyst. The uterus was 
 healthy, and its mobility free. Ovariotomy 
 was performed on March 27. A pedicle, 
 
 2 to 3 inches broad at its narrowest 
 part, and about one- third of an inch 
 thick, connected the base of the tumour 
 closely to the right side of a small hard 
 uterus, of irregular shape from a fibroid 
 nodular outgrowth. A cautery clamp was 
 applied, and the pedicle divided by hot 
 irons. On opening the clamp, the com- 
 pressed and seared pedicle appeared at 
 fii'st quite secure. But as the pedicle was 
 slowly separating from the blade of the 
 clamp to which it adhered, three vessels 
 bled freely. These were tied, and then, 
 as there was some oozing of blood all 
 along the line of eschar, I transfixed the 
 pedicle close to the uterus, tied the pedicle 
 in two halves, and allowed it to sink into 
 the abdomen, after cutting off the ends of 
 the ligature short. The left ovary was 
 healthy. 
 
 The state of the patient after operation 
 was unsatisfactory from the first, but there 
 was not much pain. Some sickness on 
 the day after operation increased on the 
 2nd day, and the abdomen became 
 tympanitic. On the 3rd and 4th days 
 the vomiting continued, a great deal of 
 dark-green or cofl^ee-coloured fluid being 
 thrown up. A free fluid motion was fol- 
 lowed on the 5th and Gth days by some 
 
TREATMENT OF PATIENTS AFTER OVARIOTOMY 
 
 111 
 
 improvement, although the vomiting of 
 larce quantities of greenish fluid con- 
 tinued. On the 7th morning the patient 
 appeared much better ; but in the evening 
 the pulse was IGO, and she appeared 
 almost moribund. Five grains of quinine 
 were given every 3 hours by mouth and 
 rectum. In IG hours 35 grains had been 
 given, and on the 8th day the pulse had 
 fallen to 120. In the next 10 days she 
 improved in many respects. There was 
 no vomiting, but she suffered at times 
 with abdominal pain and much flatulence. 
 On the 19th day she appeared remarkably 
 well ; but at night, after a free watery 
 motion, she suddenly became faint and 
 sick, and died on the morning of the 20th 
 day. 
 
 The wound was found firmly united. 
 There were scarcely any traces of general 
 peritonitis. No intestine was adherent 
 near the wound, but one coil slightly ad- 
 hered above the umbilicus. The uterus 
 was small, and had a fibroid nodule the 
 size of a marble projecting from its 
 fundus. The left ovary was healthy. 
 The pedicle of the tumour of the right 
 ovary was closely surrounded — as shown 
 in the accompanying engraving — by an 
 
 adhering coil of the ileum just before it 
 enters the cascum. About 1 ounce of pus 
 was circumscribed by this adhering intes- 
 tine around the end of the pedicle, so that 
 none of the pus entered the peritoneal 
 
 vity. The canal of the adhering coil of 
 p testine was almost completely obstructed, 
 artly by the sharp curves at Avhich it 
 was fixed, and partly by the contraction 
 of the adhering portion, the intestine above 
 being much distended. There was neither 
 blood, lymph, nor serum in the peritoneal 
 cavity, nor could any tubercular deposit 
 be found. 
 
 In all these cases the symptoms are 
 exactly those of strangulated hernia. They 
 may be relieved by opium or belladonna, 
 but are almost certainly fatal if the ob- 
 struction cannot be overcome. More than 
 once I have i-eopened the abdomen and 
 separated adhering intestine from the ab- 
 dominal wall and pedicle, with temporary 
 relief, but new adhesions folloAved and ulti- 
 mately death. I have seen several cases 
 where symptoms of obstruction have gra- 
 dually disappeared, and this has led me to 
 wait too long in other cases before re- 
 opening the wound and searching for the 
 seat of obstruction. In one case I might 
 easily have saved life by separating a mere 
 film of adhesion close to the wound, which 
 held a piece of small intestine as sharply 
 as a ligature. The preparation is in the 
 Museum of the College of Surgeons. 
 
 Two woodcuts on the next page serve 
 to make clear a point in anatomy which, 
 from being overlooked or forgotten, has 
 often led to difficulties in diagnosis and 
 sometimes to dangerous proposals or mis- 
 chievous practice. It will be seen by the 
 representation of the perpendicular section 
 of the abdomen, pelvis, and their contents, 
 how under certain circumstances Douglas's 
 pouch may become distended by fluid 
 or by a mass of intestines gravitating into 
 it. To be able to make sure of the nature 
 of the tu.mefaction thus caused, and per- 
 ceived during vaginal examination, re- 
 quires tact and experience, and I have not 
 been surprised sometimes to hear most 
 erroneous speculations about it and to find 
 myself consulted as to operative measures 
 for its relief, under what was supposed to 
 be the most urgent necessity. But a study 
 of the relations of the parts will show how 
 the presence of small intestines filled 
 with fgecal matter and falling low down 
 into Douglas's pouch between the uterus 
 and rectum may simulate abscess or 
 haematocele. The drawing also explains 
 what a scope, when the expansion of the 
 pouch has once begun, the space offers 
 for the enlargement of a cystic tumour 
 in that direction, and how hy remamiug 
 
112 
 
 OVARIAN AND ALLIED TUMOURS 
 
 for some time undisturbed it may so model 
 itself to the form of the pelvis and to the 
 outline of the organs in it, as to be raised 
 
 with difficulty and so give cause to fear 
 the presence of serious attachments. All 
 this explains one cause of obstructed 
 
 intestine which has hitherto escaped 
 notice. Adhesion of coils of intestine to 
 the pedicle, to the abdominal wall, or to 
 neighbouring coils of intestine, at such 
 
 sharp curves or angles as to close the 
 canal have been referred to ; but the fact 
 that this adhesion may take place low 
 down in the pelvis at the bottom of the 
 
 recto-uterine pouch has not been men- 
 tioned. Yet, it is nft very rare, and, 
 though recognisable when understood, it 
 
 may be mistaken for abscess or hajmatocele. 
 The first of the above drawings thows 
 how in most adults some jiortion of the 
 
TREATMENT OF PATIENTS AFTER OVARIOTOMY 
 
 113 
 
 small intestines sinks down in the normal 
 condition of parts between the uterus 
 and the rectum. After ovariotomy, especi- 
 ally when the lower part of the ovarian 
 tumour has pushed the uterus upwards 
 iind forwards, a considerable space is left 
 between the rectum and uterus, and into 
 this the small intestines fall down. I have 
 often found them there when sponging out 
 the pelvis. Now, supposing them to be 
 more or less firmly fixed there by effused 
 lymph, it is very probable that some 
 obstruction may follow, and that a con- 
 siderable swelling may be discovered be- 
 hind the uterus on examining by the 
 vagina. Rectal examination at once shows 
 that it is between the rectum and the 
 uterus, and probably that it is more to- 
 Avards the right than the left side. A 
 glance at the second of these woodciits 
 shows why this is so. The rectum, con- 
 taining fteces, fluid, or gas, occupies the 
 left side before it reaches the middle line, 
 and there is more vacant space towards the 
 right of Douglas's pouch to admit the 
 small intestines. There they may adhere 
 ynd form a considerable swelling. 
 
 Sometimes, long after recovery, more 
 or less complete obstruction of intestine is 
 followed by the formation of a fiecal 
 fistula. Such, cases are recorded by Lyon 
 of Glasgow, Keith, and Bryant. Once the 
 same thing happened in a patient of my 
 own. In Lyon's case the operation was 
 performed in February 1866, ' easily and 
 iavourably.' Hiccup and severe vomiting 
 were present for a few days, and it was 
 afterwards found that union, of the edges 
 of the wound was imperfect. A portion 
 of intestine was to be seen adherent at the 
 bottom of the wound. Pinlike perfora- 
 tions took place in this, and gave issue to 
 f?3cai matter and offensive gas. Various 
 means were taken to obtain healing, but 
 in August 1867 the wound, or rather the 
 small exposed portion of perforated intes- 
 tine, remained unchanged. 
 
 Dr. Keith operated on a patient in 
 whom at the end of 6 weeks a pelvic 
 abscess formed and pointed a little above 
 Poupart's ligament. Some months after- 
 Avards there Avas a sudden escape of 
 coagiilated blood iVom the rectum, followed 
 by a free discharge of pus from the opening 
 in the groin. Fascal matter soon made its 
 appearance and continued to How till July, 
 Avhen the fistula finally closed. This is 
 the only case of the kind which has fallen 
 to Dr. Keith, and it Avas also the only one 
 
 in which at the time he published the 
 case he had returned the pedicle with the 
 ligatures into the abdomen after ovario- 
 tomy. 
 
 Mr. Bryant's av.qs a case of successful 
 ovariotomy in 1867. The pedicle Avas 
 transfixed and tied Avith Avhipcord ; the 
 ends of the ligatures being cut off they 
 Avere allowed to sink into the abdomen 
 with the pedicle. These ligatures Avere 
 discharged some months afterwards 
 through an artificial anus at the loAver 
 part of the abdominal Avound, Avhich in 
 the end healed up completely. 
 
 The operation in my case Avas per- 
 formed on March 10, 1864 ; the patient 
 Avas 57 years of age. A large multilocular 
 cyst of the left ovary Avas removed. The 
 pedicle Avas returned into the abdomen 
 with the ligature.?, the ends of Avhichwere 
 cut off short, close to the knots. A por- 
 tion of the cyst adhered so firmly in the 
 left iliac fossa that it could not be separated, 
 and it was left adherent, after transfixing 
 and tying it, leaving the ends of the liga- 
 ture hanging out of the lower angle of the 
 Avound. The patient recovered. But 5 
 weeks after the operation the ligatures 
 still kept the lower part of the Avound 
 open, a little discharge daily escaping 
 beside them. On May 31 a ligature 
 came away, the discharge gradually les- 
 sened, and the patient considered herself 
 to be Avell. In May 1865 there Avas in- 
 crease of discharge ironi the sinus attended 
 with tineasiness, but not Avith severe pain, 
 the odour of the discharge being offensive 
 — not putrid, but faint or albuminOtis. 
 Deep in the left iliac region Avas a general 
 state of solidity of the parts, as contrasted 
 with the opposite side. 
 
 It should be remembered that, although 
 the ligature which had been lelt hanging 
 out through the Avound in the abdominal 
 Avail had come away in May 1864, there 
 Avas no proof that the ligatures tied on 
 the pedicle, and cut off short, had come 
 away. It Avas thought they might be 
 present and keeping up irritation. 
 
 After this the discharge became more 
 abundant and decidedly faical, A'arying in 
 quantity from day to day. But no solid 
 fa?ces eA'er passed. She gradually became 
 Aveaker, and died December 20, 1865, 
 about 20 months after ovariotomy. 
 
 I am indebted to Mr. T. P. Teale for 
 a report of the post-mortem examination. 
 ' The fistulous opening on the surliice of 
 the abdomen Avas larae enouirh to admit 
 
114 
 
 OVARIAN AND ALLIED TUMOUKS 
 
 the tip of the little finger. Witlain the 
 abdomen it Avas so dilated as to admit a 
 middle finger at least. On opening the 
 abdomen Ave found the edge of the omen- 
 tum adherent to the Avail at the level of 
 the AA'ound, a coil of small intestines 
 sealing the AA'ound aboA'e tlie fistula, which 
 latter Avas at the loAver extremity of the 
 Avound. A small part of the small intes- 
 tine, the sigmoid flexure, and the rectum 
 Avere matted together around the fistula 
 and the left corner of the uterus. Close 
 to the left side of the uterus Avas a mass, 
 almost spongy and pedunculated, Avhich 
 projected towards the rectum. In the 
 centre of the mass Avas a large suppurating 
 cavity, Avhich communicated Avith the 
 fistula and with the rectum by two large 
 openings. The cavity extended for some 
 distance between the uterus and the 
 rectum. It passed towards the right side 
 behind the loAver part of the uterus ; 
 downwards by the side of the rectum, 
 and forAvards as far as the femoral ring. 
 No trace of any ligature could be found. 
 The right ovary Avas healthy.' 
 
 This case, and others, as I have before 
 stated, influenced me in faA'our of the 
 extra-peritoneal treatment of the pedicle. 
 The formation of a sort of canal or sinus 
 by the adhesion together of folds of 
 omentum or coils of intestine, in such a 
 manner as to enclose the ligature and 
 shut it off from the peritoneal cavity, 
 occurs, I believe, Avhen the ends of the 
 ligature are not citt off. If the patient 
 recover, one might expect more or less 
 olistruction of intestine to folloAV such 
 adhesions ; and at page 111 is a draAving 
 of a case Avhere such obstruction Avas 
 proved. When the ends of the ligature 
 are cut off and the pedicle returned, Ave 
 knoAv that a similar adhesion of intestine 
 .sometimes takes place around the end of 
 the pedicle ; and that in some cases pus 
 lias been circumscribed in this manner, 
 until at length it has found an outlet, 
 cither through the alxlorninal wall, the 
 vagina, or intestine. The observation of 
 cases of this kind led me to believe tliat 
 the clamp, or some other extra-peritoneal 
 method, Avasnot only successful as regards 
 the immediate result of the operation, but 
 still more so if avc looked to tlie subse- 
 quent health of the patient. Patients Avho 
 recovered after the extra-peritoneal treat- 
 ment of the pedicle, as a rule soon regained 
 health. So do those Avho recover after 
 the intra-peritoncal treatment. But some 
 
 of them, sooner or later, suffer from 
 chronic suppuration, hosmatocele, or fcecal 
 fistula ; or, perhaps Avithout any definite 
 local ailment, are many months before 
 they become strong and Avell. This, 
 however, must be considerably modified 
 by what has been observed since the use 
 of antiseptics ; for in the 6 years since I 
 ha\'e combined the antiseptic and intra- 
 peritoneal methods, I can record rapid 
 and complete recovery as the rule, and 
 have not noted one case either of chronic 
 suppuration or faecal fistula, and only one 
 of ha^matocele, and that doubtful. 
 
 TETANUS 
 
 If my OAvn experience of 4 cases 
 in 1,139 cases of completed OA'ariotomy 
 may be taken as any guide in estimating 
 the frequency of tetanus after ovariotomy, 
 Ave might say that it occurred once in 
 from 250 to 300 cases. And this estimate 
 is supported by the fact that the 300 cases 
 collected by Dr. Lyman Avith a vieAV to 
 ascertain the causes of death furnished 
 only 1 case of tetanus. Olshausen gives 
 a table of 20 cases of tetanus after ovario- 
 tomy, and some particulars of 4 others, 
 only 1 of Avhich (and that in my own 
 practice) recovered. It is remarkable 
 that Stilling lost 7 patients from this com- 
 plication out of a total of 29. 
 
 It is curious that, of the 4 cases of 
 tetanus Avhich have occurred in my prac- 
 tice, 3 showed themselves very early — 
 namely, the 9th, the 12th, and the o5th 
 cases — and I did not see another till the 
 898th ; a run of more than 850 ovario- 
 tomies Avithout a sign of tetanus. I have 
 not seen 1 in the last 241 cases. The first 
 2 cases Avere in October 1859. The 3rd 
 did not appear till May 1862, at Avhich 
 time several other deaths from tetanus 
 Avcre registered in London, 2 having fol- 
 loAved the simple operation of tapping for 
 hydrocele. From May 1862 till June 
 ]<S78, or 16 years, I saw not a single case 
 of tetanus, nor have I since. Among all 
 my operations for the remoA^al of uterine 
 tumours, ovariotomy twice on the same 
 patient, incomplete operations and ex- 
 ploratory incisions, there Avas not one 
 case of tetanus. Four cases of tetanus 
 folloAving ovariotomy are all I have to 
 record, and this is in the proportion of 
 less than 1 in 300 for all gastrotomy 
 operations. I must certainly have tapped 
 ovarian cysts 1,000 times. I have re- 
 
TREATMENT OF PATIENTS AFTER OVARIOTOMY 
 
 115 
 
 moved a great many tumours of the breast 
 and from other parts of the body every 
 year; and I have performed a large num- 
 ber of plastic operations, such as closing 
 vesico-vaginal fistulaj and restoring rup- 
 tured perineum, tetanus occurring only 
 once. Then it followed tlie operation for 
 ruptured perineum. In this case, and in 
 3 out of the 4 where it happened after 
 ovariotomy, the patients themselves attri- 
 buted the access of the symptoms to a 
 chill. In the perineal case it was very 
 remarkable, as the premonitory stiffness 
 and spasms appeared soon after the re- 
 moval of the patient's bed to a spot im- 
 mediately beneath an open ventilating 
 shaft. In 1 of the ovariotomy cases no 
 note has been made as to chill ; but in 
 the 3 others it was distinctly observed 
 that the tetanic symptoms came on after 
 an exposure to a draught of cold air when 
 the patients were incautiously uncovered. 
 As preventive treatment, the necessity 
 of protecting women after operation from 
 currents of cold air, or chill in any way, 
 is clearly shown. In regard to curative 
 treatment, it is interesting to state that the 
 only case of the 29 collected by Olshausen 
 which recovered was that which I treated 
 with woorara. Any one wishing to follow 
 out this subject may refer to a paper of 
 mine read at the Medico-Chirurgical 
 Society in November 1859, and published 
 in the Proceedings. In the other cases 
 chloroform was given freely, woorara Avas 
 again tried, but without any apparent 
 good result, and opium was used. All 
 treatment, however, was as ineffectual as 
 it is generally found to be, except in the 
 
 very chronic cases. In 1 case I excised 
 the remnant of the exposed pedicle and a 
 portion of omentum which had been tied 
 and brought out thx'ough the wound ; 
 hoping that, as injured nerves in the 
 pedicle might be the origin of some in- 
 jurious reflex action, when the cause of 
 the mischief was taken away there would 
 be some mitigation of the symptoms. 
 Olshausen attributes the high mortality 
 which he has tabulated partly to the irri- 
 tation of hare-lip pins, but the greater pro- 
 portion of it to insufficient tightness of the 
 clamp, indicated by secondary heemor- 
 rhage, so that the nerves of the pedicle 
 were not so thoroughly crushed as to 
 render them powerless in exciting marked 
 reflex action. Messrs. Harris and Doran 
 recently examined the spinal cord after 
 the death of a woman in the Samaritan 
 Hospital, and in their report to the Patho- 
 logical Society state that they only found 
 appearances which are seen after other 
 diseases, such as exudations, dilated ves- 
 sels, want of symmetry, and exuberant 
 proliferation in the central canal ; and 
 they conclude that the clinical symptoms 
 do not encourage us in the expectation of 
 finding any specific change in the cord, 
 though it is unquestionably the structure 
 partly, if not chiefly, at fault. Here there 
 Avas no apparent local morbid action, and, 
 so far as my oAvn cases are concerned, I 
 have no reason to believe that any patho- 
 logical condition connected AAath the 
 operation had anything more to do with 
 the disease than as giving the same pre- 
 disposition Avhich Avould come from a 
 common Avound. 
 
 CHAPTER XII 
 
 OVARIOTOJIY DURING PREGNANCY 
 
 Ovarian tumours may not only be mis- 
 taken for pregnancy Avhen they exist 
 independently, but they are often compli- 
 cated by its occurrence even in advanced 
 stages of their growth. And though the 
 diagnosis of this condition is generally to 
 be made out by the tisual order of exami- 
 nation, yet the complication may be 
 revealed only at the time of the operation. 
 Out of these circumstances several very 
 important practical questions arise. 
 
 It may be asked, in the first place, 
 whether in such a case it Avould be 
 necessary to interfere at all, under the 
 assumption that pregnancy and ovarian 
 disease might go on together, and serious 
 trouble arise only in a small percentage 
 of cases. The early induction of prema- 
 ture labour has also been advocated on 
 the grounds that rupture of the cyst, or 
 its gangrene from rotation of the pedicle, 
 might occur under the pressure of the 
 
 I 2 
 
116 
 
 OVATITAX AND ALLIED TUMOURS 
 
 enlarging uterus, Avliile relief has some- 
 times i'oUowed spontaneous premature 
 labour. Some practitioners, again, have 
 declared themselves in favour of tapping 
 the ovarian cyst, rather than inducing 
 premature laboui-, thus anticipating the 
 dangers of rupture or gangrene of the 
 cyst without sacrificing the child. Ami 
 then comes the triple question, in refer- 
 ence to ovariotomy, whether it should 
 be performed at all during the existence 
 of pregnancy ; whether, if done, it should 
 be supplemented by the Cassarean section, 
 or Porro's operation ; and thirdly, whether 
 if, during ov^ariotomy, the uterus should 
 give way or be accidentally opened, its 
 contents should be cleared out, or the 
 parts left to themselves, or Porro's opera- 
 tion be peribrmed. 
 
 These questions are of such vital 
 importance that I will endeavour to 
 arrive at some general principles or use- 
 ful rules of practice by the consideration 
 of a series of cases in which the several 
 iifEculties presented themselves, and will 
 lirst examine the assertion that no treat- 
 ment at all is called for ; that ovarian dis- 
 ease and pregnancy may, as a rule, be 
 allowed to progress together without 
 interference. I might support this doc- 
 trine by the fact that I knew one woman 
 Avho, during the slow progress of an 
 enlarging ovarian cyst, went through 5 
 pregnancies, bore 5 living children with- 
 out imusual difficulty, although the cyst 
 had never been tapjied, nor had labour 
 ever been prematurely or artificially 
 induced. And by the fact that in 
 another case where I performed ovario- 
 tomy successfully 15 months after the 
 birth of twins, the patient had begun to 
 enlarge G months before marriage, and 
 had only suffered from her excessive size 
 during this pregnancy ; and by the fact 
 that a patient, upon whom I performed 
 ovaiiotomy with success in the 4th 
 month of pregnancy, after rupture of the 
 cyst and peritonitis, had boi-ne G living 
 children during the progress of the cyst 
 before its rupture. But I must regard 
 these cases as exceptional, for I can only 
 remember one other case where preg- 
 nancy complicated with ovarian disease 
 lias gone on to its natural termination in 
 the birth of a living child ; or where, in 
 consequence of non-interference, great 
 suffering has not arisen during or after 
 labour, or very grave danger from rup- 
 ture or rotation of the cyst; or where it 
 
 has not been necessary to guard against 
 threatening danger, and either to tap the 
 cyst, to induce premature labour, or to 
 perform ovariotomy. 
 
 In the first 3 cases which I now pro- 
 ceed to narrate, death followed the spon- 
 taneous rupture of an ovarian cyst in or 
 before the 7th month of pregnancy. 
 
 Case 1. — In July 1.SG4, I saw a lady, 
 who with the usual symptoms of early 
 pregnancy had a hard, irregular tumour, 
 in the right flank. The uterus Avas 
 pushed a little over to the left side, and 
 the movements of a child were distinctly 
 felt ; while on the right, not crossing the 
 median line, an elastic tumour extended 
 upwards beneath the false ribs, I sug- 
 gested that if premature labour did not 
 come on, this tumour should be punctured. 
 In September there was an attack of 
 peritonitis, and she was believed to be 
 in labour. The membranes protruding, 
 they Avere ruptured, and some hours 
 afterwards a female child was born, 
 which lived 24 hours. The symptoms 
 of peritonitis continued, and the patient 
 died 4 days after the delivery. 
 
 After death there was found a very 
 large cyst of the right ovary, occupying 
 the whole of the right side of the abdo- 
 men, and extending 4 inches to the 
 left of the median line. It was flaccid, 
 as if partially emptied, and a large 
 quantity of bloody serous fluid lay 
 in the lower part of the abdominal 
 cavity. The pedicle, Ih inch long, was 
 twisted, and the walls of the cyst were 
 infiltrated with blood. Within the cyst 
 there was much bloody serum with several 
 very firm clots. Some of the contents of 
 the cyst had evidently escaped through 
 an opening in a very thin part of the 
 cyst wall posteriorly, and had, no 
 doubt, caused the i^eritonitis which 
 proved fatal. 
 
 Case 2.— In May 18G8, a lady in the 
 5th month of pregnancy was also suffer- 
 ing from an ovarian tumour, Avhich had 
 been discovered by her husband on the 
 night of marriage in October 18G6. From 
 the time of marriage, the tumour evi- 
 dently but slowly increased in size, and 
 was the seat of frequent darting pains. 
 Eight months after marriage she became 
 pregnant, miscarried C weeks after con- 
 ception, and recovered without any un- 
 favourable symptom. From this time till 
 the end of 18G7 there was no decided 
 
OVARIOTOMY DURTXG PREGNANCY 
 
 117 
 
 increase nor other change in t]ie tumour. 
 Then a second pregnancy occurred. She 
 began to sudor intense pain in the tumour, 
 and became restless and desponding. It 
 was in the 5th month of this second 
 pregnancy that I saw her, and found an 
 ovarian cyst as large as an adult head 
 above and to the right of the uterus. At 
 that time there Avas no very great suffer- 
 ing, but I advised that the cyst should be 
 tapped if relief was called for. At about 
 the 6th month premature labour came 
 on spontaneously, and she was delivered 
 of a dead child. From the period of her 
 delivery many of her symptoms subsided. 
 But after al^out a Aveek she began to 
 complain o£ more pain in the tumour, 
 and it increased rapidly in size; Avhen one 
 morning, after turning somewhat suddenly 
 in bed, she cried out that something had 
 broken inside, and died almost instantly. 
 No post-mortem examination Avas made, 
 but the abdomen was found to be per- 
 fectly flaccid. Not a trace of the tumour 
 could be felt. 
 
 Case 3.— On January 16, 1869, I was 
 consulted by a lady 24 years of age, Avho 
 had been married about 9 months. She was 
 supposed to be pregnant, and an ovarian 
 tumour had been recognised in the left 
 side 4 years before. The abdomen 
 had gradually increased in size. I could 
 distinctly trace the boundaries of 3 
 tumours, or separable portions of 1 
 tumour — one central, extending upwards 
 half Avay from the pubesto the umbilicus ; 
 one on the left side, extending into the 
 left flank and reaching about 1 inch 
 above the umbilicus ; and one on the 
 right side, extending nearly to the false 
 ribs. The central tumour felt exactly 
 like a pregnant uterus. The tumours to 
 the right and left were not fluctuating, 
 but they felt softer than fibroid tumours 
 of the uterus usually do. The cervix 
 uteri was shortened and softened, strongly 
 supporting the belief in the pregnancy. 
 But no sound of foetal heart nor placental 
 murmur could be detected. To the left 
 of the cervix, projecting towards the 
 bladder, a hard nodulated tumour, as 
 large as 3 or 4 walnuts, closely 
 connected Avith the body of the uterus, 
 could be felt. This, I felt sure, Avas a 
 fibroid outgroAvth from the uterus, and I 
 made a diagram illustrating my diagnosis 
 of pregnancy Avith a small hard fibroid 
 outgrowth from the body of the uterus, 
 and two softer tumours, Avhich might be 
 
 either ovarian tumours or soft uterine 
 fibroids ; and I suggested the propriety 
 of inducing premature labour, as I did 
 not think that tapping could lead to any 
 considerable diminution in the size of 
 either of the tumours. 
 
 A fortnight after this advice Avas given 
 the foetal heart was distinctly heard. This 
 Avas on January 29. On February 8, at 4 
 in the morning, she awoke after 3 hours' 
 sleep, complained of pain, fell back, and 
 died. There was no opportunity of 
 making a post-mortem examination, but 
 there could be no doubt about the burst- 
 ing of an OA'arian cyst. 
 
 Cases 4 and 5. — It is unnecessary to 
 detail the particulars of these cases, the 
 simple facts being that two patients Avho 
 Avere pregnant had also large ovarian 
 cysts, Avhich I thought should be emptied 
 by tapping, but my advice was not fol- 
 lowed. Both women suffered excessively 
 from distension, had lingering labours and 
 still-born children. In both ovariotomy 
 Avas performed a fiew weeks after delivery, 
 successfully in one, Avith a fatal result in 
 the other. 
 
 I have also notes of 5 cases of 
 patients Avhom I have tapped during preg- 
 nancy, 1 of them three times, 1 twice, 
 and 3 once. In all these Avomen great 
 relief Avas afforded by the tapping, no 
 ill effect of any kind Avas observed to 
 follow it, and in all cases the children 
 were born alive after labours of mode- 
 rate duration. One of these cases is 
 of sufficient interest to deserve a short 
 report. 
 
 Case 6. — In NoA'ember 1865 I per- 
 formed ovariotomy Avith a successful result 
 upon a married woman, 40 years of 
 age, 4 months after the birth of a 
 living child. I had tapped this Avoman 
 2 months before her delivery, at Avhich 
 time the abdomen Avas greatly distended, 
 and nothing could be detected except a 
 A'ery large ovarian cj'st, nor could the 
 patient believe that she Avas pregnant. 
 But the cervix uteri Avas found to be short 
 and velvety, and hallottement Avas very 
 distinct. After the removal of 18 pints 
 of fluid, the enlarged uterus Avas felt 
 nearly up to the umbilicus, the collapsed 
 cyst to the left, and the foetal heart Avas 
 heard below and to the left of the umbili- 
 cus. Immediate relief foUoAved the tapping. 
 A healthy child Avas born on July 20, at 
 the fall term of pregnancy. The cyst re- 
 filled, and I removed it in the Samaritan 
 
118 
 
 OVAEIAX AND ALLIED TUMOURS 
 
 Hospital on November 29, 1865. The 
 patient made an excellent recovery, and 
 had another child in September, 1867. 
 I heard from her in November, 1881, as 
 being quite well. 
 
 As I published a very full report 
 of the following case in the ' Medical 
 Times and Gazette ' of September 30, 
 1865, I need not do more now than point 
 out its bearing upon the question of the 
 performance of ovariotomy during preg- 
 nancy. In this case I entirely overlooked 
 the coexistence of pregnancy with ovarian 
 disease, and after the removal of an 
 adherent multilocular cyst of the left 
 ovary, weighing about 28 pounds, 
 I felt what I thought Avas a cyst of the 
 right ovary, tapped it, and then found 
 that it was the gravid uterus. As this 
 stage of the operation is of some im- 
 portance in the history of the Cajsarean 
 section, being, I believe, the first case in 
 which the opening in the uterine wall was 
 closed by sutures, I quote the following 
 passage from the report published at 
 the time : 
 
 ' Some 2 or 3 pints of bloody fluid 
 having escaped through the canula, the 
 tumour became much less tense ; and 
 on bringing it up to the surface I saw the 
 Fallopian tube passing from its upper 
 part towards the left side, and knew at 
 once that I had punctured the uterus. On 
 withdrawing the canula, a soft, spongy, 
 bleeding mass jirotruded, and on putting 
 in my finger to ])ush this back and examine 
 the uterine cavity, the anterior wall of the 
 uterus — which was very soft and friable, 
 as if it had undergone fatty degeneration 
 — gave way along the middle line from 
 the puncture (which was near the fundus) 
 for an extent of from 3 to 4 inches 
 down the body towards the neck. With 
 very slight pressure a quantity of liquor 
 amnii and a fuctus of about 5 months 
 escaped. I then easily peeled olF the 
 placenta from the inner surface of the 
 uterus. The organ did not contract, and 
 there was free bleeding from three vessels 
 close beneath the peritoneum at the lower 
 angle of the rupture in the uterus. These 
 vessels were secured by three silk liga- 
 tures. Oozing still going on from the 
 surface where the jilacenta had been 
 attached, I made a free opening into the 
 vagina by passing my finger from aljove 
 through the cervix and os, and then put a 
 piece of ico into the uterus, and held it 
 within by firmly gra.sping the organ, 
 
 which then contracted. I then brought 
 the peritoneal edges of the tear in the 
 uterus together by an uninterrupted suture 
 of fine silk, one long end of which I had 
 previously passed into the uterine cavity, 
 and out through the os into the vagina. 
 By 7 or 8 points the edges were brought 
 accurately together, and the other end 
 of the silk was brought out through the 
 opening in the abdominal wall, with the 
 ends of the 3 ligatures on the vessels 
 in the uterine wall, close to the pedicle, 
 and all were tied to the clamp.' 
 
 Any one interested in the progress of 
 the patient after this complicated opera- 
 tion may find a very full report in the 
 journal to which I have referred. All I 
 need say now is that she comj^letely 
 recovered. I have seen her several 
 times since in excellent health, the last 
 time in 1880. She reported herself Avell 
 in 1881. 
 
 The interest of this case in relation to 
 the subject under notice is in its bearing 
 on the question, 'What should be done 
 when a pregnant uterus is discovered 
 during some stage of ovariotomy ? ' My 
 answer would be, ' Let it alone.' But in 
 a case of Dr. Atlee's in 1850, ovariotomy 
 performed in the 2nd month of preg- 
 nancy Avas ' followed by such great irrita- 
 bility of stomach, in consequence of the 
 state of pregnancy, that she could not be 
 nourished, and she died, 30 days after, 
 of starvation.' And in a case by J\Ir. 
 Burd, of Shrewsbury, in 1847, of ovario- 
 tomy performed between the 3rd and 
 4th months of pregnancy, abortion 
 took place 2 days after operation, and 
 was followed by alarming symptoms, last- 
 ing several days. Still the j^atient re- 
 covered. Marion Sims also performed 
 ovariotomy in the 3rd month of preg- 
 nancy, and did not detect pregnancy 
 until the ovarian tumour had been re- 
 moved. The patient recovered well, went 
 the full term, and Avas safely delivered. 
 
 Supposing the operator has penetrated 
 the uterus, if any conclusion can be 
 draAvn from the case in Avhich I made this 
 mistake and eu)ptied the uterus, and from 
 two other cases in Avhich the same mis- 
 take Avas made by other surgeons Avho 
 did not empty the uterxis, but closed the 
 puncture in its Avail by Avire sutures, both 
 I«itients ha\'ing died after aborting while 
 mine recovered, it Avoidd appear to be 
 the safer practice to empty the uterus, 
 and either to close the opening in the 
 
OVARIOTOMY DURING PREGNANCY 
 
 119 
 
 uterine "vvall by suture, or to perform 
 supra- vaginal amputation of the uterus as 
 advised and practised by Porro, afterwards 
 by other Continental surgeons, and more 
 recently here by Dr. Godson, as will be 
 seen by referring to a subsequent chapter. 
 I now proceed to relate 4 other 
 cases occurring in my first series of 
 500, in one of which ovariotomy was 
 performed at the 4th month of preg- 
 nancy, after rupture of the cyst and 
 peritonitis ; in the 2nd, 3rd, and 
 4th the operation was a matter of 
 election to avoid other dangers. The 
 result was successful in all of them, the 
 mothers being saved, o of them giving 
 birth to living children after natural 
 labours at the lull period of pregnancy, 
 and the 4th having, recovered well after 
 a rapid labour 11 weeks after ovario- 
 tomy. 
 
 Case 330. — The mother of 8 chil- 
 dren, 36 years of age, was first seen 
 ■on August 13, 1869. About a month 
 before this an abdominal tumour, which 
 had been slowly increasing after the birth 
 of twins 16 years before, and had not 
 prevented the birth of 6 other children, 
 had suddenly and rapidly increased in 
 size after an attack of severe abdominal 
 pain and tenderness with sickness and 
 lever. I ascertained the presence of an 
 ovarian tumour with free fluid surround- 
 ing it in the peritoneal cavity, and de- 
 pressing the recto- vaginal pouch, and the 
 existence of pregnancy about the com- 
 mencement of the 4th month. The fluid 
 in the peritoneal cavity was from the 
 rupture of the wall of a multilocular cyst, 
 and the escape of the contents of a large 
 cyst. On the following day I performed 
 ovariotomy. The timiour, with its con- 
 tents and the fluid surrounding it, 
 ^veighed altogether 37 pounds. 
 
 This patient was delivered of a living 
 child on February IS, 1870, after a natu- 
 ral labour, and went on Avell afterwards. 
 But she died in 1871, of malignant disease 
 of the uterus. 
 
 Case 399. — In this case a single cyst 
 was removed at about the 3rd month 
 of a 3rd pregnancy. A healthy child 
 was born at the full time, and 3 other 
 pregnancies have followed. 
 
 Case 419. — A married lady, 38 years 
 of age, mother of 5 children. Her own 
 mother had died of dropsy and abdo- 
 minal tumour. A dermoid cyst, without 
 pedicle, but with intestinal and omental 
 
 adhesions, and of 18 years' growth, was 
 taken away about the 2nd month of the 
 6th pregnancy. Recovery complete, and 
 child born at full time. Died 10 years 
 afterwards of pidmonary disease, but had 
 also another abdominal tiimour of doubt- 
 ful nature. 
 
 Case 476.— On March 13, 1872, I 
 operated on a married woman 29 years 
 of age in the 4th month of pregnancy. 
 To the right and above the uterus was 
 a hard tumour, held up by omentum, 
 which adhered to it, and having the right 
 Fallopian tube only separated from it by 
 the broad ligament. I cut away the 
 tumour, leaving the Fallopian tube un- 
 touched. I did not feel either ovary, the 
 uterus being so large and tense. The 
 patient recovered, was delivered of a 
 child at the 6th month of pregnancy, 
 and did Avell, She has since given birth 
 to a girl at the full time (1873), who is 
 still living. The mother reported herself 
 well in 1881. 
 
 The tumour was a nearly solid mass 
 of white fibrous tissue, infiltrated in 
 places with a thick transparent fluid, 
 which had here and there collected in the 
 distended areoke. But towards the upper 
 part there was a large irregular cavity 
 divided by imperfect septa, lined with 
 smooth membrane, and nearly filled 
 Avith blood clot, partially organised. The 
 pedicle was a small double layer ot 
 peritoneum, about 1^ inch long and 
 ^ inch wide, enclosing a few vessels and 
 some areolar tissue. The tumour mea- 
 sured in its long diameter 6^ inches and 
 in its short diameter 3^ inches. It was 
 the first fibrous tumour of the ovary that 
 I had seen. 
 
 In the second series of 500 cases of 
 ovariotomy, I performed the operation 
 during pregnancy 5 times — making 10 
 cases in the 1,000. The following are 
 brief notices of the 5 cases which occurred 
 in the second 500. 
 
 Case 507. — Was a married woman, 
 32 years of age, and mother of 7 chil- 
 dren. Pregnancy was not suspected, but 
 the incision disclosed a large uterus below 
 and to the left side. AVith it on the 
 right side was a nuiltilocular cyst, weigh- 
 ing 26 pounds. The left ovary was 
 found applied to the side of the uterus, 
 which was as large as at the 6th month of 
 pregnancy. The clamp caused too much 
 dragging, and was replaced by ligatiu'e. 
 Labour pains came on the next morning, 
 
120 
 
 OVAlilAN AND ALLIED TUMOURS 
 
 the membranes were punctured, and in 
 about 10 minutes a living child was 
 expelled. The patient recovered rapidly, 
 and after wai-ds presented herself at the 
 hospital with another healthy child. 
 This has since been followed by another 
 birth and a 3rd pregnancy. 
 
 Case 752. — The lady was 37 years of 
 age, at the 5th month of pregnancy, suffer- 
 ing from peritonitis and obstructed intes- 
 tines, and almost moribund. Some relief 
 Avas obtained by tapping and the removal 
 of 9 pints of ovarian fluid from the peri- 
 toneal cavity. The next morning I took 
 aAvay a bur.st ovarian cyst. The child Avas 
 born 9 hours after. The patient went on 
 well for 2 days, but died on the 5th day 
 after the operation. Considering that 
 this is the only death after my 1 1 
 operations daring pregnancy, and the 
 desperate circumstances under wliich 
 this one was imdertaken, it will certainly 
 appear that pregnancy does not add much 
 to the danger of ovariotomy. 
 
 Case 798. — This lady was the wife of 
 a medical man. She was -41 years of age 
 and the mother of 6 children. I re- 
 moved an ovarian tumour weighing 7 
 pounds. The uterus then extended up- 
 wards about half way between the pubes 
 and umbilicus. The pedicle on the right 
 side was secured by a clamp. She re- 
 covered perfectly, was delivered after an 
 easy labour on April 23, LS77, and in 
 188-1: was quite well. 
 
 Case 817.— The wife of a soldier 
 admitted into the Samaritan Hospital, 
 187G, Avas 27 years of age, and had 1 
 child 2 years old. She was in the 3rd 
 or 4th month of pregnancy. Two months 
 later the fa;tal heart sounds were very 
 distinct in the right iliac region. The 
 fundus uteri was 7 inches above the sym- 
 physis pubis, and .above it Avas a large 
 ovarian cyst. Ovariotomy Avas per- 
 formed. The tumour Aveighed 11^ 
 pounds — 9 pints of fluid, 2^^ pounds solid. 
 When she was convalescent, uterine pains 
 came on and a child was born alive. 
 She has had 2 boys since, 1 born in 
 1878, the other in l.SSO, and in 1881 Avas 
 quite Avell. 
 
 Case 879. — The Avife of a surgeon 
 consulted me in October 1877, 4 
 months after her marriage. She Avas 28 
 years of age, and although unsuspected 
 at the time of marriage, there can be 
 very little doubt that ovarian disease 
 had begun a year or two before. She 
 
 Avas married on June 27, IS77, and 
 pregnancy may be dated from the 1st 
 Aveek in August. I operated on her 
 on November 9, 1877. An ovarian 
 tumour Aveighing 10 pounds Avas removed, 
 a short pedicle on the left side being 
 secured in a clamp. RecoA^ery Avas un- 
 interrupted, and a child Avasborn on April 
 15, 1878. She Avas quite Avell in Aus- 
 tralia in December 1884, having had 
 four healthy children since the ovario- 
 tomA^ 
 
 I have only once operated during 
 pregnancy since completing 1,000 cases 
 of ovariotomy. 
 
 Case 1138. — I performed ovariotomy 
 on January 22, 1885, on a married lady 
 28 years of age. She Avas married in- 
 1881, had a miscarriage in July 1882, 
 and until I first saw her Avith Di-. 
 Priestley, in December 1S84, suffering 
 from an OA'arian cyst Avhich Avas in- 
 creasing rather rapidly, there luid been 
 no suspicion of a subsequent pregnancy. 
 After removing a large multilocular 
 cyst of the left ovary, the uterus Avas 
 seen to be about the size expected. 
 A fa2tus of the 3rd month came nvray 
 without pain or difficulty 6 days after- 
 Avards. The Avound Avas quite healed 
 and the stitches removed on the 7th day, 
 and recovery Avcnt on quite as Avell as iu 
 patients not pregnant. 
 
 Careful consideration of the cases just 
 related Avill lead, I think, to the folloAving 
 conclusions : 
 
 1. Pregnancy and OA'aiian disease may 
 go on together. The birth of a living 
 child and the safety of the mother have 
 been observed under this complication. 
 
 2. But in a large proportion of cases — 
 probably in nearly all Avhere an ovarian 
 tumour is large — there is danger of abor- 
 tion ; or, if the pregnancy proceed to the 
 full term, of lingering labour and a still- 
 born child; and throughout the latter 
 months of pregnancy there is danger of 
 sudden death to the mother from rupture 
 of the cyst or rotation of its pedicle. 
 
 3. Spontaneous premature lal)0ur may 
 not save the mother from these perils, and 
 the induction of premature labour artifi- 
 cially almost implies sacrifice of the child 
 with considerable risk to the mother. 
 
 4. There is no proof that tapping an 
 ovarian cyst is more dangerous during 
 pregnancy than at any other time ; and if 
 there bo a large single cyst, tapping Avill 
 afford immediate relief to distension at a. 
 
OVARIOTOMY DURING RREG NANCY 
 
 121 
 
 very slight risk to the mother, and lead 
 to the natural termination of pregnancy in 
 the birth of a living child, i£ proper pre- 
 cautions be taken to prevent the escape of 
 ovarian fluid into the peritoneal cavity, 
 and the entrance of air carrying germs into 
 this cavity, or into the cavity of the cyst. 
 In cases of multilocular cyst, tapping can 
 be of very little use. 
 
 5. In cases of multilocular cyst, or 
 solid tumour, the rule should be to remove 
 the tumour in an early period of pregnancy: 
 
 and if an ovarian cyst should burst during 
 pregnancy at any period, removal of the 
 cyst and complete cleansing of the peri- 
 toneal cavity may save the life of the 
 mother, and pregnancy may go on to the 
 full term. 
 
 G. 01; o cases on record ■where a preg- 
 nant uterus has been punctured during 
 ovariotomy, the only recovery was in the 
 one case •where tlie uterus was emptied 
 before the completion of the operation, and 
 the opening in its wall closed by suture. 
 
 
 
 Cases or Ovariotomy 
 
 DURING Pregnancy 
 
 
 No. 
 
 jredical 
 
 Age of 
 
 Period of 
 
 Date of 
 
 Weight 
 of 
 
 Result to 
 
 Result to Child 
 
 Subsequent 
 
 Attendant 
 
 Patient 
 
 Pregnancy 
 
 Ovariotomy 
 
 Tumour 
 
 ]>J.otUer 
 
 History 
 
 1 
 
 Mr. Cook, 
 
 24 
 
 4th to 5th 
 
 Aug. 1865 
 
 28 lbs. 
 
 Recovery 
 
 Foetus removed 
 
 Well in 1881 
 
 
 Clovelly 
 
 
 month 
 
 
 
 at same time 
 
 
 2 
 
 Mr. Batenian, 
 
 Islington 
 
 3G 
 
 3rd month 
 
 Aug. 18G9 
 
 S7 lbs. 
 
 Recovery 
 
 Alive ; 
 Natural lal)our 
 
 Died of Cancer 
 of Uterus, 
 
 
 
 
 
 
 
 Feb. 1870 
 
 March 1871 
 
 3 
 
 Dr. Goddard, 
 
 28 
 
 3rd month 
 
 Dec. 1870 
 
 15 lbs. 
 
 Recovery Alive ; 
 
 Children born. 
 
 
 Highbury 
 
 
 
 
 
 
 Natural labour 
 
 1873, 1876. 
 
 
 
 
 
 
 
 
 July 1871' 
 
 1878. Well 
 in 1884 
 
 4 
 
 Dr. Eoss, 
 
 38 
 
 3rd month May 1871 1 34 lbs. 
 
 Recovery 
 
 Alive ; 
 
 Child born. 
 
 
 Bloomsbury 
 
 
 
 
 
 
 Natural laliour 
 Dec. 1871 
 
 Jan. 7, 1877. 
 Pulmonary 
 disease and 
 abdominal 
 tumour of 
 doubtful na- 
 ture in 1881 
 
 5 
 
 Dr. Moore, 
 Ipswich 
 
 29 
 
 4th month 
 
 March 1872 1 10 lbs. 
 
 Recovery 
 
 Alive; 
 
 Natural labour 
 
 jMay 1872 
 
 Child born, 
 Mav 1873. 
 Well in 1881 
 
 6 
 
 Mr. Coleman, 
 
 32 
 
 7th month 
 
 Aug. 1872 2G lbs. 
 
 Recovery 
 
 Seven months' 
 
 Five cliildren 
 
 
 Woolwich 
 
 
 
 
 
 
 child, born day 
 after operation 
 
 since — viz. 
 1873-75-76- 
 78 and 79. 
 Died soon 
 after last 
 birth 
 
 7 
 
 Dr. Kidd, 
 Dublin 
 
 38 
 
 Gth month 
 
 March 1S76 
 
 40 lbs. 
 
 Died five 
 days after 
 
 Foetus expelled 
 
 9 hours after 
 
 operation 
 
 
 8 
 
 Dr. Roberts, 
 Cheshunt 
 
 41 
 
 4 th month 
 
 Oct. 1876 
 
 7 lbs. 
 
 Recovery 
 
 Cliild born 
 
 April 1877 ; 
 
 Labour natural 
 
 Well 1884. No 
 more children 
 
 9 
 
 Surgeon -Ma- 
 jor Perry 
 
 27 
 
 7th month 
 
 Dec. 1876 
 
 12 lbs. 
 
 Recovery 
 
 Child born 
 25 days after 
 
 Bovs born, 
 1878 & 1880. 
 
 
 
 
 
 
 
 
 Well in 1881 
 
 10 
 
 Mr. Stirling 
 
 28 
 
 4th month 
 
 Nov. 1877 
 
 10 lbs. 
 
 Recovery 
 
 Child born 6 
 months after 
 
 Four children 
 since. Well 
 in Dec. 1884 
 
 11 
 
 Dr. Priestley 
 
 28 
 
 3rd month 
 
 Jan. 1885 
 
 15 lbs. 
 
 Recovery 
 
 Abortion 6 
 days after 
 
 Well March 
 18S5 
 
 CHAPTER XIII 
 
 ON INCOMPLETE OVArJOTOMY AND EXPLORATOnY INCISIONS 
 
 When I began to publish every case 
 where I had con:ipleted the operation of 
 ovariotomy, and published, in separate 
 
 series, cases where the operation was com- 
 menced but not completed, and caseswhere 
 an exploratory incision only was made, I 
 
122 
 
 OVARIAN AND ALLIED TUMOURS 
 
 had to reply to objections advanced by 
 critics who considered that the fatal cases 
 of exploratory and incomplete operations 
 ought to be counted among the unsuccess- 
 ful cases of ovariotomy. If I asked 
 whether the cases which recovered from 
 the operation when only part of the cyst 
 had been removed, or when a cyst had 
 been simply emptied, should be counted 
 among the successful cases, the answer 
 was, ' Certainly not, because ovariotomy 
 had been only attempted, and the attempt 
 had failed.' One great reason why ovario- 
 tomy was so long before it was received 
 at all cordially by the profession was, 
 that incomplete cases, or cases of simple 
 incision, had been classed among cases 
 of ovariotomy, Avhile unsuccessful cases 
 were left unpublished. In the so-called 
 statistical tables, cases of complete and 
 incomplete ovariotomy and of exploratory 
 incisions were so grouped together that it 
 was impossible to ascertain, Avithout a good 
 deal of inquiry, what where the real 
 results of even the published cases ; and 
 in more than one of the most recent tables 
 this confusion is still more deplorable. 
 Cases of abdominal section are confounded 
 together, without any separation of cases 
 of ovariotomy from others of very different 
 ■character, thus grouping together sections 
 made with widely diverse objects, and 
 involving risks, in some very great, in 
 others very slight. The best way of 
 avoiding this error seems to be to give a 
 truthful and exact account of every case 
 of ovariotomy, or of myomotomy, neph- 
 rectomy, or of obstructed intestine, or any 
 other condition which leads to the section 
 in the order of its occurrence. When 
 considering ovariotomy, it should be 
 shown how frequently the attempt to 
 remove an ovarian tumour had been 
 made, how often it had .succeeded, what 
 were the results of completed operations, 
 how often the attempt had been only 
 partially successful or had failed, Avhat 
 were the results of incomplete operations, 
 how often diagnosis had been so doubt- 
 ful that an exploratory incision was 
 necessary before the doubt could be 
 solved, and what risk the i)ationt incurred 
 by submitting to an exploratory incision. 
 This plan appeared, and still app-^ars to 
 be, better calculated than any other to 
 present a true picture of the occurrences 
 of actual daily practice; and, I think, the 
 tables which I published in 1872, includ- 
 ing every case where I completed ovario- 
 
 tomy, and every case where I had not 
 completely succeeded, or had made an 
 exploratory incision either to satisfy my 
 own doubts or those of others, or in com- 
 pliance with the earnest solicitation of a 
 patient, gave far better means of forming 
 a correct estimate of the real results 
 of ovariotomy than if the 52 cases 
 which the supplementary tables contained 
 had been included among the completed 
 cases of ovariotomy. The proportionate 
 mortality would have been slightly in- 
 creased. Instead of 500 cases, with 127 
 deaths, and a mortality of 25'4 per cent., 
 we should have had 552 cases, with 146 
 deaths, and a mortality of 26*44 per cent, 
 —a difference of not much more than 1 
 per cent. — Avhile discredit would have 
 been thrown upon the whole series of 
 cases by the manifest fallacy that cases 
 were enumerated as ovariotomy where the 
 operation had only been begun and could 
 not be finished, and that the patients who 
 recovered from the operation were not 
 cured of the disease even if they gained 
 some temporary benefit. By correctly 
 classifying all the cases, as I did in three 
 series, all possible objection was removed. 
 The tables show that while in some 
 14 years the operation of ovariotomy had 
 been completed by me 500 times, it had 
 during the same period been found im- 
 possible to complete it in 28 cases, and 
 that in 24 other cases exploratory incisions 
 were necessary to perfect diagnosis. 
 
 On looking over in 1881 the tables 
 published in 1872, and in adding cases of 
 exploratory and incomplete operations 
 between these years, 33 in number, 
 making 85, to the 1,000 completed ovario- 
 tomy cases, I found that in almost every 
 case doubts or suspicions entertained 
 before the incision was made were con- 
 firmed, and I scarcely recollect a case 
 where an exploratory incision was 
 thought to be necessary Avhich proved to 
 be an ordinary case of ovarian disease. 
 My experience since 1881 confirms my 
 former statement, that occasionally, after 
 commencing by an exploratory incision, 
 I have found it possible to remove an 
 ovarian tumour, but there has always 
 been some peculiarity in the case 
 which led to this unusually cautious 
 mode of procedure. Anyone who Avill 
 carefully study the chapter on diagnosis, 
 in the earlier part of this volume, will 
 find good reason for believing that the 
 diagnosis of ovarian tumours, and of the 
 
INCOMrLETE OVARIOTOMY AND EXPLORATORY INCISIONS 
 
 conditions fuvourable or otherwise for 
 operation, is already as "well established 
 as that of any other form of disease 
 requiring surgical operation. No surgeon 
 about to attempt to relieve a strangulated 
 hernia can foresee exactly the conditions 
 he may meet with. The lithotomist may 
 find a larger or smaller stone than he 
 expects ; aneurism is not always cured by 
 the ligature of the artery supposed to be 
 involved; and mammary tumours sup- 
 posed to be malignant are found not 
 to be so in some cases after removal, or 
 those supposed to be innocent prove to 
 be malignant. Indeed, throughout all 
 surgery we share with physicians the 
 difficulty of p]-actising an ars conjectiuxdis, 
 and it is no repi'oach to a surgeon, if, 
 acknowledging doubt, he endeavours to 
 clear up that doubt by commencing his 
 operation with an exploratory incision. 
 With our present knowledge it is almost 
 incomprehensible that Frederick Bird 
 should have been compelled by Caesar 
 Hawkins to acknowledge that, in addition 
 to the few cases of ovariotomy which he 
 had completed and published, he had also 
 made exploratory incisions, or had com- 
 menced the operation and had failed to 
 complete it, in about 40 other cases. 
 And there can be no doubt that if a 
 surgeon for every case of completed ova- 
 riotomy must necessarily encounter such 
 difficulties that he would be compelled 
 
 tube and antiseptic injections, the risk 
 of pyajmic fever or septicaemia must be 
 encountered ; but in several cases a cure 
 has been obtained. In one case which I 
 operated on in 18G5 in the Samaritan 
 Hospital, where an ovarian cyst depressed 
 the anterior wall of the vagina and 
 extended 4 or 5 inches above the 
 umbilicus, I made an incision from I 
 inch below the umbilicus downwards for 
 5 inches. There were no adhesions 
 anteriorly, but after tapping the principal 
 cyst, and emptying it of several pints of 
 fluid containing much blood, its attach- 
 ments to the brim of the pelvis and to the 
 right side of the uterus were found to be 
 so close that I resolved not to attempt 
 their separation, but to replace the empty 
 cyst. There was, however, such free 
 hajmorrhage from the opening into the 
 cyst made by the trocar, and even from 
 the little ^^unctures made by the hooks 
 which seized the cyst wall, that it was 
 obviously imsafe to return it; and I 
 transfixed the edges o£ the external pari- 
 etal wound, and of the cyst wound, Avith 
 a hare-lip pin, and secured them together 
 with a twisted suture. The rest of the 
 abdominal wound was closed with 4 
 deep silk sutures above the pin, and 1 
 below it. The patient rallied well, but 
 for a few days had feverish symptoms. 
 The stitches were removed in due time, 
 and a very free discharge of serum 
 
 to leave several cases incomplete, or [ gradually set up, just at the point where 
 repeatedly meet with such insuperable I the cyst had been pinned to the abdominal 
 
 difficulties in diagnosis that he could only 
 satisfactorily clear them up by an incision, 
 it would be a very grave objection to the 
 principle of the operation. Happily, with 
 advancing knoAvledge doubts are being 
 cleared up and difficulties lessened, ex- 
 ploratory incisions are becoming less fre- 
 quently necessary, and incomplete are 
 bearing a diminishing proportion to com- 
 plete operations. 
 
 Of late years simple exploratory'' inci- 
 sions, made under due precautions against 
 septicasmia, have been almost free from 
 risk. If a cyst be simply tapped, the risk 
 is hardly, if at all, greater than that of an 
 ordinary tapping, and the patient is neither 
 more nor less relieved. Where adhesions 
 are separated and portions of a cyst or 
 tumour are removed, the danger is con- 
 siderably increased. When a permanent 
 
 wall. Convalescence progressed. There 
 was but a very little discharge from the 
 bottom of the cicatrix, and a slight hard- 
 ness and elastic swelling felt per vaginam. 
 The abdominal tumour disappeared, and 
 I saw her in 1872 in excellent health, 
 without any trace of her tumour. 
 
 In another case the patient was in 
 good health for nearly 3 years after the 
 operation, and then died almost immedi- 
 ately after a subcutaneous injection of 
 morphia, in Germany. 
 
 In May 1877, I attempted to remove 
 an ovarian cyst from a girl, 17 years of age, 
 ii^ the Samaritan Hospital. I found such 
 inseparable attachments that I contented 
 myself with clearing the cyst cavity of 
 G pints of purulent fluid and flakes of 
 lymph, closing the cyst and abdominal wall 
 round a glass tube, and covering the end 
 
 opening of the cyst by incision, and imion i of the tube with a carbolised sponge, 
 of cyst wall to abdominal wall by suture i The patient remained in the hospital till 
 is accomplished, even with a drainage. | August 16, suffering from a good deal of 
 
124 
 
 OVARIAN AND ALLIED TUMOURS 
 
 fevei', treated l3y the ice-cap and quinine, 
 ■while tlie cyst was washed out with car- 
 bolised solutions. Aftei* she left the 
 hospital sulphurous acid was substituted 
 for the carbolic with an immediate change 
 for the better. A continuous stream of 
 the diluted solution Avas kept running 
 through the cyst by a siphon arrangement, 
 and at the same time she was vigorously 
 nourished. She recovered sufficiently 
 well to become a nurse, although there 
 was at times some discharge from the 
 sinus in the abdominal wall which never 
 entirely closed. She was nursing in the 
 Samaritan Hospital in the early part of 
 1881, but died towards the end of the 
 year, or the beginning of 1882. 
 
 In 1880, and in 18(S1, 1 twice laid open 
 adherent cysts, but did not attempt to 
 remove them, trusting to the free escape 
 of their fluid contents into the peritoneal 
 cavity and absorption. In neither case, 
 so far, has there been any sign of reforma- 
 tion of fluid. 
 
 The painful position of a surgeon who 
 lias laid bare an ovarian tumour, has 
 partly emptied it, has separated some 
 adhesions, and then begins to fear that he 
 cannot completely remove the tumour, can 
 only be estimated by those who have un- 
 expectedly found themselves in similar 
 difficulties. If the difficulty is recognised 
 early, and the cyst only exposed and 
 emptied, the patient is scarcely in a worse 
 condition than after tapping. Indeed, the 
 incision leads to the avoidance of some of 
 the dangers of tapping ; the surgeon can 
 see what vessels he wounds, and he can 
 close the opening in the cyst if he please, 
 while a short incision in the abdominal 
 wall can by itself add little to the risk to 
 the patient. But if extensive adhesions 
 have been separated, the surgeon is tempted 
 at any risk to complete the operation by 
 the feeling that he can hardly leave his 
 patient in a worse state, and that her only 
 hope is in his boldly following out his 
 intentions. In the very first case I ever 
 operated on, the patient recovered from 
 the incision, died 4 months afterwards 
 from spontaneous rupture of the cyst into 
 the peritoneal cavity, when it Avas found 
 that there would have been no insuper- 
 able difficulty if the operation had 
 been proceeded with. On the other 
 hand, post-mortem examination has 
 shown that some of the tumours could 
 not have been removed during the 
 life o£ the patient, as they could only 
 
 be separated after death by careful 
 dissection. 
 
 In any case Avhere difficulty threatens 
 to be insuperable, rather than persevere at 
 any risk, the surgeon acts more prudently 
 if he trusts to antiseptic drainage after one 
 or other of the methods just described. 
 
 A simple mode of drainage is described 
 by Dr. Robertson in the first number of 
 the 'Medical Chronicle,' published at 
 Manchester, October 18S4. The object 
 in this plan of draining is the absolute 
 exclusion of air both from the cavity 
 containing the fluid and from the drain- 
 ing apparatus. Its peculiarity consists in 
 the fixing of an air-trap to the free end 
 of the rubber draining-tube. This traj) 
 is merely a V-shaped piece of glass 
 tubing, each arm measuring from 2 to .'> 
 inches. The discharge is conveyed from 
 the trap into any convenient receptacle 
 by a second piece of tubing. 
 
 When this apparatus, filled with an anti- 
 septic solution of corrosive sublimate, 
 1-1000, is properly fixed in a cyst or 
 abscess, the contents flow in obedience to 
 the laws that regulate the movements 
 of fluids. Proper precautions are taken 
 in the introduction of the tube into the 
 wound or cavity to prevent the access of 
 air by the opening. To secure its action 
 the trap is fixed below the level of the 
 abscess or cyst, and the draining force is 
 measured by the perpendicular distance 
 between the fluid level of the cavity and 
 the fluid level of the trap. The longer 
 the distance the greater the force. In 
 draining for an amputation, a fall of I 
 inch serves the purpose. In cysts or 
 abscesses, 2 or 3 inches to a foot may be 
 employed so long as the discharge is free. 
 Excess of force is indicated by obstruction 
 of tlie tube, due to the tissues being sucked 
 
OOPHORECTOMY — OR BATTEY'S OPERATION 
 
 ^2o 
 
 into it, or by the recurrence of pus after 
 the discharge has become serous. If used 
 in a case of incompleted ovariotomy, the 
 opening in the abdominal wall and tlie 
 cyst cavity would of course be accurately 
 
 closed around the tube. If used as a 
 supplement to tapping, it would be neces- 
 sary to use the trocar and elastic canula, 
 afterwards fitting the tube over the end 
 of the canula. 
 
 CHAPTER XIV 
 
 OuPIIOIiECTOMY on BxVTTKY's OPERATION' 
 
 There are no means of iudofing what \ 
 Avould be the risk of simple castration in 
 healthy adult women. But from what we 
 know of it as practised on the lower 
 ;mimals, the risk would probably be 
 trifling. 
 
 Modern surgery has shown what can 
 be accomplished in extirpating ovarian 
 cysts, and with what small danger. With- 
 out this demonstration no one Avould have 
 thought of treating functional diseases of 
 the ovaries by the same surgical operation. 
 Battey did this when he castrated a young 
 woman in 1872, acting, as there is reason 
 to believe, independently of any acquaint- 
 ance with the suggestion made by Blundell 
 in 1823, that 'extirpation of the ovaries 
 would probably be found an effectual 
 remedy in the worst cases of dysmenorrho3a 
 and in bleeding from monthly determina- 
 tion in the inverted womb where the 
 extirpation of that organ was rejected.' 
 Though the procedure had about it an air 
 of plausibility, it was a piece of surgery 
 about on a par Avith amputating for an 
 aneurism. Battey had to deal with organs 
 supposed to be at fault, and to prevent the 
 mischief they were causing, all other 
 treatment having failed. Two alternatives 
 Avere at his choice ; he could either cut 
 out the ovaries, or he could try to bring 
 about their atrophy. He took the first, 
 and nothing in Avhat he has said or written 
 shows that he ever thought the second 
 possible. 
 
 When Bell snipped out part of a nerve, 
 or when the surgeons of today have 
 stretched a nerve to stop a neuralgic pain, 
 a well-known principle guided them. So 
 it was with Hunter, when he tied the 
 femoral artery to cure aneurism of the 
 popliteal. And Nature herself has recourse 
 to the same device in twisting the pedicle 
 of an ovarian tumour. But it is not 
 always so easy as it might seem to carry 
 
 out scientific principles in surgical prac- 
 tice. No one had tied the spermatic 
 artery, and no one had cut or stretched 
 the spermatic nerve, and Battey cautiously 
 Avithheld his hand from such experimental 
 practice. Ovariotomists had shown him 
 what was Avithin his power, and he elected 
 to try that which Avas possiljle and easy. 
 So the science of the 19th century 
 has had for a time to give place to the 
 rude chirurgical art of the 17th. Other 
 surgeons have accepted this position, and 
 have repeatedly extirpated the normal 
 ovaries of Avomen. 
 
 Battey 's object Avas to bring about 
 premature cessation of menstruation in 
 Avomen who suffer from the malperform- 
 ance of their monthly functions ; but 
 others, as Hegar, have given a Avider 
 range to the idea of suspending the func- 
 tions and influence of the ovaries. They 
 remove them to stop the growth of uterine 
 fibroma or myoma, thereby lessen their 
 hoBmorrhagic tendencies, and lead to atro- 
 phy of the growths. And the amount of 
 success which I and others have obtained 
 in cases of bleeding uterine myoma by 
 removing the OA^aries, is quite sufficient to 
 justify the proceeding in cases Avhere the 
 removal of the uterine tumour Avould be 
 very difficult or dangerous. But the ex- 
 tension of this practice, or the carrying 
 out of Battey's proposal far further than 
 he ever advocated or intended, is so open 
 to abuse, that in mental and neurotic 
 cases it is only to be thought of after long 
 trials of other tentative measures and the 
 deliberate sanction of experienced prac- 
 titioners. 
 
 In the case of fibroid groAvths Avith 
 much bleeding, the position is not the 
 same. There life is threatened, the danger 
 constantly increasing, and the last resource 
 the very serious operation of amputation 
 of the tumour or of the uterus. If it can 
 
126 
 
 OVARIAN AND ALLIED TUMOURS 
 
 be proved that the annulment of ovarian 
 function, even at the cost of the organs, 
 arrests the development of the uterine 
 growth, or checks bleeding, then the sur- 
 geon may rightfully remove the ovaries. 
 But that the neurotic or mental conditions 
 justifying such an operation are exceed- 
 ingly rare is evident from the fact that, 
 since 1878, I have only met with 8 
 patients to whom I could recommend the 
 operation. One of these refused to the last 
 the chance of relief from surgery, although 
 it was urged upon her both by Battey. 
 Marion Sims, and by me. Four opera- 
 tions were purely Battey's. The first of 
 these was reported in the Transactions of 
 the American Gynrccolo^^ical Society for 
 1880. The patient was in her 50th year 
 and had never been pregnant. Her history 
 was that of 14 years' suffering, with every 
 kind of experimental treatment. There 
 was association of severe suffering Avith 
 pre-menstrnal congestion, justifying the 
 belief that ovariotomy, performed with the 
 view of anticipating the climacteric, would 
 be a legitimate proceeding. We had 
 deferred the operation in the hope that 
 at the age of 49 the catamenia would 
 cease. But a sister, aged 54, Avas still 
 menstruating regularly ; and the patient 
 felt that it would be impossible for her 
 to go through 4 or 5 years more of 
 such repeated suffering. After full con- 
 sideration, both ovaries were removed. 
 The patient was very grateful for the 
 relief afforded her. I saw her in 1884 
 quite well, there having been no return 
 of catamenia since April 1880. The 
 recurrence a few times after the opera- 
 tion is explained by the difficulty I had in 
 removing every fragment of the left ovary. 
 I mav quote here the conclusions which 
 I drew from a consideration of this case : 
 * If I meet with what I believe to be a 
 suitable case, and a willing patient, I 
 shall certainly do this operation again ; 
 removing both ovaries, and being especi- 
 ally careful that every fragment of both 
 ovaries is removed. I should operate 
 rather through the abdominal wall than 
 by the vagina ; and be prepared for the 
 probability of intestines being wounded 
 when dividing the peritoneum. In uniting 
 the edges of the wound, I should place the 
 sutures nearer to each other than is usual 
 in ordinary ovariotomy, in order to guard 
 afTainst the occurrence of a ventral hernia.' 
 I still adhere to these conclusions. I 
 think it would be only in an exceptional 
 
 case, where an ovary could be felt low 
 down between the vagina and the rectum, 
 that a surgeon would now do oophorec- 
 tomy through the vagina. In almost all 
 cases the abdominal operation would be 
 preferred, and a word of caution is neces- 
 sary to anyone about to perform it under 
 the impression that it is very facile in 
 execution ; for it is more difficult than 
 ordinary ovariotomy. It is not as easy 
 to divide the peritoneum without injury 
 to the intestines. They have a greater 
 tendency to protrusion, and cannot be 
 replaced readily after they have protruded. 
 The opening into the abdomen should be 
 made large enough to admit two fingers. 
 With these the uterus is to be felt ; one 
 finger being in front of the fundus and one 
 behind it. Then, by carrying them out- 
 wards, first on one side and then on the 
 other, an ovary is felt and may be brought 
 up outside the abdominal wall. Its con- 
 nections with the uterus are transfixed 
 and tied in two parts with a silk ligature ; 
 a third ligature being placed behind the 
 other two. The ends of all must be 
 snipped off close to the knots, and the 
 ovary cut away not too near the ligatures, 
 which are then alloAved to slip down into 
 the pelvis. It is not yet decided if the 
 fimbria and part of the Fallopian tube 
 had better be lemoved with the ovary. 
 If not quite healthy, they should certainly 
 be removed. After the second ovary has 
 been removed, the wound must be closed 
 as usual after ovariotomy, but Avith the 
 sutures nearer to each other, to obviate 
 the greater tendency of omentum or 
 intestines to separate the lips of the in- 
 cision. The tension is ahvays greater in 
 these cases than after removing large 
 ovarian tumours, Avhere the integuments 
 have been a long time on the stretch. 
 The dressing and after treatment should 
 be precisely the same as for a case of 
 ovariotomy. 
 
 Between January 1878, the date of 
 this first case, and November 1881, or 
 nearly 4 years, I did not repeat this ope- 
 ration, and I had only advised it in one 
 other case, that lady not being willing to 
 submit to it. The lady on whom I ope- 
 rated in November 1881 Avas a AvidoAv, 37 
 years of age. She had suffered excessively 
 for about 1 8 months from the pressure of 
 a hard pelvic tumour, Avhich obstructed 
 the rectum and caused great agony and 
 daiiger at each catamenial period. At the 
 operation the tumour was found to consist 
 
OOPHORECTOMY — OR BATTEY'S OPERATION 
 
 ]2T 
 
 partly of tlie right ovary, not mucli en- I 
 larged, and p:irtly of the thickened and 
 retroflexed fundus uteri, which I was able, 
 but with great difficulty, to draw up above 
 the brim of the pelvis. I removed the 
 right ovary, the left was atrophied, and 
 so closely applied to the side of the uterus 
 that I could not distinguish its outlines, 
 and did not disturb it. The patient made 
 a recovery Avithout any fever, and in the 
 summer of 1884 was quite well, having 
 menstruated regularly since the operation, 
 at 3 weeks' interval, Avithout any incon- 
 venience. Here, of course, it is doubt- 
 ful how far the relief is due to removal of 
 one ovary, or to the reposition of the dis- 
 placed viterus. Neither in my own ope- 
 rative practice, nor in consultation with 
 others, have I seen more than 4 patients 
 since November 1881, to Avhom I have 
 advised ouphorectomy, or the removal of 
 ovaries not distinctly enlarged, on account 
 of neurotic or neurasthenic symptoms, or 
 of dysmenorrhoeal suffering. In one of 
 these cases the operation was performed 
 by a provincial surgeon. Another patient 
 is a ward in Chancery, and legal obstacles 
 have led to postponement. I performed the 
 operation on the third patient in October 
 1882, removing the right ovary and the 
 Fallopian tube. The left ovary had been 
 removed in March of the same year in 
 Paris by Pean, who wrote to me that he 
 found it in a condition which he described 
 as ' Kystique, liypertropliique et cicatriciel 
 tres prononceJ' The right ovary was, he 
 said, ' a peu-pres normal,^ and was therefore 
 not removed. The history of the case 
 before Pean's operation is that of an ex- 
 tremely sensitive, excitable, clever woman, 
 unmarried, who, between her 20th and 
 30th year, was occasionally treated by Dr. 
 Oldham for irregular menstruation, but 
 did not suffer much pain at her periods 
 until her 30th year. Then followed 10 
 years of invalid life, with great pain at 
 her periods. An operation in 1879, Avhen 
 her age was 37, was done by Mr. Heath 
 for internal piles. In 1880, Dr. IMeadows 
 and Dr. Graily HcAvitt treated her for 
 enlargement of the left ovary. This was 
 followed by enfeebled general health and 
 increase of pain, with failing nerve power. 
 In 1881, 3 months' trial of electric cur- 
 rent and German baths gave no relief; 
 until physical and mental prostration, 
 with recurring ideas of suicide, led Dr. 
 Pratt, of Paris, to recommend the opera- 
 tion, which was performed by Pean, as I 
 
 have just said, in March 18S2. The 
 patient rapidly recovered from the opera- 
 tion. The wound healed by first inten- 
 tion. She Avalked on the 18th day, but 
 on the 23rd day menstruation returned 
 with excessive suffering and high fever, 
 and she was considered in great danger 
 for more than 8 days. She returned to 
 England in May, 9 weeks after the opera- 
 tion, and consulted Dr. Oldham and Dr. 
 Herman AVeber. As her distressing sym- 
 ptoms increased to an alarming extent, her 
 menstrual periods being regular, with the 
 pain and the mental depression invariably 
 aggravated at the periods, she consulted 
 Dr. Playfair, who sent her to me. I 
 operated on October 10, 1882. Mr. 
 Meredith assisted me. Dr. Allan, of 
 Cleveland, U. S., and Dr. Fontana, of 
 Zurich, were present. I made an incision 
 ^ an inch to the right of the cicatrix left 
 by Pean's operation. After separating 
 omentum, which adhered along the whole 
 line of union, I drew up the right ovary, 
 transfixed the broad ligament with a 
 double ligature, and after tying the liga- 
 ment in two parts, cut away the ovary. 
 As the Fallopian tube was very red, tor- 
 tuous, and irregularly though slightly di- 
 lated, I put another ligature round the 
 tube, about 2 inches from the fimbria;, and 
 cut away all beyond the ligature. I then 
 separated all the omentum which adhered 
 on either side of the united incision of 
 Pean's operation, puttifig 2 ligatures upon 
 omental vessels. The wound in the abdo- 
 minal wall was closed in the usual manner. 
 The whole proceeding was completed in 
 less than half an hour. The ovary removed 
 was about 3 times the normal size, and 
 contained cystlike cavities, one as large as a 
 chestnut. The patient recovered without 
 trouble of any kind, went to Brighton 3 
 weeks after the operation, and I have re- 
 ceived most grateful letters from her since. 
 She called on me in December 1884, saying 
 that there had never been any return of 
 menstruation since the operation, and that 
 in spite of unfavourable surroundings and 
 family trouble, she Avas perfectly well. 
 She mentioned a curious fact, Avhich other 
 patients who have recoA'ered after ovario- 
 tomy have also observed — that her hair, 
 Avhich she had almost entirely lost during 
 her illness, had groAvn luxuriantly since 
 the operation ; and I noticed that it was 
 fine, abmidant, and Avithout a tinge of grey. 
 I operated on the '1th patient Au- 
 gust 26, 1884, at Amsterdam. She Avas 
 
128 
 
 0^'ARIAN AND ALLIED TUMOURS 
 
 Tinmarrled, 25 years old, and since her 
 17th year had suffered excessively from 
 pain in the right side of the abdomen. 
 After a great variety of medical treatment, 
 Professor Simon Thomas, of Ley den, at 
 the suggestion of her usual medical at- 
 tendant, Dr. Van Geuns, took away the 
 right ovary in September 1878. The pains 
 on the right side disappeared, but recurred 
 so severely on the left side, that in Sep- 
 tember 1879, Professor Simon Thomas 
 removed the left ovary, but without good 
 result. He did not remove either Fal- 
 lopian tube. Menstruation recurred, and 
 the pains became worse. In September 
 1880, Dr. Berns opened the abdomen for 
 the third time, hoping that it might be 
 possible to remove a tumour which it was 
 thought could be felt on the left side of 
 the uterus. There were, however, so 
 many adhesions that he desisted, and closed 
 the woimd. During all these years the 
 patient was always in bed, every movement 
 causing a great increase of pain. In 1883 
 Marion Sims went to Amsterdam to see 
 her. He thought the tumour on the left 
 side of the uterus was the cause of the 
 suffering. Being obliged to go to America, 
 he would not operate then, but promised 
 to do so on his return to Europe. His 
 death greatly distressed the patient, and 
 led to my being consulted. She and her 
 iamily, as well as Dr. Van Geuns, were so 
 anxious that some attempt to relieve her 
 continual sufferings should be made, and 
 the habit of daily repeated subcutaneous 
 injections of morphia should be broken, 
 that, although I was unable to feel any 
 tumour on either side of the uterus, I con- 
 sented to open the abdomen for the fourth 
 time, and did so to the left of the central 
 cicatrix. The cicatrix of the second ope- 
 ration was still nearer to the left ilium. 
 I only divided the peritoneum far enough 
 to admit two fingers. This enabled me to 
 feel that the rxterus was of normal size, 
 movable, with no tumour on either side 
 of it, but that a piece of omentum adhered 
 both to tiie fundus uteri and the cicatrix 
 to the extreme left, and that a coil of small 
 intestine also adhered both to the uterus 
 and the omentum. These I separated, but 
 did notliing more, and closed the wound. 
 I could not find any trace of either ovary. 
 The wound healed by first intention, and 
 recovery took place without any fever. 
 There have been three menstrual periods 
 since th(^ operation, with diminisliingpain. 
 Very much sinuUer quantities of morphia 
 
 have been injected, and Dr. Van Geuns 
 sends a very hopeful report of continued 
 improvement. 
 
 Since the printing of this edition was 
 begun I have removed both ovaries from 
 a married lady, a patient of Dr. Lendon 
 of Notting Hill, under very peculiar cir- 
 cumstances. She has 2 living children ; 
 one, born alive, is noAv dead. After 
 each confinement she suffered from puer- 
 peral mania ; and once the consequences 
 were tragically distressing. Dysmenor- 
 rhoeal suffering was also very great. 
 Partly to prevent this, and partly to 
 avert another pregnancy, after some 
 hesitation and careful consultation, I 
 removed both ovaries on January 27, 
 1885. There was no difficulty in the 
 operation, and recovery followed without 
 pain or fever. It is, of course, too soon 
 to say more as to the ultimate result. 
 
 The removal of the ovaries Avith the 
 hope of influencing uterine growths will 
 be further considered in the chapter on 
 these tumours. But I cannot conclude 
 this chapter without a word of caution 
 against the extreme frequency with which 
 the operation has been resorted to in this 
 country, and at which Dr. Battey publiclv 
 expressed his astonishment, at the meeting 
 of the Medical Congress in Loudon. Many 
 cases where the symptoms have been de- 
 scribed as sleeplessness, hysteria, nerve 
 prostration, dysmenorrhoea or ' neuras- 
 thenic disorder,' have led to Battey's ope- 
 ration, and in the majority of such cases 
 healthy ovaries have been removed. These 
 are just the cases in which Dr. Weir 
 Mitchell's systematic treatment, so success- 
 fully followed in this country by Dr. Play- 
 fair, should surely have been tried. Dr. 
 Playfair says, ' If a case is purely neuras- 
 thenic it cannot under any conditions, I 
 apprehend, be one even for the considera- 
 tion of Oophorectomy. If, on the other 
 hand, there exist those chronic organic 
 changes in the ovaries which afford the 
 most justifiable ground for this operation, 
 any attempt at their cure by this treatment 
 will inevitably fail.' Except in cases where 
 bleeding fibroids may call for the removal 
 of the healthy ovaries, or where some such 
 reason arises for preventing future preg- 
 nancy as that in the case just related, we 
 ought at least to require some evidence of 
 the ovaries being diseased before consenting 
 to their extirpation in the hope of curing 
 any of those vague nervous disorders to 
 which women are so subject, which are 
 
OOPHORECTOMY — OR BATTEY S OPERATION 
 
 129 
 
 often dispelled by moral treatment or social 
 changes, are often benefited by measures 
 that can have but little effect except on 
 the imagination, often return after appa- 
 rent cure in any way, and leave the 
 hapless beings tlie prey of unscrupulous 
 or illogically enthusiastic experimenters. 
 
 In a paper read at the Medical and 
 Chirurgical Society in 1882, on hernia of 
 the ovary, Dr. Barnes contended that this 
 condition furnishes a legitimate motive 
 for Battey's operation. He related a case 
 in which an ovary, accompanying a hernia 
 in the left groin, had been removed from 
 one of his jDatients in St. George's Hos- 
 pital. In the discussion which followed 
 Mr. Hulke alluded to the comparative 
 frequency of this form of hernia, and 
 cited a case, under the care of Mr. Law- 
 son some years ago, in which the suffering 
 was so great that at the wish of the patient 
 the organ was extirpated. Mr. Langton 
 also showed, from his own experience of 
 20 years at the Truss Society, that out of 
 4,084 cases of inguinal hernia no less 
 than 67 were instances of these displaced 
 ovaries. Forty-two of the 67 were con- 
 genital and 25 acquired. Those which 
 were congenital were generally double, 
 most of them Avere irreducible, and the 
 effects with regard to the menstrual 
 periods varied very much. Dr. Barnes 
 attributed the larger number being on 
 the lelt side, to the greater length and 
 laxity of the left round ligament, and the 
 greater depth of Douglas's pouch on the 
 left than on the right side ; and said that 
 in this way other pathological conditions 
 more frequently observed on the left than 
 on the right side, such as haamatocele, 
 might be accounted for. He was of opi- 
 nion that whei'e there was pain and distress 
 it was better tu remove the hernial ovary, 
 which was liable to become inflamed and 
 diseased, while trusses were apt to cause 
 distress. 
 
 At the Meeting of the Medico-Chirur- 
 gical Society of Edinburgh, November 7, 
 1883, Dr. MacGillivray showed an ovary 
 and a Fallopian tube which he had removed 
 from an inguinal hernia in a girl about 20 
 years of age. And at the same Society 
 Professor Chiene showed an ovary and 
 part of a Fallopian tube which he took 
 away from the inguinal region of a child 
 only 3 months old. 
 
 It is somewhat curious that in all 
 my practice I have never met with a case 
 of hernia of the ovary. 
 
 The last reports which I have respect, 
 ing Battey's operation are those to be 
 found in Professor Agnew's ' Surgery,' 
 published in Philadelphia. He mentions 
 107 cases, of which 88 were complete 
 I double operations. Sixty-seven recovered 
 : and 21 died, a mortality of 23'86 per cent. 
 In all, he gives the figures of 171 cases; 
 144 by abdominal section, with a loss of 
 27, and 27 vaginal, of which ."> died. 
 
 In the ' Ingleby Lectures' for 1881, 
 Dr. Savage, of Birmingham, said that, 
 while Battey, from all the information he 
 could obtain, found the mortality to be 
 about 18 per cent., in his own (Dr. 
 Savage's) practice he had ' had 40 com- 
 plete cases, with a result that all have 
 recovered from the operation, and I 
 believe that nearly every one has been 
 cured of the disorder for which the 
 operation was undertaken ' (p. 33). 
 Writing again, December 5, 1884, he 
 says, ' My figures are as follows up to 
 this date : 
 
 Removal of the Uterine Appendages 
 
 For Mj-oma .... 37 with 1 death from Tetanus 
 „ Hydrosalpinx .10 „ 1 „ 
 ,, Pyosalpinx . . 6 „ 1 ,, 
 „ Chronic Ovaritis V 
 „ Dysmenorrhoea, [r^-. „ 
 
 and Neuralgic [ " " 
 
 Symptoms, &c. ■' 
 
 Total 
 
 134 cases with 6 deaths. 
 
 Dr. Savage removes both ovary and 
 Fallopian tube, but he appears to agree 
 with me in the impression that liga- 
 ture of the spermatic artery has more 
 to do with the cessation of menstruation 
 after operation than the removal of the 
 tube itself. 
 
 Dr. Fehling, of Stuttgart, contributes 
 to the 'Archiv. fur Gynakologie ' (Band 
 xxii. Heft 3) an interesting article on the 
 ' Castration of Women.' He relates 10 
 cases, and then expresses opinions based 
 upon these and upon other recorded 
 cases. As to mortality, this will di- 
 minish. Hitherto it has been about 10 
 per cent., but he thinks with our pre- 
 sent experience it is not likely in the 
 future to exceed at most 5 per cent. 
 Next as to the effect upon menstruation. 
 In 4 cases out of 9 he found the meno- 
 pause immediately follow. The same 
 happened in 4 cases out of 10 published 
 by Tautfer, and in 31 out of 41 recorded 
 by Hegar. Irregular hcemorrhages for a 
 time followed by complete cessation 
 resulted in 3 of our author's 9, in 3 of 
 
130 
 
 OVARIAN AND ALLIED TUMOURS 
 
 Tauffer's 10, in 8 of Hegar's 41. 
 Hsemorrhage continued to recur for a 
 long period (2 years or more) after 
 operation in 2 of Fehling's cases, 3 of 
 Tauffer's, and 1 of Hegar's. The results 
 of other operators give similar figures. 
 He then considers the effect in different 
 classes of cases. In cases of uterine 
 fibroids the results are excellent. In 5 
 out of 6 cases of his own in which spay- 
 ing was performed for fibroids, the meno- 
 pause followed. In 21 similar cases of 
 Hegar's, 3 died. The menopause fol- 
 lowed immediately in 11, gradually in 
 6 ; in only 1 did hajmorrhase persist. 
 Fehling removed the ovaries for ovarian 
 neuralgia in 1 case only ; relief was 
 slow but complete. In nervous and 
 mental diseases he finds the results are 
 not good ; even when benefited for a 
 time, symptoms return. Goodell's pro- 
 . posal, that all insane women ought to be 
 
 spayed, Dr. Fehling rejects absolutely. 
 He quotes Liebermeister to the effect 
 that in hysteria, unaccompanied with 
 local disease, castration ought not to be 
 performed. He does not think it neces- 
 sary, even if possible, to feel the ovaries 
 before commencing the operation. He 
 has not observed any loss of sexual 
 feeling as a result of the operation. 
 
 The Samaritan Hospital register shows 
 no otjphorectomies until December, 1880, 
 from which date up till December, 1884 
 — i.e. exactly four years — the number 
 recorded reaches 20. Of these 15 were 
 for fibro-myoma with menorrhagia, and 1 
 of them proved fatal. The remaining 5 
 were for dysmenorrhoea, and all reco- 
 vered. Bantock operated 8 times, and 
 Thornton 12. Two cases recorded by 
 Meredith were not patients in the Sama- 
 ritan, but in the New Hospital for 
 Women in Marylebone Road. 
 
 CHAPTER XV 
 
 EESULTS OF OVARIOTOMY. SUBSEQUENT HISTORY OF PATIENTS WHO RECOVERED 
 
 The fact that of 1,139 who have had one 
 or both ovaries removed by me, 891 have 
 recovered from the operation, is alone 
 sufficient to justif}'^ the principle of the 
 operation, and to prove that the mortality 
 — namely, 21*7 per cent, on the whole 
 number, but which has fallen from 34 in 
 the first 100 to 11 in the last — is 
 smaller than that of many capital opera- 
 tions which are constantly performed with- 
 out hesitation in suitable cases. And this 
 mortality has of late become so small, 
 death scarcely ever occurring except in 
 cases known before operation to be unfa- 
 vourable ; while recovery is secured In 
 almost every favourable case, that (exclud- 
 ing septicaemia) we may confidently cal- 
 culate upon an average death-rate of not 
 more than 3 or 4 per cent. And when 
 we consider that a patient from whom one 
 ovary has been removed can scarcely be 
 said to be mutilated ; as she is perfectly 
 capable of fulfilling all the duties of a 
 wife and mother, menstruating regularly, 
 and bearing children of both sexes, witli- 
 out any unusual suffering either during 
 pregnancy or labour ; ovariotomy ought to 
 be accepted as a more certain means of 
 
 saving life from threatened death, restor- 
 ing the sufferer to perfect health, and 
 rendering her apt for all the require- 
 ments of daily life, with a smaller risk 
 than almost any other serious surgical 
 operation. 
 
 Fears have been expressed that when 
 a patient recovered after ovariotomy she 
 would in some way or other suffer in after 
 life, that she would not menstruate regu- 
 larly — that, if she married, she would not 
 have children, or have children of only 
 one sex — that she would become exces- 
 sively fat, or lose her feminine appear- 
 ance and her sexual instinct — or that her 
 life might be shortened by some disease 
 originating in the operation, or by the 
 effects either Tipon some bodily organ or 
 upon the mind. In order to ascertain 
 how far any of these fears were well 
 founded, or were exaggerated, or were 
 purely imaginary and destitute of founda- 
 tion, I asked every patient who recovered 
 to write to me once every year, on the 
 anniversary [of the operation, giving me 
 full information as to her state. Nearly 
 all pi'omised compliance, and a few have 
 written several years in sutcession. 
 
RESULTS OF OVATIIOTOMY 
 
 131 
 
 Many have written once or twice, some I 
 have occasionally seen, but there were so 
 many of whom I heard nothing that in 
 May and June, 1872, and at the latter 
 end of 1881, I sent a circular to every 
 patient who had recovered after ovario- 
 tomy in my practice, or to the medical 
 friend by whom she was sent to me, 
 asking for information on the following 
 points, and in this form : 
 
 Name of patient. 
 Date of operation. 
 Present state of liealtli. 
 If married since — when ? 
 Is husband still alive ? 
 If any children — 
 
 Date of births. 
 
 Sex of children. 
 Anything unusual in — 
 
 Pregnancy, 
 
 Or labour. 
 If dead, cause and date of death. 
 Any other information connected with the 
 
 operation or the patient which may seem 
 
 important. 
 
 ISignatiire . 
 
 Date 
 
 From circulars returned to me, and 
 from other sources, I am able to say that 
 of the 1,000 women who submitted to 
 ovariotomy by me between February 
 1858 and June 1880 : 
 
 449 reported themselves well in 
 
 1881. 
 11 were well in 1880, and have 
 
 not been heard of since. 
 86 were well in 1872 and have 
 
 since made no report. 
 55 have reported themselves 
 
 well within the last 10 
 
 years without answering 
 
 my last letter in 1881. 
 50 have made no report of 
 
 themselves since the ope- 
 ration : 
 
 651 
 
 Making 651 either alive or not known to 
 be dead. 
 127 died after operation among 
 
 the first 500. 
 105 died after operation among 
 
 the second 500. 
 117 died since recovering from 
 
 the operation. 
 
 1,000 
 
 Of the 117 deaths since recovery from 
 operation : 
 
 29 died without cause assigned. 
 43 died of diseases of the brain, 
 
 heart, or lungs, quite un- 
 connected with the operation. 
 7 died of diseases of the 
 abdominal or pelvic organs. 
 32 died of malignant disease of 
 various parts. 
 6 died of return of the ovarian 
 disease. 
 
 117 
 
 Of the 1,000 women operated on : 
 
 439 who were married at the time 
 recovered from the operation. 
 70 of these have since given birth 
 
 to 126 children. 
 36 have had one child (1 still- 
 born) = 36 
 18 have had 2 children (one 
 
 twins stillborn) =36 
 
 11 have had 3 ,, (one 
 
 twins) =33 
 
 4 have had 4 „ =16 
 
 1 has had 5 ,, =: 5 
 
 126 
 
 1 woman has had triplets. 
 4 women have been married a 
 second time ; one having two 
 children by her second husband. 
 369 have remained sterile. 
 329 women unmarried at the time of 
 operation recovered. 
 70 of these have since married. 
 
 1 woman has been married three 
 times. 
 
 44 of these married women have 
 given birth to 99 children. 
 
 18 married women have, since 
 operation, had 1 child (1 
 stillborn) =18 
 
 11 married women have had 
 2 children (one twins) =22 
 
 10 married women have had 3 
 
 children =30 
 
 2 married women have had 5 
 children (3 stillborn) =10 
 
 2 married women have had 6 
 children =12 
 
 1 married woman has had 7 
 children = 7 
 
 99 
 3 single women have had 1 child = 3 
 
 Making a total of 228 children born 
 amongst 117 women after their recovery 
 from ovariotomy. 
 
 K 2 
 
132 
 
 OVARTAX AND ALLIED TUMOURS 
 
 lilany in writing the report add that j 
 they are well and strong, or better than 
 they have been for many years, or some 
 such phrase, expressive of their complete 
 restoration. A few complain of some 
 trilling ailment. I know that a large 
 proportion of those who filled up the 
 returns in 1881 are still alive and well, 
 and that other children have been born 
 since ; but as only 3 years have 
 elapsed, 1 have not issued fresh circulars. 
 
 I have not been able to trace any 
 peculiarity in the subseqi;ent condition of 
 patients who have recovered after removal 
 of both ovaries as compared with those 
 from whom only one was removed, 
 except that, with only three exceptions, 
 there has not been menstruation after 
 recovery. One young unmarried woman 
 became very florid and stout ; but I have 
 seen nothing like the excessive corpulence 
 anticipated by those whose expectations 
 were based on the effect of castrating 
 domesticated animals. 
 
 1 have ascertained from the husband 
 or medical attendant of some of my own 
 patients, that sexual desire and gratifica- 
 tion have certainly not been less than 
 before operation. In some cases, where 
 only one ovary was removed, desire had 
 been increased. One husband told me 
 that his wife had been remarkably cold 
 before ovariotomy, but was afterwards 
 extremely amorous. 
 
 To the best of my knowledge this is 
 the first time that any such extended 
 inquiry into the subsequent history of 
 patients who have recovered froai a capital 
 operation has been carried out. As a 
 rule, in all statistical returns from hos- 
 pitals, the bare fact of death or recovery 
 is all the information that is given, and 
 any attempt to follow up the successful 
 cases afterwards is found to be excessively 
 difficult. Some years ago, I endeavoured 
 to ascertain what became of patients who 
 recovered after amputation of the tliigh. 
 I had good reason for believing that many 
 died within a year, but was never able to 
 obtain anything like correct statistical 
 information. The hospital reporters of 
 the * Lancet ' once collected together par- 
 ticulars of all the cases in which amputa- 
 tion at the hip-joint had been performed 
 for several years in London liospitals. A 
 large proportion of the patients died 
 within a day or two of the operation, 
 and of those who recovered the only one 
 alive a year after operation was a woman 
 
 whose thigh I removed at the hip-joint, 
 in the Samaritan Hospital, on account of 
 malignant disease. It is well known that 
 patients who have been cured of aneu- 
 rism, either by ligature or compression, 
 are very apt to suffer from the disease in 
 some other artery ; but it is left to some 
 future inquirer, or some committee of 
 collective investigation, to ascertain the 
 frequency and date of such return of 
 disease. We have a little more infor- 
 mation as to patients who undergo litho- 
 tomy a second time. Most of the in- 
 formation ends with the immediate result 
 of the operation, and but little is known 
 of the subsequent history of the patient. 
 I hope that what has been done in thirt 
 respect with regard to ovariotomy, and 
 latterly by Sir H. Thompson with rega/rd 
 to lithotomy and lithotrity, will not only 
 be useful in enabling us to form a correct 
 estimate as to the value of these opera- 
 tions, but will induce other surgeons to 
 obtain similar information as to the sub- 
 sequent history of patients who recover 
 after amputation of a limb, excision of a 
 large joint, ligature of main arteries, 
 herniotomy, or trephining. 
 
 When a surgeon has removed a large 
 diseased ovary and the woman recovers, 
 he has in very many cases the great satis- 
 faction of feeling that his patient has been 
 restored to perfect health. Experience 
 has proved that the remaining ovary 
 generally carries on its functions, and 
 that the woman may become the mother 
 of healthy children of both sexes. The 
 patient is not mutilated as by the amputa- 
 tion of a limb, nor does the general health 
 suffer as it frequently does after the 
 greater amputations. There certainly is 
 nothing like the tendency to recurrence 
 Avhicli there is after the removal of malig- 
 nant tumours; probably by no means 
 so frequent an occurrence of disease else- 
 where as after successful ligature of 
 a diseased artery, or disease of the 
 opposite lens after successful removal of 
 one cataract, or formation of a second 
 calculus after a removal of one by litho- 
 tomy or lithotrity ; and certainly no such 
 prolonged suffering as from the chronic 
 cystitis which not unfrequently follows 
 these two operations. 
 
 The rule is, that by a successful 
 ovariotomy the patient ia restored to a 
 state of health so perfect that she and her 
 friends are as surprised as they are 
 gratified. But there are exceptions to 
 
IIESULTS OF OVAKIOTOMY 
 
 .00 
 
 ttliis rule. In some cases a disease be- 
 lieved to be innocent proves to be malig- 
 nant, soon recurs, and proves fatal within 
 a few months, or even within a few weeks 
 ■after apparent recovery. In other cases 
 the ovary which is left untouched because 
 "it is believed to be healthy, or so slightly 
 •diseased that its removal is uncalled for, 
 becomes the seat of disease. In what 
 proportion of cases this occurs we have 
 •even now but little more information 
 than may be found in this volume. It 
 is only within the last 20 years that ova- 
 riotomy has been performed sufBcieutly 
 •often to furnish data for reliable sta- 
 tistics, and it is difficult to ascertain, 
 even in some of these later cases, what 
 has been the state of the patient's health 
 a few years after operation. But it 
 would be unreasonable to expect that in 
 all cases the ovary left in the body would 
 remain healthy. It is for future obser- 
 vation to decide how often and in what 
 class of cases a recurrence of disease may 
 be feared. The fact that in my practice 
 
 there were 11 recurrences requiring a 
 second operation out of 1,139 patients, 
 gives a proportion of 1 in about every 100 
 cases, and, so far as I can make out, the 
 character of the cysts was generally pro- 
 liferous ; at any rate, it Avas so in almost 
 all the cases in Avhich an accurate report 
 has been kept of the character of the 
 tumours. It is satisfactory, however, to 
 learn that if the remaining ovary should 
 become diseased, the first operation does 
 not add to the difficulty of a second, and 
 tliat the second ovariotomy has proved 
 successful in II out of the 13 cases in 
 which I have operated, and in the case in 
 which Atlee operated 16 years after the 
 first operation by Clay. 
 
 The rare exceptions to the general 
 rule of complete restoration of health 
 cannot be considered as invalidating the 
 claim of ovariotomy to be considered as 
 one of the greatest of surgical triumphs 
 — relieving suffering, saving life, and 
 restoring Avomen doomed to inevitable 
 death to good health. 
 
134 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 PAET II 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 CHAPTER I 
 
 UTERINE TUMOURS 
 
 After looking through much of the 
 English, French, German, and American 
 literature of the subject of uterine 
 tumours, I may say that in the course of 
 my practice I have met with, either 
 among the cases upon which I have 
 operated, or which have been under my 
 treatment, or that I have seen in con- 
 sultation, every variety of fibroid tumour 
 described or figured by the Avriters. I 
 have not observed any special peculi- 
 arities in the composition or structure of 
 these tumours, and have always found 
 them to consist of the same histological 
 elements. The difference amono: the 
 tumours has been more that of form, 
 owing to the way in which those elements 
 have been arranged. The main substance 
 is white fibre tissue, merging on the one 
 hand into the form of unstriped muscular 
 tissue, on the other into that of connective 
 tissue. The relative quantity of these 
 tissues varies in all the tumours, and 
 even in the different parts of the same 
 tumour; and according as one or the 
 other predominates, so do the remaining 
 constituents become less conspicuous. In 
 the simplest tumours, with little more 
 than white fibre, the vascular, nervous, and 
 lymphatic tissues are scanty ; while in a 
 tumour lobulated.and intersected through- 
 out without connective tissue septa, the 
 blood-vessels, lymphatics, and nerves are 
 more abundant. In contrast with the 
 papillomatous growths and cancerous 
 degenerations which assail the uterus, 
 they take their origin from the tissue 
 cells, and are in no way e])ithelial. 
 In the section of a simple fibroid tumour, 
 or a lobule of a conglomerate tumour, the 
 appearance of the distinctive part of 
 
 which it consists is more like that of in- 
 tervertebral fibro-cartilage than anything 
 else, unless it be certain indurated con- 
 ditions of the uterine walls themselves. 
 When the tumours are small, and in 
 their early stages, the fibrous elements 
 have often a concentric arrangement 
 round a single centre, and the same 
 distribution may be traced in the nodules 
 of the larger conglomerate masses. As 
 might be expected from the abnormal 
 character of these neoplasms, the histo- 
 logical elements are generally imperfectly 
 developed, and the less they are developed 
 the more abundantly are nuclei dispersed 
 among them. The condition of the con- 
 stituent parts of the tumour, and the 
 rapidity and slowness of growth, depend 
 very much upon the supply of blood. 
 This in some cases is so small that the 
 arteries are of diminutive size, and 
 injections are with difficulty introduced 
 into the substance of the tumour, though 
 it occasionally happens that arteries large 
 enough to cause great hemorrhage are 
 found distributing blood to all parts. 
 The form of these tumours is in almost 
 all cases at first round or pear-shaped. 
 As they enlarge they become modelled 
 by the parts with which they come in 
 contact, and the direction of their growth 
 is in a measure influenced by the resist- 
 ance which they meet Avith from the 
 neighbouring organs. It is seldom that 
 they are solitary, and where there is a 
 tendency to their formation it is common 
 to find other growths of the same kind, 
 either as offshoots from the parent 
 tumour, or implanted on other parts of 
 the same uterus. They are by no means 
 uncommon, though not often formed at an 
 
UTERINE TUMOURS 
 
 135 
 
 early time of life. My experience leads 
 me to believe that none of the estimates 
 of frequency during the period of sexual 
 activity are exaggerated. 1 should be 
 inclined to think them quite as common 
 as cystic disease of the ovaries, perhaps 
 more common, though fortunately neither 
 so detrimental to health nor so rapidly 
 fatal. The frequent, almost accidental 
 discovery by women of their unsuspected 
 existence, and their unlooked-for dis- 
 closure in post-mortem examinations, 
 their sometimes temporary existence and 
 spontaneous disappearance, and the effect 
 of surgical treatment in causing their 
 diminution or inactivity, all show how 
 little prejudicial is their nature, and that 
 much of the evil they cause is mechanical. 
 As they are for the most part excrescences 
 of a fleshy hollow organ, it is only natural 
 that they should be found on the outer 
 and inner surfaces, and sometimes im- 
 bedded in the muscular walls. In some 
 cases the tumour is nothing more than a 
 symmetrical overgrowth of the walls all 
 round the uterine cavity, though these 
 cases are seldom free from either sub- 
 peritoneal outgrowths or sub-mucous in- 
 growths. The tumours growing either 
 on the sub-peritoneal surface or projecting 
 into the uterine cavity, although sessile 
 when growth commences, are often in 
 later stages of grov/th pedunculated, and 
 receive their supply of blood through the 
 pedicle. Most hard growths originating 
 in the wall substance of the iiterus are 
 capsuled. The larger blood-vessels 
 ramify in the capsule, those entering the 
 growth itself being usually small. There 
 is sometimes a special tendency to the 
 formation of cystic cavities in the interior 
 of these tumours. This cystlike condition 
 has come under my notice with greater 
 frequency than most other writers have 
 recorded. Sometimes it has seemed to 
 arise from a softening of tissue, especially 
 in that kind of tumour, first clearly 
 brought under notice by Barnes, which is 
 chiefly seen in the body of the uterus, and 
 is large, soft, of loose texture, without very 
 distinct capsule, more vascular, often 
 oedematous, less liable to calcareous 
 degeneration, and generally the cause of 
 metrorrhagia. In other cases their pro- 
 duction has arisen from a process of cyst 
 formation, such as that recognised in 
 cystic disease of the breast and other 
 organs. The character of the tumour 
 depends very much upon that of the 
 
 tissues of the part of the organ from 
 which it springs, and it takes a solid 
 or looser form, according to the density 
 or looseness of the texture of the parent 
 layers. Thus on the outside, attached to 
 the cortical layer of the uterus, we find 
 the hard, unsucculent tumours, tenacious 
 of life, and lasting oftentimes till old age, 
 even in a condition of degeneration. In 
 the walls of the womb we find the soft, 
 pulpy, vascular growths which have a 
 tendency to inflammatory action and 
 necrosis from injuries ; and on the mu- 
 cous side of the organ the quick-growing, 
 bleeding excrescences which approach in 
 certain respects to the hsemorrhagic con- 
 dition of the erectile tumours occasionally 
 found in this situation. In the recurrent 
 form of fibroid tumours generally growing 
 towards tlie cavity, there is some affinity 
 with malignant disease, especially as to 
 its tendency to reproduction if removed, 
 and to secondary appearance in other 
 parts of the body. 
 
 Of size, I have seen instances varying 
 from that of a pea to some of enormous 
 bulk and weight, filling up all available 
 space in the pelvis and abdomen compa- 
 tible with the continuance of the organic 
 functions, and in one example of successful 
 removal amounting to the weight of 70 
 pounds, with a measurement of 57 inches 
 by 53. 
 
 The contour of the originally rounded 
 nodules soon becomes modified by con- 
 tact with the hard parts of the pelvis, and 
 by the continued resistance of all that it 
 meets in the course of its growth. The 
 extension, of course, is most rapid in the 
 direction where the obstacles are the least 
 strong, and it would be useless to attempt 
 to give an idea of the strange forms pro- 
 duced by external modelling, and the 
 varying degrees of nutrition depending 
 iipon changes in the vascular condition ot 
 the interior. The external appearance of 
 the conglomerate tumours is affected by 
 the same causes, and they are equally 
 multiform. 
 
 The life history of these structurally 
 orthodox excrescences, when not compli- 
 cated by accident or induced functional 
 derangement, is simple enough. They 
 commence their existence at a time when 
 the organ which they affect is in a state 
 of high functional activity, they partici- 
 pate in its periodical variations, increase 
 with its accessions, slacken growth with 
 its torpidity, and if nothing happens to 
 
136 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 check the even tenour of their progress 
 they often dwindle away with the cessa- 
 tion of sexual life, or submit to one of 
 those comparatively innocent forms of 
 degeneration which we know as fatty 
 transformation and calcification. This 
 petrifaction, it must be remembered, has 
 no relation to the organising tendency of 
 the process of ossification, but consists in 
 a mere interstitial deposit of calcareous 
 matter, Avhich replaces the living tissue 
 and remains a foreign body lodged in the 
 abdomen as a peritoneal calculus, some- 
 times to extreme old age. It is the study 
 of this life history which has led logically 
 to the modern surgical treatment of some 
 kinds of these tumours, and the amount 
 of success which has attended it would 
 induce one to hope, if not to believe, that 
 Avhen the physiological and pathological 
 conditions attending the rise and progress 
 of some other tumours have been investi- 
 gated in the same philosophical spirit, and 
 with as miich perseverance, correspond- 
 ing means may be found of holding them 
 in check or causing their suppression. 
 
 But the life of these tumours is 
 subject to too many accidents and inter- 
 ferences for this course and teriuination 
 to be the rule. It is rather the exception, 
 as much so as centenarian duration is in 
 human existence. Still, there are other 
 modes in which early involution has been 
 brought about. It has been observed 
 after delivery, and to correspond with the 
 process of involution of the womb. And 
 with the organ unimpregnated I have 
 many times noted the disappearance of 
 these tumours, which, though doubted by 
 some, has been well attested. It is owing 
 probably to the arrest of nourishment by 
 diminution of the vascular supply, and 
 the attendant retrograde changes of fatty 
 degeneration and absorption, or more or 
 less continuous discharge of debris from 
 the uterine cavity, after menstrual influ- 
 ence cnases. At any rate, the atrophy of 
 these tumours from time to time, either 
 without interference or under medical 
 treatment, is a pathological fact. Then 
 there is another way in which the uterus 
 rids itself of the mural excrescences, and 
 it is easy of comprehension. The pre- 
 sence of the interstitial growth causes 
 hypertrophy of the uterine wall. Its 
 force is increased, and when the pressure 
 of the growth lias gone on to such an 
 extent as to occasion absorption of the 
 intervening substance and ulceration of 
 
 the mucous lining, this force may be 
 called into action by some occasional 
 stimulus, and the expulsive power is 
 sufficient to enucleate the whole mass, 
 and drive it out not only from its seat, 
 but into the uterine cavity, or even into 
 the vagina. It is doubtful whether these 
 uterine fibroid tumours ever undergo can- 
 cerous degeneration. There is no reason 
 why this tissue should be exempt from 
 such a process, but the records of it are 
 so rare that it is virtually regarded as a 
 termination not to be looked for. There 
 is nothing known as to the causes of the 
 development of these tumours, and the 
 peculiarities of temperament or bodily 
 constitution which give a tendency to 
 their formation are not understood so 
 well as the conditions which conduce to 
 their disappearance. 
 
 In many cases these tumours exist for 
 a long time without being discovered, 
 and still more frequently they cause only 
 discomfort without injury to the general 
 health. When bulk and weight increase 
 they produce the same local symptoms as 
 other tumours in the same situation, but 
 still without the same amount of consti- 
 tutional derangement. Yet when the 
 pressure becomes excessive the organs 
 encroached upon must suffer, and the 
 symptoms depend upon the direction in 
 which the tumour is acting. There may 
 be difficulty with the bladder, and there 
 may be pressure on one or both ureters, 
 and suspension of the renal function. 
 Nutrition may be arrested, and ail that 
 depends upon the proper action of the 
 alimentary canal may be at fault. There 
 may be incessant variations of nervous 
 symptoms, and in some cases excessive 
 pain from nerve pressure. The uterine 
 troubles assume an infinite variety of 
 forms, including spasmodic action, dis- 
 charges, and ha-morrhages, accompanied 
 with the well-known sympathetic affec- 
 tions of distant parts and responding 
 organs. Of course the symptoms depend 
 much upon the position and character ot 
 the tumour itself. Usually with the sub- 
 peritoneal tumours the haemorrhage is not 
 much, but the tendency to ascites greater. 
 The sub-mucous variety, on the contrary, 
 is more likely to be attended with profuse 
 bleeding. And in cases where the bleed- 
 ing is not only profuse but persistent, we 
 may expect to find the cause in a tumour, 
 probably of no great size, of the lower 
 part of the body of the uterus, or of the 
 
UTERINE TUMOURS 
 
 137 
 
 cervix. The inter-menslrual secretions 
 are not much affected, though sometimes 
 leucorrhosal discharges become trouble- 
 some. Menstruation is more frequently 
 than otherwise rendered difficult and 
 superabundant, while in some instances 
 there is a more or less marked condition 
 of amenorrho3a. Fecundity is generally 
 diminished, but conception is not ren- 
 dered impossible. Few women with 
 these tumours have large families, partly 
 owing to the predisposition to miscarriage 
 under such circumstances. But I have 
 known several patients with uterine 
 tumours who have become pregnant, 
 have gone on to the full term, and have 
 borne living children. In some of these 
 the tumour has disappeared, more or less 
 entirely, within a few weeks or months of 
 the delivery. In 3 cases repeated preg- 
 nancies have occurred without much 
 change in either the uterus or the 
 tumour. In one of these the tumour 
 was so large that it was mistaken at the 
 labour by an experienced accoucheur, 
 after the birth of the child, for a second 
 child. 
 
 It is only since ovariotomy has be- 
 come a familiar operation that the fact 
 of uterine tumours frequently attaining 
 a very large size has become generally 
 known. Even now I am often told by 
 men of great experience that a tumour 
 must be ovarian because it is too large to 
 be uterine. They have never seen nor 
 heard of any such enlargement of the 
 uterus, and are astonished when I say 
 that the largest abdominal tumours I have 
 ever seen have been fibroid or fibro- cystic 
 tumours of the uterus. 
 
 In one of the earliest attempts to 
 perform ovariotomy in Great Britain, 
 in 1825, Mr. Lizars fell into this error 
 of diagnosis. He opened the abdomen 
 and found a large uterine tumour. And 
 the first tumour supposed to be ovarian 
 which was removed in London — by Dr. 
 Granville, in 1827 — proved to be a 
 fibroid tumour of the uterus, weighing 8 
 pounds. Of the 8 first published cases 
 by Kceberle of removal of uterine tu- 
 mours by gastrotomy, in only 3 was 
 the diagnosis of uterine tumour made 
 accurately before operation. In 2 the 
 diagnosis was doubtful, and in 3 the 
 tumour was believed to be ovarian. In 
 fact it has happened to many surgeons, 
 and to myself among the number, that we 
 have commenced operations as ovariotomy, 
 
 and even removed tumours from the abdo- 
 men, under the impression that we were 
 dealing with diseased ovaries, when, upon 
 examination, they have proved to be pe- 
 dunculate fibroid outgrowths from the 
 uterus. At first, when it was discovered 
 that a tumour was uterine, it was left 
 alone. Then, if pedunculate, it was re- 
 moved. It is only of late years that large 
 solid uterine groAVths, not pedunculate, 
 have been operated on designedly. 
 
 The revival of ovariotomy between 
 1858 and 1865 led, in the words of 
 Paget, to ' an extension of the whole 
 domain of peritoneal surgery.' This 
 extension, naturally enough, began with 
 the removal of uterine tumours. 
 
 In my first work on * Diseases of the 
 Ovaries,' published in 1865, I have re- 
 corded cases where I removed large 
 uterine tumours containing solid fibroid 
 masses many pounds in weight, and cyst- 
 like cavities containing more than 20 
 pints of fiuid, these tumours being so 
 far pedunculated outgrowths from the 
 peritoneal surface of the uterus that the 
 mobility of the cervix uteri was free, and 
 no enlargement of the uterine cavity could 
 be detected by the sound. 
 
 THE DIAGNOSIS OF UTERINE FROM OVARIAN 
 TUMOURS 
 
 is a difficulty which frequently arises 
 in practice, which may often be solved 
 wath great ease, which as often requires 
 much cautious investigation, and which in 
 some cases can only be cleared up by an 
 exploratory incision. 
 
 It is quite certain that both uterine 
 and ovarian tumours may lead to very 
 great enlargement of the abdomen, and I 
 can add from my own experience that the 
 tumours may be central in position, or 
 inclined to one or other side; either round, 
 ovoid, or irregular in form; smooth or 
 lobulated on their surface ; either hard, 
 or elastic, or fluctuating ; either tender or 
 insensible to pressure ; and either adher- 
 ing to the abdominal wall or moving 
 beneath it with or without crepitation. 
 
 It is also certain that there is nothing 
 in the history of a doubtful case which 
 affords any very decisive assistance in 
 diagnosis; for, although the increape of 
 ovarian tumours is often rapid, it is al- 
 most as often slow ; and if the increase of 
 uterine tumours is generally slow, it is 
 not unfrequently rapid. Uterine hsemor- 
 
138 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 rhage, either in tlie form of excessive 
 menstruation or of flooding at irregular 
 intervals, is certainly more common in 
 uterine than in ovarian tumours, but is 
 occasionally associated with the latter. 
 Probably the rule is that menstruation is 
 scanty when a tumour is ovarian, and 
 excessive when it is uterine ; but excep- 
 tions to this rule are numerous, and dis- 
 charges of albuminoid fluids from the 
 vagina at variable intervals are common 
 in both classes of tumours. 
 
 So with the age of the patient. Per- 
 haps uterine may be more common than 
 ovarian tumours in old persons, and 
 ovarian more common than uterine tu- 
 mours in young persons ; but it is certain 
 that both uterine and ovarian tumours are 
 common in single, married, and widowed 
 women at all ages after puberty, and in 
 all conditions of life. 
 
 Both are also observed in some women 
 who are extremely fat, in some who are 
 otherwise healthy and well nourished, and 
 in some who are extremely emaciated ; 
 and there is a facial expression common 
 to women suffering from both classes of 
 tumours, associated commonly Avitli a 
 very florid complexion when the tumour 
 is uterine. In the majority of ovarian 
 cases the complexion is pallid ; but in 
 some cases, where the patient is fat or 
 well nourished, the complexion may be 
 florid. 
 
 Remembering the numerous exceptions 
 to all the rules just stated, we may now 
 inquire what may be learned by the eye, 
 the touch, and the ear, in an examination 
 of the abdomen ; in other words, what 
 are the signs afforded by inspection and 
 measurement, by palpation, and by per- 
 cussion and auscultation, which are of 
 value in diagnosis. The results of this 
 inquiry may be arranged in the following 
 order : 
 
 INSPECTION 
 
 1. Visible enlargement of the abdo- 
 men is more often general in cases of 
 ovarian tumour, and partial in cases of 
 uterine tumour, being confined to the 
 lower part of the abdomen until a very 
 large size has been attained. 
 
 2. The depression of the umbilicus is 
 diminished, or the umbilicus may become 
 prominent in large ovarian cysts. This is 
 rarely seen in uterine tumours unless fluid 
 is also present in the peritoneal cavity. 
 
 3. Enlargement of the superficial veins 
 of the abdominal wall, and oedema of the 
 abdominal wall and of the linea2 albicantes, 
 are more general in uterine than in ovarian 
 tumours of moderate size, but are not 
 uncommon when ovarian tumours have 
 attained a very large size. 
 
 4. "When the abdominal wall is thin, 
 both uterine and ovarian tumours, if not 
 very closely adherent to the abdominal 
 wall, may be seen to move downwards as 
 a recumbent patient inspires, and upwards 
 during expiration, falling downwards and 
 forwards as she sits or stands, and more or 
 less to either side according to the inclina- 
 tion of her body. But nearly all uterine 
 tumours, though visibly moving above, 
 seem to be fixed below in the hypogastric 
 region. 
 
 5. "When a recumbent patient attempts 
 to sit up without aid from any other than 
 the abdominal muscles, the recti are seen 
 to bulge forward in fi'ont of a tense non- 
 adherent ovarian tumour or with a flaccid 
 adherent cyst. This is seldom well marked 
 in uterine tumours, a solid mass fixed 
 centrally below the umbilicus interfering 
 with the free action of the recti. 
 
 MEASUREMENT 
 
 6. Increase in the circular measure- 
 ment of the abdomen is usually greater 
 on one side than the other in ovarian 
 tumours. In uterine tumours the increase 
 is more often symmetrical. In both classes, 
 vertical measurement shows the distance 
 between the pubes and the sternum to be 
 increased. But very great proportionate 
 increase of the space irom the pubes to 
 the umbilicus is more common in uterine 
 than in ovarian tumours. 
 
 PALPATION 
 
 7. Large masses of apparently solid 
 matter, and smaller masses or nodules of 
 very hard or bonelike substance, are 
 sometimes observed in ovarian tumours. 
 But it is excessively rare to find such 
 solid T^oxiion^ preponderating in an ovarian 
 tumour. As a rule, the fluid or cystic 
 portion is the larger, the hard or solid 
 portion the smaller, in ovarian tumours. 
 In uterine tumours, on the contrary, the 
 solid is the larger, the fluid the smaller 
 portion. 
 
 8. The mobility of ovarian tumours 
 is generally greater from below upwards 
 
UTERINE TUMOUKS 
 
 139 
 
 than that of uterine tumours, unless the 
 latter are distinctly pedunculated. If one 
 hand be pressed backwards between the 
 tumour and the pubes, an ovarian tumour 
 can generally be raised considerably, and 
 the hand can sometimes be pressed back- 
 wards almost to the brim of the pelvis ; 
 while a tumour which involves the body 
 and neck of the uterus cannot be raised 
 at all, or only with difficulty, and the 
 hand cannot be pressed down between the 
 pubes and the tumour. 
 
 9. When there is fluid free in the 
 peritoneal cavity, and a hard tumour can 
 be felt on displacing this fluid by sudden 
 pressure, the tumour may be either 
 uterine or ovarian. If the tumour be 
 very hard and the quantity of fluid small, 
 the tumour is probably uterine and the 
 fluid ascitic. An ovarian tumour which 
 has given way, and emptied one or more 
 of its cysts into the peritoneal cavity, is 
 seldom hard or well defined in outline, 
 and the quantity of fluid is often so large 
 that the size and shape of the tumour 
 cannot be ascertained until after removal 
 of the fluid by tapping. The characters 
 of the fluid will then complete the 
 diagnosis. 
 
 PERCUSSION 
 
 10. As percussion elicits a dull sound 
 all over both uterine and ovarian tumours, 
 which dulness ceases abruptly at the 
 border or outline of the tumour in all 
 positions of the patient — except in the 
 rare cases Avhere a cyst contains gas, or 
 where a coil of intestine is adherent in 
 front of a tumour — percussion cannot 
 affbrd much aid in distinguishing ovarian 
 from uterine tumours. 
 
 AUSCULTATION 
 
 11. In ovarian tumours the impulse 
 from the aorta is often perceptible, and a 
 sound sometimes accompanies the impulse. 
 The sounds of the heart are rarely trans- 
 mitted, and any distinct vascular murmur 
 is excessively rare. But in about half the 
 cases of uterine tumours which I have 
 examined some variety of vascular murmur 
 may be heard. In some cases the murmur 
 is tubular, in others vesicular, and some- 
 times a tubular and a vesicular murmur 
 may be heard in different parts of a 
 uterine tumour. These murmurs are 
 synchronous with the pulse. They may 
 
 vary in intensity with the amount ot 
 pressure by the stethoscope, and may dis- 
 appear on very firm pressure. Common 
 in uterine, very rare in ovarian tumours, 
 vascular murmurs are valuable aids in 
 diagnosis. 
 
 EXAMINATION BY VAGINA AND RECTUM 
 
 Having thoroughly examined the abdo- 
 men, the pelvis is next to be examined by 
 the vagina and rectum, and a conjoined 
 examination of the tumour by the abdo- 
 men and pelvis should also be made. 
 
 Examination of the vagina may at 
 once remove all doubt, by showing that 
 the OS and cervix uteri are in a healthy 
 state, that the uterus is normally mobile, 
 that its cavity is neither elongated nor 
 shortened, and that any tumour felt 
 through the vaginal wall is independent 
 of the uterus. In such a case the tumour 
 is almost certainly ovarian. On the con- 
 trary, we may find the vagina more or 
 less completely obliterated by a solid 
 mass, the cervix uteri gone, the os reached 
 with difficulty, the cervical canal so closed 
 or distorted that the u erine sound cannot 
 be passed, or the cavity may be so en- 
 larged or elongated that the sound may 
 pass many inches beyond the normal 
 length. Here the tumour is almost cer- 
 tainly uterine. The sound may also give 
 valuable information as to the extent oi 
 the connection of the ingrowth with the 
 wall of the cavity. 
 
 But it must be remembered that 
 considerable peritoneal outgrowths, or 
 large growths within the walls of the 
 fundus or body of the uterus, have been 
 observed, while the uterine cavity has re- 
 mained unaltered in dimensions and the 
 cervix in structure. And, on the other 
 hand, the cervix may be draAvn up out of 
 reach, or the whole uterus may be elon- 
 gated, when the connection with an 
 ovarian tumour is close; or the lower 
 portion of an ovarian tumour may be so 
 moulded to the true pelvis that the uterus 
 is pressed upwards and forwards, or flat- 
 tened behind the pubes, so that the 
 tumour and the uterus are either really 
 or apparently inseparable from one an- 
 other. Abnormal arterial impulse in the 
 vagina and cervix uteri may be felt in 
 both classes of tumours. In one case I 
 found during the operation that the 
 pulsations at the base of a uterine tumour 
 arose from some large vessels in a portion 
 
i4t) 
 
 UTEEINE AND OTHEE ABDOMINAL TUMOUES 
 
 of omentum which had contracted adhe- 
 sions low down. The pulsating omental 
 vessels had been felt through the vagina. 
 But T have never felt the vascular thrill 
 Jike that of varicose aneurism, occasionally 
 felt in the lower segment of a fibroid 
 uterus, in any ovarian tumour. I have 
 felt this thrill in some 20 to 30 cases, and 
 thought it of some value in the differential 
 diagnosis between uterine and ovarian tu- 
 mours, but I never suggested that the 
 thrill was due to the presence of an 
 aneurism. Yet Dr, Bailey, of Louisville, 
 Kentucky, furnished me with a curious 
 •exemplification of the ease with which 
 ■even intelligent commentators may put 
 different interpretations upon the simplest 
 bit of text when they overlook the context. 
 In consultation with other eminent prac- 
 titioners, he saw a patient who for 8 
 or 10 years had had fibroid tumours of 
 the uterus, and he wrote to me thus : 
 ^ Latterly a new feature occurred in the 
 case. AH the phenomena of an aneurism 
 appeared in the lower segment of the 
 uterus. A purring thrill could be heard 
 •and felt very distinctly indeed. Several 
 very prominent gynaecologists unhesita- 
 tingly pronounced it aneurism. Upon 
 the paragraph quoted from your work I 
 stated that you taught that the phenomena 
 of varicose aneurism occurred in the lower 
 segments of fibroid uteri witnout there 
 being aneurism. Did I interpret your 
 language correctly ? Dr. Atlee, of Phil- 
 adelphia, as well as the other eminent 
 gentlemen, maintained that you merely 
 expressed the idea that fibroid uteri had a 
 pulsatory thrill in their lower segments 
 that was not found when the tumours 
 were ovarian. Noav while this is true, I 
 claimed that your language taught more 
 than this — namely, that the lower segments 
 of fibroid uteri occasionally gave out all 
 the phenomena of varicose aneurism when 
 there was no aneurism, and that this was 
 not the case with ovarian tumours. 
 
 ' Dr. Atlee performed gastrotomy, and 
 as the shock and loss of blood lost to him 
 the patient upon the table, the dissection 
 of the tissues where the aneurismal phe- 
 nomena had presented themselves de- 
 monstrated no aneurism. So if I have 
 interpreted your teachings aright they 
 have in this case received additional 
 support.' 
 
 In order to prevent any further mis- 
 reading of my words, in which, however, 
 I can see nothing equivocal when taken 
 
 in their connection, I may notify that I 
 fully accept Dr. Bailey's construction, and 
 gladly add his case as an illustration of 
 the truth of what I wrote. 
 
 The vaginal walls may be so de- 
 pressed, when there is much fluid free in 
 the peritoneal cavity surrounding either a 
 uterine or an ovarian tumour, as to form 
 a vaginal rectocele, more rarely a vaginal 
 cystocele. And the uterus may either 
 remain above the brim of the pelvis if 
 greatly enlarged, or if fixed by adhesion ; 
 or it may prolapse with the vagina, the 
 OS appearing at the most depending part 
 of the protrusion. Here the uterine 
 sound will generally remove all doubt ; 
 for if the dimensions of the uterine cavity 
 are normal, and the weight of the uterus 
 is not increased, the tumour can hardly be 
 uterine. And a uterus which is not much 
 enlarged can generally be pushed up to 
 its normal position. 
 
 In some cases where the uterus is 
 much elevated, it may be felt through the 
 abdominal wall above the pubes, while 
 the OS uteri cannot be reached by the 
 vagina. The urethra may be elongated 
 or drawn to one side, and the bladder 
 may also be displaced. If the abdominal 
 tumour and the pelvic portion of the 
 tumour fluctuate, while the uterus does 
 not much exceed its normal dimensions, 
 it is almost certain that the uterus is 
 adherent to, and is elevated by, an 
 ovarian tumour. 
 
 Examination by the rectum may 
 show that the uterus preserves its normal 
 size, shape, and position. Or it may be 
 displaced by some tumour above or in 
 front ol it, and one or both ovaries may 
 sometimes be felt. This, however, is nut 
 very common if they are not enlarged nor 
 lower in the pelvis than usual. By one 
 finger in the rectum and another in the 
 vagina, the consistence, form, and size of 
 any intervening structure can be ascer- 
 tained and valuable information so ob- 
 tained. And if the sound be passed into 
 the uterine cavity, and examination then 
 made by the rectum, it is often easy to 
 ascertain whether any solid or fluid tu- 
 mour is situated between a normal uterus 
 and the rectum, or whether the uterus is 
 fixed and its posterior part enlarged. 
 
 When a tumour can be felt in the 
 pelvis by vagina and rectum, as well aa 
 in the abdomen by the abdominal wall, 
 simultaneous examination will be required 
 to ascertain if there is more than one 
 
UTERINE TUMOURS 
 
 141 
 
 tumour, and if the uterus is independent 
 or not. Pressing one finger firmly on the 
 cervix uteri, and moving the abdominal 
 tumour with the other liand from side to 
 side, then upwards and do;v'n\vards, the 
 uterus may be felt to remain almott un- 
 affected by the movements of the tumour, 
 or only to receive some transmitted move- 
 ment as the pelvic portion of the tumour 
 moves. Here the strong probability is 
 that the tumour is ovarian. On the other 
 hand, every movement of the abdominal 
 tumour may be communicated imme- 
 diately to the uterus, Avhich is felt to 
 move in all directions with the pelvic 
 portion of the tumour. If this portion is 
 solid, it is almost certain that the tumour 
 is uterine. 
 
 Cases are sometimes met with where 
 ovarian tumours and fibroid tumours of 
 the uterus are both present at the same 
 time. Small uterine fibroids are often 
 observed when the only important tumour 
 is ovarian. I have seen a large cyst of 
 one ovary and a large uterine fibroid co- 
 existing. I have twice seen tumours of 
 both ovaries present when the uterus was 
 enlarged by fibroids, and several cases 
 where both uterus and ovaries were sim- 
 ultaneously affected by malignant disease. 
 In (Jase 979,1 removed an ovarian tumour 
 weighing 7 pounds, and a fibroid out- 
 growth from the uterus weighing 2 
 pounds. And in 1882 I removed a der- 
 moid tumour of the left ovary, and a 
 fibroid outgrowth from the right side of 
 the uterus. Both these patients were 
 young unmarried women, and both re- 
 covered. 
 
 EXPLORATORY INCISION 
 
 If these possible complications be 
 borne in mind, such an examination as I 
 have suggested will in most cases suffice 
 to establish an accurate diagnosis between 
 uterine and ovarian tumours. In some 
 cases doubt may still remain, and ex- 
 ploratory puncture or incision will then 
 be necessary. When a uterine outgrowth 
 is not entirely solid — but partly solid and 
 partly fluid or cystic — forming a fibro- 
 cystic tumour — the diagnosis is still more 
 difficult. A case of fibro-cystic tumour 
 of the uterus was reported by me in the 
 ' Dublin Quarterly Journal of Medical 
 Science,' Aug. 1864. The report has 
 been reprinted in each of my works on 
 diseases of the ovaries. Although prac- 
 
 tically important, and historically in- 
 teresting, as a sort of landmark indicating 
 one stage in the settling of the principles 
 of our diagnosis, and the date at which it 
 became generally known that fibro-cystic 
 tumours of the uterus could contain so 
 large a quantity of fluid as to bring them 
 into diagnostic comparison Avith ovarian 
 cysts, and marking the limits of safety in 
 any operative proceedings undertaken 
 either for determining the nature of the- 
 growth or the possibility of its removal, 
 it is unnecessary now to repeat all the 
 details. The patient was a single lady, 45 
 years of age, with the abdomen enor- 
 mously distended, measuring 5G inches iri 
 girth at the level of the umbilicus, 19 
 inches from the ensiform cartilage to the 
 umbilicus. The skin covering the um- 
 bilicus was distended by fluid simulating 
 an umbilical hernia. Above the um- 
 bilicus fluctuation was very evident; but 
 the fluid was evidently free in the peri- 
 toneal cavity, and covered a solid or 
 semi-solid tumour that could be felt on 
 displacing the fluid by deep pressure. 
 
 I first tapped above the umbilicus, 
 and removed about oO pints of clear 
 rather viscid fluid. After removing the 
 canula, and closing the small opening, 
 I made an incision below the umbilicus 
 about 6 inches long, and exposed what 
 appeared to be 2 ovarian cysts separated 
 by a deep fissure. I tapped that on the 
 left side, and about 10 pints of bloody 
 serum escaped ; 2 or 3 pints more of 
 similar red fluid escaped after puncturing 
 again within the cyst first opened, by 
 pushing on the trocar without removing 
 the canula. The tumour was then with- 
 drawn, and found to have .2 attachments 
 — one above to the tumour on the right 
 side, and one below to the uterus. The 
 former attachmi^nt was broken through, 
 and 2 bleeding vessels on the torn surface 
 of the right tumour were secured by silk 
 ligatures. The left broad ligament was 
 then transfixed, tied in two halves with 
 strong silk, and the tumour was cut away. 
 It then became a question what should 
 be done with the tumour on the right 
 side ; and, looking to its great size, 
 solidity, evident close connection with the 
 transverse colon and with the omentum, 
 which contained some enormously dis- 
 tended veins, it was decided that no 
 attempt to remove this tumour should be 
 made, especially as the patient was be- 
 coming very feeble. The wound was 
 
142 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 accordingly closed and the patient placed 
 in bed. Brandy was administered freely ; 
 but she never rallied nor recovered con- 
 sciousness, and died about 3 hours after 
 she had begun to take chloroform. 
 
 The tumour which I removed weighed 
 about 20 pounds, and was almost entirely 
 solid. It consisted of fibrous tissue, 
 everywhere permeated by large blood- 
 ve^^sels, and in several places there were 
 blood cysts, the size of a barley-corn to 
 that of a pea. The largest cyst was at 
 the superior extremity ; it was about the 
 size of an adult head, and its internal sur- 
 face presented traces of having primarily 
 been divided into several compartments. 
 
 The tumour which we did not attempt 
 to remove was found after death to con- 
 sist partly of a cyst and partly of a fibro- 
 cystic tumour. The cyst was spherical, 
 about a foot in diameter, empty, and it 
 adhered to the anterior abdominal wall 
 and to the transverse colon ; the fibroid 
 mass measured 18 inches in length, 16 
 inches in breadth, and near its centre 
 fully 7 inches thick. 
 
 The walls of the uterus were of nor- 
 mal thickness. From the fundus sprang 
 a fibrous column, 5 inches long, 3 inches 
 deep, and 1^ inch broad, encircled 
 at its upper extremity by a ligature. 
 The left side of this fibrous column pre- 
 sented a roughly cut surface, 5 inches 
 long and 3 inches broad or deep, being 
 the point at which the tumour first 
 described had been cut through at the 
 operation. 
 
 In the 14th volume of the ' Trans- 
 actions of the Pathological Society of 
 London,' p. 204, may be found a short 
 account of a fibro-cystic tumour of the 
 uterus which I removed from a single 
 lady, aged 53, on April 30, 18C3. 
 ' One large cyst had held 26 pints of 
 fluid and 4 pounds of fibrine ; and there 
 was a solid mass, which weighed more 
 than 16 pounds. It was not imtil after 
 post-mortem examination that the true 
 nature of the case was discovered. 
 Given a large semi-solid tumour, fluctu- 
 ating in some parts, containing cysts 
 holding upwards of 20 pints of fluid, 
 moving beneath the abdominal wall, the 
 uterus being movable, and not enlarged 
 so far as measurement by the sound can 
 detect, no sound or arterial impulse to be 
 heard which is not often heard in ovarian 
 tumours, and no history of haemorrhage 
 leading to a suspicion of uterine disease 
 
 — and it will be admitted that these 
 characters of the two fibro-cystic tumours 
 of the uterus which I removed so 
 closely resemble those of semi-solid 
 ovarian tumours, that diagnosis must 
 be very uncertain. Even after an ex- 
 ploratory incision, I know of nothing 
 but a rather darker — less pearly — aspect 
 of the tumour Avhich would put the 
 surgeon on his guard. In any doubtful 
 case it Avould be well to tap the largest 
 cyst and examine the fluid. In both the 
 above cases, as in others since, this was 
 peculiar — not the viscid mucoid fluid of 
 multilocular ovarian cysts, but a thin 
 serum, with 5, 10, or 15 per cent, of 
 blood intimately mixed with it, and not 
 separating until after standing for some 
 hours. In this way I have satisfied 
 myself, in several cases, that tumours, 
 which others considered to be ovarian, 
 were really fibro-cystic uterine growths. 
 If the operation has been commenced, and 
 the dark aspect of the tumour is observed, 
 it would certainly be advisable not to do 
 more than tap one or more of the largest 
 cysts before examining attentively the 
 connections between the uterus and the 
 tumour. If these should prove to be 
 very intimate, it will be the iinpleasant 
 duty of the surgeon to desist from any 
 attempt to do more, and to close the 
 wound as soon as possible.' We shall see 
 presently how recent experience modifies 
 this last sentence. 
 
 MEDICAL TREATMENT 
 
 There is more time for the treatment 
 with patients suffering from fibroid tu- 
 mours of the uterus of moderate size than 
 with those who are subject to the more 
 rapid course of ovarian cysts. Even when 
 the symptoms are urgent we have time to 
 try a variety of medical resources, not only 
 for the relief of symptoms, but with some 
 hope of arresting growth before resorting 
 to surgical measures ft)r extirpation. 
 When the tumour has attained a consider- 
 able size, one of the first things which 
 strikes us is the distress arising from the 
 pendulous state of the abdomen. We 
 net rid of this trouble at once by a suit- 
 able bandage or apparatus, and put the 
 patient at comparative ease. The support, 
 too, may be carried to an extent sufficient 
 to steady the tumour, and to prevent the 
 pain caused by its rolling, and falling 
 upon the sensitive viscera with which it 
 
UTERINE TUMOURS 
 
 143 
 
 comes in contact as the patient moves 
 about. But beyond this pro\tection pres- 
 sure is useless, and it is generally in vain 
 that it is employed to get any amount of 
 absorption ; to say nothing of the aggra- 
 vation of other symptoms by any great 
 degree of constriction. Without this 
 girding, the weight of the tumour pressing 
 upon nerves, vessels, and the abdominal 
 organs is enough to cause distress, for 
 which we have to find means of relief. 
 We sometimes meet with the most excru- 
 ciating sciatica when the tumour sinks 
 down in the pelvis, and the pain can only 
 be moderated by changes of position, and 
 dislodging the mass from the place where 
 it has become impacted. Without such 
 manual interference embrocations and sub- 
 cutaneous injections are thrown away. 
 We must deal in the same way with 
 any other part which is the seat of neu- 
 ralgia from the same cause. At the same 
 time, we are doing as much as possible 
 to remove the vascular obstruction Avhich 
 is giving rise to congestion and oedema, 
 though it will often be found that bandages 
 on the lower limbs, when they are much 
 swollen, are an additional means of com- 
 fort to the patient. With the presence of 
 a foreign body, such as one of the fibroid 
 tumours, encroaching upon the space duly 
 adjusted for the joint occupation and action 
 of the several abdominal viscera, some or 
 all of them must needs be interfered with 
 and their functions embarrassed. Thus 
 we see produced all the evils of lymphatic 
 engorgement, of impeded intestinal action, 
 of renal and vesical irregularity. We may 
 have to exert all our ingenuity to disengage 
 the lymph channels, to assist imperfect di- 
 gestion, disperse flatulence, moderate spas- 
 modic pains, overcome constipation, and 
 take off tenesmus — all which things, to- 
 gether or alternately, make life a torment. 
 Pancreatic and hepatic difficulties are 
 often very marked, and need to be at- 
 tended to. The bladder symptoms some- 
 times become distressing, and pressure 
 in the ureters may suspend kidney func- 
 tion and give rise to the well-known 
 symptoms. Beyond these troubles of the 
 mechanism of organic life, we may find 
 the vital organs of the thorax no less 
 affected, and when we come to add the 
 host of miseries from diverse reflex action, 
 there is an ample field for the art of 
 relieving medicine to show its powers. 
 Then the Avhole range of constitutional 
 effects have to be considered, and every- 
 
 thing compatible with the circumstances 
 and condition of the patient must be done 
 to maintain the general health, since the 
 better the condition of the patient the 
 less rapid will be the development of the 
 embryonic tissues forming the tumour. 
 Change, moral support, sedatives, tonics, 
 nourishment, must all be regulated 
 according to circumstances. The loss of 
 blood, generally aggravated periodically, 
 is one of the most serious consequences 
 of fibroid tumours, especially of those in- 
 growing ot seated in the walls of the 
 viterus. This has to be restrained. The 
 most important matter here is rest, and 
 this ought to be absolute. Some sur- 
 geons trust very much to dilatation of the 
 cervical canal, or to the effect of incisions, 
 followed by the application of styptics. 
 Of these there are many ; none, perhaps, 
 better than the preparations of iron. 
 Sometimes it may become necessary to 
 plug the vagina or to use injections. At 
 the same time, internal remedies of the 
 same character can be given with advan- 
 tage. Most men have, after a time, their 
 preferences, and familiarity with the use 
 of certain agents often gives unexpected 
 power in the use of them. I have fre- 
 quently tested the long-continued employ- 
 ment of the perchloride of mercury with 
 bark, and I believe the good results from 
 it are mainly due to its action on the 
 digestive organs, and to its effect in 
 restoring and keeping up the general 
 health. It conduces, too, as much as any- 
 thing, to what we may hope to do in the 
 way of cure — that is to say, in checking 
 the growth, or promoting the absorption, 
 of the tumour. With this end in view, I 
 have also given chloride of ammonium, 
 alone or with the bromide, for a long 
 time, and in many cases with apparent 
 benefit. A great variety of absorbent 
 remedies have been suggested, but from 
 none of them can any good be expected. 
 The subcutaneous injection of ergotine or 
 of sclerotic acid is said to have brought 
 about a diminution of size, while at the 
 same time it controlled the haemorrhage, 
 and, b}' giving the patient comfort, en- 
 abled her to gain health and strength. 
 Ergot, in the form of liquid extract, 
 given internally, acts in the same way. 
 Wonderful reports have also been made 
 of the effect of the Kreuznach and Wood- 
 hall Spa waters, and even of the home 
 use of the salts obtained from them, and 
 one may suppose that there is some truth 
 
144 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 therein, or the popularity of the springs 
 would not have outlasted the common 
 duration of credulity. At one time the 
 artificial petrifaction of the tumour by 
 the continued administration of chloride 
 of calcium, in imitation of the natural 
 process of calcification which occasionally 
 takes place, seemed to promise a chance of 
 success, at least in arresting the growth 
 of fibroid tumours; but the equal affinity 
 of the arterial coats for this substance 
 brought patients into a serious dilemma, 
 and it seemed better for them to go on 
 strugpling for life with a non-malignant 
 parasite, than to run any risk of losing it 
 by the failure of a damaged circulating 
 apparatus. 
 
 Tumours not projecting into the 
 cavity of the uterus are no bar to mar- 
 riage. A pregnancy may even give the 
 chance of getting rid of the tumour by an 
 involution coincident with that of the 
 uterus after delivery. 
 
 SURGICAL TREATMENT 
 
 This may be most conveniently dis- 
 cussed in detail according to the varieties 
 of the tumours to be operated on in the 
 following order: 1st, fibroid or fibro- 
 cystic sub-peritoneal outgrowths ; 2nd, 
 mural or interstitial growths ; 3rd, in- 
 growths. The alternative practice of 
 removing the ovaries instead of the 
 uterine tumour will afterwards be con- 
 sidered. 
 
 INDICATIONS FOR MYOMOTOMY 
 
 Before considering the methods of 
 operating in these three classes of cases, 
 the surgeon has to decide whether any 
 operation should be recommended, or 
 whether the patient should be advised to 
 wait either imtil some clear necessity for 
 relief removes all doubt, or until the 
 ordinary changes in the uterus which fol- 
 low the cessation of the catamenia are 
 accompanied or followed by diminution 
 in the morbid growth and by the dis- 
 appearance of the distressing symptoms 
 depending upon it. Here ovariotomy and 
 myomotomy stand upon very different 
 grounds. I adopt the word 'myomotomy' 
 because, without being etymologically 
 accurate, it is becoming pretty generally 
 received as a convenient term for the 
 removal of uterine tumours. With some 
 rare exceptions, ovarian tumours, if not 
 
 removed, kill the patient within 4 years. 
 Innocent uterine tumours, on the con- 
 trary, may persist for many years almost 
 without the knowledge of the patient, 
 are often discovered quite accidentally, 
 and as age advances disappear more or 
 less completely, without shortening life 
 or leading to any important affection of 
 the general health. It is only when 
 accompanied by free bleeding or by the 
 formation of ascitic fiuid that uterine 
 tumours of moderate size, and not rapidly 
 increasing, should be operated upon in 
 any way ; or when pressure on intestine, 
 bladder, uterus, or nerves causes symptoms 
 which can only be relieved by removal of 
 the tumour ; or the case is complicated 
 by pregnancy. When a uterine tumour 
 attains a very large size, the suffering 
 caused by its Aveight and pressure, and by 
 its interference with the respiration, is 
 sufficient to justify operation at even great 
 risk. Putting aside cases where the great 
 size of the tumour is the only indication 
 for operation, the other indications for the 
 removal of tumours of moderate size are. 
 either their rapid increase, some inflam- 
 matory or other changes in the tumour 
 causing fever, profuse bleeding, peritoneal 
 irritation with ascitic effusion, or local 
 consequences depending directly upon 
 pressure. At the present day, the indi- 
 cations for the operation have to be con- 
 sidered under very different estimates as 
 to the probable results of its performance 
 than could have been calculated upon 20 
 years ago. Up till about the year 1865, 
 when ovariotomy was beginning to be 
 accepted as a legitimate surgical opera- 
 tion, uterine tumours Avere scarcely ever 
 removed designedly. The rule was, that 
 when a surgeon, performing Avhat he 
 expected to be ovariotomy, found that he 
 had made a mistaken diagnosis, and Avas 
 unexpectedly called upon to deal Avith a 
 uterine tumour, he should desist. In 
 many cases he desisted. The Avound was 
 closed. But in some exceptional cases 
 tumours Avere removed, and as the num- 
 bers of such cases increased, technical de- 
 tails in the mode of operating Avere learnt. 
 Kimball's operation in September 1853 
 appears to be the first in Avhich any sur- 
 geon, having made an accurate diagnosis, 
 undertook to remove the tumour Avith a 
 distinct knoAvledge of Avhat he had to do. 
 His operation Avas followed by the re- 
 covery of the ])atient. The work of Pean 
 and Urdy,ou ' Ilysterotomie,' published in 
 
UTERINE TUMOURS 
 
 14; 
 
 1873, probably contains the first systematic 
 account of the mode of removing fibroid 
 and fibro-cystic uterine tumours. The 
 history of this operation is by them 
 divided into 3 very distinct periods. 
 In the first, before 1843, surgeons, meeting 
 in the abdomen with uterine tumours 
 instead of the ovarian tumours they 
 expected, shranlc from the consequences 
 of proceeding, and did not complete the 
 operation they had begun. In the second 
 period, from 1843 to 18G3, which Pean 
 calls the stage of essaying and groping- — 
 ' periode d'essais et de tatonnements' — 
 and when ovariotomy had found nume- 
 rous followers, some surgeons, finding 
 themselves after an error of diagnosis in 
 the presence of a uterine tiimour, impro- 
 vised tlie operation, although everything 
 had been prepared for an ordinary ovario- 
 tomy. This is true only to a certain 
 extent, for in Sept. 1861, in a case where 
 before operation I had been doubtful as 
 to diagnosis, and went prepared either to 
 perform ovariotomy, or to deal with the 
 suspected contingency of a uterine fibroid, 
 I removed a solid uterine tumour weigh- 
 ing 27 pounds, with both Fallopian tubes 
 and both ovaries; and in January 1863 
 I enucleated a solid tumour weighing 16 
 pounds, previously known to be a fibroid 
 outgrowth from the uterus, after a very 
 accurate diagnosis had been made in a 
 careful consultation and with a full expla- 
 nation of the unknown risk to the patient. 
 In another case, in 1863, I took away a 
 fibro-cystic tumour weighing 46 pounds. 
 The third period dates from April 1863, 
 Avhen Kceberle, in a case of doubtful 
 diagnosis, prepared himself for either con- 
 tingency, and decided, before he began the 
 operation, to remove the whole of the tu- 
 mour, even if obliged to perform a supra, 
 vaginal amputation of the uterus. Inl866 
 he operated 3 times in cases Avhere, sure 
 of his diagnosis, he designedly performed 
 hysterotomy ; and it is claimed for the dis- 
 tinguished surgeon of Strasburg, that to 
 him the honour is due of having first 
 performed amputation of the uterus de- 
 liberately, and Avith a full knowledge of 
 his case. The latest returns of Koeberle's 
 practice are given by Bigelow up to 1882 
 as 19 operations — 9 recoveries and 10 
 deaths. Plan's first case was in 1869 — 
 the first successful case in Paris. This 
 was a fibro-cystic tumour, and it was not 
 until 1871 he removed a solid fibroid. 
 Up to Feb. 1872, Pean had operated upon 
 
 9 patients, 7 of whom recovered. Before 
 July 1881, according to Bigelow, Pean 
 had had 51 cases, with 33 recoveries and 
 18 deaths. 
 
 The later results of the German ope- 
 rators, Hegar, Kaltcnbach, Schroeder and 
 Olshausen, as having done amongst them 
 the greater part of the operations in their 
 country, enable us to foim some com- 
 parison between the results of myomo- 
 tomy when the treatment of the pedicle, 
 or connection with the utei'us, is extra or 
 intra-peritoneal, and Avhen elastic or other 
 ligatures are used. In the latest publica- 
 tion which I have seen, that of Hofmeier, 
 published in 1884, he gives the results of 
 100 operations by Schroeder, all, with one 
 exception, with intra-peritoneal treatment. 
 Of 21 cases where the tumours were 
 removed without opening the utei'ine 
 cavity, there Avere only 2 deaths; of 58 
 cases where the uterine cavity Avas opened 
 there Avere 18 deaths; and of 20 cases of 
 enucleation of the uterine tumours there 
 Avere 12 deaths; making in all 100 cases, 
 Avith 32 deaths. Hofmeier gives the re- 
 sults of Hegar and Kaltenbach's opera- 
 tions up to Sejot. 1881, as 12 cases, Avith 
 only 1 death ; of Kaltenbach's only% up to 
 1883, as 10 cases, Avith only 1 death; of 
 Billroth's, to 1882, 25 cases— 10 reco- 
 veries and 15 deaths; and Olshausen's, 
 to 1884, 29 cases — 20 recoveries and 9 
 deaths. But all these latter numbers 
 Avere taken from Bigelow's table in the 
 ' American Journal of Obstetrics,' which 
 table certainly requires correction. 
 
 Indeed, the Avhole of the inquiry as to 
 results of operation upon the uterus for 
 fibroid tumours by different operators 
 and by different methods, either in 
 Germany, France, Great Britain or 
 America, leads to the conclusion Avhich 
 Schroeder, in his preface to Ilofmeier's 
 Avork, has expressed, ' that Avhile ovaiio- 
 tomy may now be looked upon, except as 
 regards possible advance in minute de- 
 tails, as a closed chapter, myomotomy, 
 on the contrary, stands exactly^ in the 
 opposite position.' 
 
 I perfectly coincide Avith Avhat Schroe- 
 der says, and Avithout venturing to lay 
 down any distinct rules for practice, 
 Avill proceed to illustrate different modes 
 of operating by narrating part of Avhat 
 I have done myself. The Avhole group 
 shows that the operation is more suc- 
 cessfully done noAv than formerly, and 
 that, Avhen the tumour can be removed 
 
 L 
 
146 
 
 UTERIXE AND OTHER ABDOMIXAL TUMOURS 
 
 withoixt opening the uterine cavity, a 
 better hope of ri^covery may be entertained 
 than when the cavity must be cut 
 through. 
 
 THE OPERATION' OF MYOMOTOMY 
 
 For every patient about to undergo 
 the operation of myomotomy, the same 
 preparation must be made, and the same 
 precautions observed, as for ovariotomy. 
 The patient is placed on the table, as shown 
 on page 7G, and the instruments are ar- 
 ranged in the same manner. The trocar 
 is only necessary when the tumour is 
 fibro-cystic. The instruments required, 
 not usually taken to an ovariotomy, are 
 the pins, wire constrictor, or a large 
 clamp, to be ready in case the extra-peri- 
 toneal method is selected, iron or cojiper 
 cauteries, or Paquelin's cautery, the 
 cautery clamp, and a supply of elastic 
 ligatures of different sizes. 
 
 Except in cases of small solid tumours, 
 or cases in which considerable cystlike 
 cavities may be emptied, the incision Avill 
 usually be much longer than in ovario- 
 tomy ; probably extending 2 or 3 inches 
 above the umbilicus, possibly quite up to 
 the ensiform cartilage. Even more caution 
 than in ovariotomy is necessary at the 
 lower angle of the incision, as the bladder 
 is very apt to be pushed or drawn up 
 towards the umbilicus. I have never fol- 
 lowed the practice of Pean in what he calls 
 ' morcellement,' or dividing the tumours 
 into several parts before extraction, in 
 order to render a long incision unnecessary. 
 This was a very long and tedious process, 
 and the prolongation of the operation and 
 the greater loss of blood appeared to me 
 far to outweigh any advantages gained 
 by diminishing, by a few inches, the length 
 of the incision. Still it is not always 
 necessary to carry the incision to the 
 extreme border of the tumonr, as an oval 
 tumour, or a tumour with irregular pro- 
 jections;, may often be so turned and 
 pressed out, as to pass without force 
 througli a much smaller opening than 
 Avould at first sight be thought possible. 
 
 Adhesions are dealt with precisely as 
 in ovariotomy. The chief difference ob- 
 servable in the vascularity is that, when 
 the tumour is covered by the broad liga- 
 ment, the veins are apt to be much larger. 
 They should be avoided when possible, 
 or, if opened, closed at once by pressure 
 forceps. 
 
 "When a long incision has been made, 
 it is a good plan to pass 2 or 3 sutures 
 near and above the umbilicus as soon 
 as the tumour has been brought out, in 
 order to prevent escape of intestine be- 
 fore proceeding to a separation of the 
 tumour. The mode of separating the tu- 
 mour will of course depend upon its con- 
 nections. When there is a distinct pedicle, 
 this may be secured exactly as in ovario- 
 tomy. When there is no pedicle, many 
 plans of treatment are open to us, which 
 will be described in one or other of the 
 cases I am about to relate. The remarks 
 upon the after treatment of cases of ovario- 
 tomy are equally applicable to those of 
 myomotomy. 
 
 SOLID SUB-PERITONEAL UTERINE OUT- 
 GROWTHS, TREATED INTRA-PERITONE- 
 ALLY 
 
 Solid tumour ; no 2^^dicle ; ligature ; 
 death from ha'inorrhage. — In the case of a 
 single lady, 32 years of age, upon whom 
 I operated in December 1874, removing 
 a solid fibro-myoma which weighed 9 
 pounds, there was no pedicle, but the 
 tumour appeared to be a prolongation 
 of the fundus uteri tOAvards the right, 
 forming a circular neck about 2 inches 
 in diameter. This was transfixed and 
 tied in two halves. A third ligature was 
 put on below the others. The tumour 
 was cut away, and the uterus then 
 appeared to be about the normal size. 
 It was returned along with the ligatures, 
 just as in ovariotomy. The patient died 
 40 hours after operation, of haemorrhage. 
 The ligatures were not sufficiently tight. 
 I suppose that the uterine tissue had 
 shrunk soon after the operation, the 
 ligatures becoming loose. If the Avound 
 had been reopened and fresh ligatures 
 applied, life might have been saved. The 
 uterus, as well as the tumour removed, 
 may be seen in the Museum of the Col- 
 lege of Surgeons. 
 
 Solid sub-peritoneal outrjrowth ; second 
 tumour not removed ; recovery. — I do not 
 think it has occurred to me more than 
 twice to remove an outgrowth from the 
 uterus, and then find that there were other 
 growths which could not be removed, or 
 which I thought it more prudent not 
 to disturb. Occasionally a second growth 
 has been removed, and in other cases 
 there lias been merely felt such slight 
 enlargement, irregularity of surface, or 
 
UTERIXJ': TL'MOL'RS 
 
 .147 
 
 partial hardening as led me to believe 
 that there might be some small inter- 
 stitial fibroids. In the two cases 1 am 
 about to mention, the growth not removed 
 was nearly as large as that which was 
 taken away. The first was in December, 
 1879, with Dr. Godson, who had recog- 
 nised a fibroid outgrowth from the fundus 
 as removable, and another from the cervix 
 or body, which we explained to the patient 
 Avould probably prove to be irremovable. 
 At her desire 1 removed the mobile out- 
 growth, applying a clamp at the seat of 
 connection between the fundus and the 
 tumour, before cutting the tumoiir away. 
 Wishing to treat the pedicle intra-peri- 
 toneally, I tied a ligature behind the 
 clamp, but it cut quite through the 
 uterine tissue, and the clamp came off. 
 There was no bleeding, and I did not apply 
 another ligature. The uterus was very 
 irregular in form, with fibroid projections 
 in different directions. Except some pro- 
 trusion of omentum between two of the 
 stitches, recovery was most satisfactory. 
 The patient has remained remarkably 
 well, Avithout any further uterine enlarge- 
 ment. 
 
 Tv:o fibroids^ suh -peritoneal ; one re- 
 moved, the other left; 2-)eritoneum sewn 
 over surface of stumj). — The other case 
 .in which I removed a fibroid outgrowth 
 from the fundus, about the size of a fatal 
 head, leaving undisturbed a considerable 
 growth attached posteriorly and directed 
 downwards into Douglas' pouch, was a 
 single lady, a patient of Dr. Ord. In this 
 case the treatment of the pedicle was also 
 intra-peritoneal,the edges of the peritoneal 
 coat of the uterus being closely brought 
 together by uninterrupted suture over the 
 surface where the tumour had been cut 
 aAvay. This patient also recovered well, 
 and has not yet suffered from any en- 
 largement of the growth which was not 
 removed. 
 
 Solid fihvo-myoma ; ligatures ; re- 
 covery. — In previous cases I had been 
 content with the pressure-forceps described 
 and figured in the ' British I\Iedical 
 Journal,' vol. i. 1879, ji. 928 ; but, feel- 
 ing the want of more effectual means of 
 securing bleeding vessels before dividing 
 them, I had forceps made similar in form, 
 but with longer handles, and a compress- 
 ing surface more than an inch in length. 
 With several pairs of such forceps, applied 
 before any tissues are cut through, large 
 tumours may be cut away with only very ^ 
 
 small loss of blood. They were used with 
 excellent effect in the following case. 
 
 On September 27, l'S80, assisted by 
 Mr. Thornton and Mr. A. Doran, I re- 
 moved a large solid uterine libro-myoma 
 from a sin;i;le lady, aged 41. By an 
 incision 8 inches long, the tumour was 
 exposed, or rather the omentum, contain- 
 ing very large vein.s, which covered the 
 tumour and adhered to it.' Two ligatures 
 were applied to the omentum, wliich was 
 then divided between them. Some ad- 
 hesions to the abdominal Avail were then 
 separated, and the tumour turned out 
 entire. It Avas a solid outgrowth from 
 the left side of the fundus uteri. The 
 band of connection between the uterus 
 and the outgrowth Avas between 2 and 3 
 inches in length, and about 1 inch in 
 breadth. This Avas first compressed and 
 held by 2 of the large forceps just de- 
 scribed, and the tumour Avas cut away. 
 Then a large needle Avith double thread 
 Avas pushed throusrh the uterine tissue 
 behind the forceps, and each thread Avas 
 tied as the forceps were taken off. Lastly, 
 the peritoneal edges of the divided uterine 
 Avail Avere brought together by an un- 
 interrupted suture of fine carbolised silk. 
 After the removal of the tumour, the rest 
 of the uterus appeared to be quite normal 
 in size and consistence. Both ovaries 
 were healthy. Recovery Avent on Avith- 
 out fever — the highest temperature Avas 
 1002°. There Avas unusual nervous 
 irritability during convalescence, perhaps 
 explained by the facts that her father 
 and an uncle had both been insane and • 
 attempted suicide ; but she Avent aAvay 
 30 days after operation in a very good 
 state of health, and has since been quite 
 Aveil. Mr. Doran described the tumour 
 as a solid uterine fibro-myoma, Aveighing 
 between 7 and 8 pounds. This lady 
 called on me in December 1884 in excel- 
 lent health. The catameuia had been 
 quite regular until October 1884. The 
 size of the uterus AViis normal, and the 
 only cause of complaint a protrusion of 
 viscera behind the thin cicatrix in the 
 abdominal Avail. 
 
 .SOLID FIDROIDS, SLT.-PEKITOXEAL ; TUEAT- 
 MEXT EXTUA-PEUITOXEAL 
 
 Sub-peritoneal fibroid ; clamp ; reco- 
 very. — The patient Avas single, 37 years 
 of age, and the operation Avas performed 
 in April 1S7G. The tumour was a solid 
 
 L 2 
 
148 
 
 UTERINE AND OTHER ABDOMIXAL TUMOURS 
 
 fibroid outgrowth from the fundus uteri, 
 and connected Avith it by a pedicle 
 about 2 inches in length and 1^ inch 
 in breadth and thickness. This pedicle 
 was secured in a middle-sized clamp, 
 ■which "was kept outside without much 
 pull upon the uterus, simply holding it 
 up close to the abdominal wall. Both 
 ovaries, Fallopian tubes, and the uterus 
 appeared to be quite normal. The out- 
 growth Avhich Avas removed seemed to be 
 the only part diseased. The patient has 
 been in good health ever since. The 
 tumour was a solid iibro -myoma, which 
 measured 25 inches in the longer and 13 
 inches in the shorter circumference, and 
 is preserved in the Museum of the College 
 of Surgeons. 
 
 Sab-peritoneal fibroid ; pins and liga- 
 ture acting as clamp ; recovery. — In June 
 1871 I removed, in the Samaritan Hospi- 
 tal, from a married woman, aged 40, a 
 solid outgrowth from the fundus uteri, 
 which Aveighed 11 pounds 11 ounces, and 
 Avas surrounded by 59 pints of serous 
 fluid. The neck or connection between 
 the tumour and the fundus uteri Avas first 
 compressed by a large ecraseur, but as 
 this Avas tightened it cut through the 
 uterine tissue, and free bleeding had to be 
 stopped by twisted suture over long pins, 
 Avhich were afterwards fixed outside the 
 Avound like a clamp. On the 0th day 
 these pins and ligatures came away ; there 
 Avas free bleeding. On tying the project- 
 ing stump the ligature cut through it, bi;t 
 the bleeding Avas stopped partly by per- 
 chloride of iron and partly by tying a 
 vessel over a tenaculum, Avhich did not 
 come away till the 13th day. The patient 
 perfectly recovered, and Avas in good health 
 in thft summer of 1884. 
 
 Tico solid fibroids ; clamp on one, 
 ligaim'C on the other; recovery. — I removed 
 two solid fibroid outgrowths from the 
 uterus of a single Avoman, 52 years of age, 
 in the Samaritan IIosj)ital, April 1877. 
 One of these tumours had a pedicle, Avhich 
 Avas secured by a clamp; the other, which 
 liad no pedicle, Avas removed after trans- 
 fixion and tying the connection Avith the 
 uterus. Each of these groAVths weighed 
 a little more than 4 pounds. One of them 
 Avas partly calcified. A third outgrowth 
 from the posterior part of the fundus, 
 quite low down in Douglas's pouch, was 
 not disturbed, as it Avas not larger than 2 
 Avalnuts and its connection Avas broad. 
 The clamp was removed on the 0th day, 
 
 Avith two thick silk ligatures and a slough 
 through Avhich they passed. On the loth 
 day some fetid pus escaped, when another 
 slough, about l?y inch long, AA-as draAvn 
 out. The patient recovered rapidly, left 
 the hospital Avithin a month of the opera- 
 tion, and Avas well in July 1878. 
 
 Solid fibroid ; pins and ligatures as 
 clamp ; death from embolic pneumonia. — 
 In June 1870 I removed a solid myoma, 
 Aveighing 22 pounds, from a .single lady, 
 3G years of age, Avho died 14 days after- 
 Avards. The pedicle Avas treated extra- 
 peritoneally, 2 long pins and a ligature 
 acting as a clamp. I had first used an 
 ecraseur, but the chain cut through the 
 uterine tissue. Very free bleeding fol- 
 loAved, Avhich the actual cautery and liga- 
 tures fliiled to check. The patient went; 
 on very Avell for 14 days, and then she died 
 of embolic pneumonia. It Avas most dis- 
 appointing, for there Avas only a small 
 superficial abscess in the abdominal Avail, 
 and no other reason to account for the 
 condition of lung Avhich caused death. I 
 dressed the Avound every day, and had not 
 noticed anything indicating this collection 
 of pus. But she became feverish, had 
 symptoms of pyremic pneumonia, and she 
 died owing to this small abscess in the 
 abdominal Avail; for inside the peritoneum 
 eA'erything Avas absolutely healed. There 
 Avas nothing about the uterus to attract 
 attention. Its surface Avas quite smooth, 
 the peritoneal edges of the incision per- 
 fectly united, and no traces Avhatever of 
 any peritonitis. 
 
 Solid fibroid ; forciprcssnre ; no 
 bleeding ; no ligature. — In September 
 1870 I drcAv out, by tapping, about 30 
 pints of fluid from the peritoneal cav^ity 
 of a Avidow, 52 years of age, and then 
 found a solid uterine tumour as large as 
 a foetal head, Avljich I removed on October 
 15, 1S70, Avith I'S pints of ascitic fluid 
 Avhich had again accumulated. The 
 tumour Avas an outgroAvth from the fundus 
 uteri, Avith a pedicle in circumference nor 
 much larger than half-a-crown, but only 
 about V, an inch in length. This Avas 
 temporarily secured in a straight screw 
 forceps and the tumour cut away. On 
 opening the forceps nobleeding took place 
 Irorn the pedicle. The vessels had been 
 so effectually crushed by the compression 
 that a ligature Avas not needed. The 
 tumour itself Avas about the size of two 
 fists. It Avas not Aveighed. Both o\-aries 
 Avcre n;irmal and tlie uterus also, except 
 
 J 
 
UTEllINE TTjMOUKS 
 
 149 
 
 Tvliere tlie tuinonr had grown from the 
 iundus. The patient i-ecovered admirably 
 well. It was remarkable that there 
 was no re-formation of ascitic fluid, al- 
 though before the operation 3 tappings 
 had been necessary — one hi March, 1871), 
 of 5 gallons ; a 2nd in April, of 3| 
 .gallons ; and a 3rd G weeks later, of 5 
 gallons; and fluid to the amount of 25 to 
 30 ounces daily had been removed after 
 the 3rd tapping by one of Southey's. 
 capillary tubes. The patient was reported 
 to be wonderfully well in January 1885. 
 SoVul Jibroid from fundus ; pin passed 
 tliroiif/h stiniip and abdominal wall ; death. 
 —On April 7, 18G9, I exhibited, at a 
 meeting of the Obstetrical Society a fibroid 
 outgrowth from the fundus uteri, weigh- 
 ing 34 pounds and 10 ounces, which I 
 •had removed a few hours before from a 
 •single woman, 36 years old. Eleven years 
 before, half her lower jaw had been re- 
 moved Avith a fibrous tumour by JMr. 
 
 Pemberton of Birmingham. An abdo- 
 minal tumour was discovered in 1864; it 
 enlarged gradually, and she was twice in 
 the Birmingham Hospital. During the 
 last 6 months the tumour had increased 
 rapidly, and she became very weak and 
 lost flesh. On admission to the Samaritan 
 Plospital a very large abdominal tumour 
 ■could be felt, but it evidently contained 
 no cyst large enough to warrant tapping, 
 and did not feel so hard as a fibroid 
 tumour of the uterus. No vascular mur- 
 mur was audible in it, and it appeared to 
 move quite independently of a uterus of 
 normal size. When the tumour was ex- 
 posed I was surprised to find that it was 
 not ovarian. It sprang from the posterior 
 . surface of the fundus uteri by a short 
 
 pedicle, as shown in this drawing to scale 
 by Dr. Junker, Avhich represents the 
 posterior surface of the uterus, with the 
 Fallopian tubes and both ovaries. A 
 rujitured Graafian vesicle is .seen on the 
 left ovary. The pedicle was secured by 
 a clamp forceps and the tumour was cut 
 away. Some bleeding spots where ad- 
 hesions had been sepaiated were secured 
 by an acupressure needle, and the clamp 
 was removed. Bleeding vessels were 
 secured by hare-lip pins and twisted 
 sutures, which also served to fix the 
 bleeding surface to the abdominal wall by 
 transfixion. The patient died on the 3rd 
 day alter the operation, not from any 
 bleeding, peritonitis, or other direct con- 
 sequence of the operation, but from 
 fibrinous deposit in the right side of the 
 heart. At the present day we should refer 
 the cause of death in this patient to septi- 
 cfemia, and believe that it might have 
 been averted by antiseptics. 
 
 Dr. Braxton Hicks reported of the 
 tumour that ' it was about 17 inches in 
 diameter. It had a fiuctuation very 
 similar to tliat of an ovarian polycystic 
 growth, which it also resembled much in 
 appearance. 
 
 ' The interior was found to be free 
 from cysts, excepting a few of small size, 
 of a false kind, formed by separation of 
 the layers of the tissues, the largest not an 
 inch in diameter, of irregular form. The 
 tissue of which it was composed was 
 arranged in a manner concentric with the 
 true centre, except in the lobules, where 
 it was arranged around the centres 
 differing from the irregularly concentric 
 arrangement generally found in mural 
 uterine fibroid growths. When cut into, 
 serum exuded rather freely. The inside 
 of the growth was of a pink, semi-trans- 
 lucent colour. 
 
 ' The microscopical examination of the 
 growth i-howed it to be composed of 
 areolar wavy tissue, interlacing in all 
 directions, but the arrangement of the 
 fibres was very open, and between them 
 the serum w^as held ; very little, if any, 
 true uterine fibres existed.' 
 
 My present belief, founded on later 
 experience, is that if the pedicle or con- 
 nection Avith the fundus uteri had been 
 treated either j'«/r«-peritoneally by or- 
 dinary or elastic ligature, or extra-pevl- 
 toneally by a clamp, the result Avould 
 have been better than by the combined 
 method adopted of securing the stump to 
 
150 
 
 UTERIXE AND OTHER ABDOMINAL TU.MOURS 
 
 the ahdominal wall by a pin ■which passed 
 through both stump and ■wall. 
 
 FIDRO-CYSTIC UTERINE TUMOURS 
 
 Fibro - cijStic outf/rowth ; l.'r/afure 
 Ironrjlit out of wound ; daith. — In the 
 3rd uterine case upon which I operated 
 in 18G3, there Avere very extensive pa- 
 rietal adhesions, which were, however, 
 easily bioken down. Some long hands 
 of thickened onicnttim were also attached 
 to the tumoiir, but the closest adhesion 
 ■was to the right iliac fossa. On account 
 of this close adhesion no proper pedicle 
 could be defined. A thick band reached 
 from the right side of the uterus to the 
 tumour, which was embraced by a wide 
 expansion of broad ligament that blended 
 Avith the adhesions to the right iliac fossn. 
 I transfixed below the Fallopian tube, tied 
 and cut awa-y^ the tumour. I then tied 3 
 large arteries in the Ibid of the broad 
 ligament, and 2 on the surface of the 
 stump. The left ovary could not be 
 accurately defined. Two small fibroid out- 
 growths Irom the uterus were cut aAvay ; 
 one of them was the size of a filbert, the 
 other of 2 walnuts. They bled a little 
 at first, but ceased on the vessels being 
 compressed. The hremorrhage during 
 the operation, though rather iree, was by 
 no means alarming ; perhaps G or 8 ounces 
 of clot may liave been taken from the 
 abdominal cavity. I closed the wound 
 with 6 deep and several superficial su- 
 tures, and brought out the ends of the liga- 
 tures at tlie inferior angle of the wound. 
 The patient died in a few hours. Clot 
 and serum were found in the pelvis. The 
 uterus was about twice its natural size. 
 The left ovary, slightly enlarged, retained 
 its natuial connection with the uterus. 
 The tumour removed was a fihro-cystic 
 outgrowth from the right side of the 
 fundus of the uterus. The solid fibroid 
 mass weighed IG pound.s G oiinces, and 
 the large cyst had held 2G pints of fluid 
 and 4 pounds of lumpy masses of de- 
 composed fibrine. Tlie right ovary, 
 slightly enlarged, adhered to the outer 
 surface of the tumour. 
 
 fII5R0-CY.STIC OUTGROWTHS — INTRA- PERI- 
 TONEAL ti;i:a'1.ment 
 
 Fihro-cij^tic, tumour; ligature; re- 
 covery. — I do not remember to have seen 
 more than 1 case where a fibro-cystic 
 
 tumour of the uterus had a very distinct 
 pedicle. I removed such a tumour in 
 December 1884 from a single lady, 30 
 years of age, a patient of Mr, Aikin. The 
 tumour was a fibroid outgrowth from the 
 fundus, with a pedicle about the length 
 and size of a small finger. Near the pedicle 
 the tumour was quite solid. In the upper 
 
 portion ■were several cystlike cavitie.'--, 
 Avhich contained clear reddish fluid. These 
 Avere tapped, their thin membranous coats, 
 Avhich adhered to the inner surface of the 
 abdominal Avail, Avere separated, and draAvn 
 out Avith the base of the tumour and 
 the pedicle. This Avas transfixed and tied 
 in 2 portions Avith silk ligatures, which 
 Avere cut off and returned after dividing 
 the pedicle. The uterus then appeared 
 to be of normal size, and both ovaries 
 Avere normal. The patient recovered 
 Avithout fever, sickness, or pain, and the 
 only dressing Avas a Aveek after the opera- 
 tion, Avhen the stitches Avere removed. 
 
 Flbro-eiistic uterine tumour ; lif/atures; 
 recovery. — In October 1879 I treated a 
 much larger fibro-cystic tumour in the 
 same AA-ay, although there Avas not nearly 
 so distinct a pedicle. The solid portion 
 of this tumour weighed 5 poimds, and the 
 cystlike cavities contained 21 pints of 
 fluid and a great deal of old blood-clot. 
 The patient Avas a Dutch lady, 40 years 
 of age. There Avere extensive adhesions 
 to the abdominal Avail, to omentum, and 
 to several coils of small intestine. The 
 connecting medium betAveen the fundus 
 uteri and the tumour Avas first com- 
 
UTEllINE TUMOUnS 
 
 101 
 
 pressed by 3 pairs of large forceps. After 
 cutting away the tumour, the stump was 
 transfixed and tied in two parts, as the 
 ibrceps were removed. A 3rd ligature 
 was afterwards tied round the other 2. 
 The ends were all cut off close to the 
 knots and returned with the uterus, 
 which was irregularly enlarged to 2 or 3 
 times its normal size. Both ovaries were 
 normal. The patient recovered Avithout 
 one bad symptom, and returned to Holland 
 24 days after operation. I heard of her 
 in August lb84 as quite well. 
 
 riDRO-CYSTIC TUMOUnS, TREATED EXTRA- 
 PERITONEALLY 
 
 Fihro-ajstic tumour of nterus ; clamp ; 
 recovery. — In the case of a German lady, 
 single, 40 years old, from whom I removed 
 in May 1IS75 a fibro-cystic uterine tumour, 
 7v, pounds solid with ll^ iluid, there was 
 u sort of pedicle, or prolongation, from 
 the left side of the fundus uteri, about 
 3 inches broad and |- of an inch thick. 
 This was secured in a large clamp. The 
 patient perfectly recovered, and is still in 
 good health. But the most curious point 
 in the case was, tliat about 6 hours after 
 the operation she appeared to be almost { 
 dead, as if from internal bleeding. On I 
 removing one of the stitches, nothing | 
 but red serum escaped. This continued I 
 to flow in such quantity that a large 
 drainage-tube was introduced, through 
 which the discharge continued to be very 
 free for 3 days. The tube was then re- 
 moved, biit discharge went on until the 
 clamp was found loose in the dressings ; 
 on the 10th day. After this there was 
 gradual improvement. 
 
 Fihro-cystia tumour; clamp ; recovery. 
 —On July'24, 187X, Mr. Cowan of Bath 
 wrote to ask me to see a lady who, by 
 his desire and that of Dr. Swayne of 
 Clifton, was leaving for London that day, 
 in order to consult me. The next day 
 I saw this lady, 39 years of age, suffer- 
 ing consideral)le abdominal pain and diffi- 
 culty of breathing after her journey. 
 She had been married 4 years, and had 
 not been pregnant. The catamenia were 
 regular, and a period was due. She was 
 suffering so much that I did not make 
 a complete examination ; and the next 
 day the suffering was so great that I 
 tapped a large cyst, felt between the 
 ximbilicus and the sternum, and removed 
 19 pints of dark fluid, with which (as 
 
 , the cyst became empty) a little blood 
 was mixed. A large semi-solid tumour, 
 \ reaching a little above the umbilical level, 
 was then felt, and a harder portion was 
 I found in the right iliac fossa, which, 
 by combined external and internal ex- 
 amination and the use of the sound, was 
 ascertained to be the uterus, high up and 
 to the right, closely connected with the 
 lower portion of the tumour, but appa- 
 rently separable the one from the other. 
 
 Mr. Cowan informed me that the ill- 
 ness commenced in the summer of 1870, 
 in Italy, Avhither the patient had gone to 
 recruit after great mental strain. The 
 first symptoms Avere dull pain in the left 
 iliac region, Avith a sense of fulness, pain 
 on pressure, and constipation, followed by 
 a steady increase in size till February 
 1877, when he (Mr. Cowan) found ' fluc- 
 tuation in the left iliac region, and a solid 
 tumour passing down into the pelvis 
 anterior to the iiterus.' There was steady 
 but slow increase ixntil October 1877, 
 when sudden painful swelling of the left 
 leg set in, with acute pain in the left 
 groin. After a fortnight this subsided, 
 but the cyst increased more rapidly, and 
 a solid mass was found to the right of the 
 median liup in the umbilical region. 
 Dyspnoea anu general distress inci'eased, 
 and walkii-g became difficult. 
 
 My diagnosis Avas a multilocular 
 ovarian cyst, displacing the uterus up- 
 wards and to the right. This Avas con- 
 firmed by an examination of the fiuid re- 
 moved by tapping, by Mr. Thornton, Avho 
 reported it as ' not differing in any way 
 from ordinary ovarian fluid, except the 
 blood, Avhich is fresh, and probably from 
 some accidental Avound of a vessel. Noav 
 the blood has settled, it looks like the 
 ordinary " linseed-tea " fluid, and the tests 
 and microscope confirm its ovarian cha- 
 racters.' 
 
 Great relief followed the tapping. 
 The catamenia came on and ceased on 
 Axigust 1. But the fluid began to collect 
 again, and some interference Avith respira- 
 tion became an increasing trouble. Dr. 
 Day examined the chest on August 10, 
 and found some dulness on the loAver 
 part of the left lung, Avhich he attributed 
 to pressure. We therefore decided on 
 removal of the tumour. 
 
 I j^erformed the operation on August 
 12, under spray and Avith strict antiseptic 
 precautions, assisted by Dr. Bantock, Dr. 
 Woodham Webb, and Mr. Cowan of Bath, 
 
152 
 
 UTElfIXE AND OTHER ABDOMINAL TU3I0URS 
 
 Dr. Day admiiiisterinir methylene. By an 
 incision 5 inches long, in the median 
 line between the umbilicus and symphysis 
 pubis, a very thin cyst was exposed. It 
 was bluish in appearance, like the peri- 
 toneum. On tapping it, reddish serum 
 escaped. Extensive adhesions to the 
 abdominal wall above, and to the intes- 
 tines behind and to the left, were sepa- 
 rated, and the empty cyst was drawn 
 out with a mass of solid substance at 
 its base. I then found that both ovaries 
 were healthy ; that the uterus was about 
 twice the normal size, irregularly nodu- 
 lated and hardened ; and the tumour was 
 an outgrowth from the back part of the 
 fundus. The connecting medium or 
 pedicle was fully an inch in length, and. 
 about 2 inches in breadth and 1 in thick- 
 ness. I .secured this in a large clamp and 
 divided the attachment. Then 1 had to 
 dissect off the back part of the tumour 
 from the sigmoid flexure of the colon and 
 from the rectum, with scissors. In doing 
 this, I accidentally made an opening into 
 the upper p u-t of the rectum, about an 
 inch long, but sewed it up immediately 
 with an uninterrupted suture, carefully 
 sponged out the peritoneal and pelvic 
 cavities, secured seveial bleeding vessels 
 in parts where adhesions had been sepa- 
 rated, and closed the wound by silk sutures 
 around the clamp, which lay at the lower 
 angle of the closed Avound. 
 
 Dr. Woodham Webb examined the 
 tumour, and reported as follows : ' Weight 
 of solid, 2^- pounds ; fluid contents, 14 
 pints. The tumour wa.s an outgrowth 
 Irom the upper and back part of the 
 uterus, about 7 inches long, 4 broad 
 at its widest part, and at one point 
 2 inches thick. It was of a flattened 
 lozenge shape, and consisted of uterine 
 tissue very .slightly changed in appeai'ance. 
 It was surroimded liy ,'5 large c} sts, which 
 had developed on its surface, 2 of about 
 equal size and 1 not more than half that 
 of the others — the -'i having contained 
 14 pints of a red serous fluid. The 
 walls of the 3 cysts were thin, with 
 a fine layer of muscular tissue, sj^read 
 out in irregular bundles between the 2 
 serous membranes — the peritoneum and 
 the cyst lining. Inside the cysts, on the 
 solid mass, were several ecchymosed spots, 
 the lining membrane being detached and 
 giving rise to .small secondary cysts. There 
 were a few nodules of fibrous tissue in 
 various parts of the cjst- walls.' 
 
 The progress after operation was one 
 of uninterrupted recovery. The highest 
 temperature was 100"2°; the most rapid 
 pulse, 108. The clamp came off on the 
 eighth day. The wound above the clamp 
 healed by first intention. Thymol gauze 
 was the only dressing used. 
 
 Writing to me, December 5, 1878, the 
 patient says : ' I am wonderfully Avell, 
 and am getting back my walking powers. 
 I have not felt so well nor in such spirits 
 for years past.' She was still quite well 
 in the summer of 1881. 
 
 SUPRA-VAGINAL AMPUTATION OF UTEUUS 
 WITHOUT OPENING THE CAVITY 
 
 Amjnif.aiion ; cavil;*/ not opened ; inira- 
 peritoncal iif/atiire ; recovery. — In a case 
 where the tumour was removed without 
 opening the uterine cavity, the bleeding was 
 arrested temporaxily by pressure- forceps. 
 Ligatures were afterwards tied upon all 
 bleeding vessels as the forceps were re- 
 
 moved, and I took away a solid fibrous 
 tumour, which, after about 3 pints of blood 
 had drained from it, measured 2'J inches 
 in the longest, and 24 in the shortest, cir- 
 cumference. I performed the operation 
 in August, 1870, at Kidderminster, assis- 
 ted by Mr. Stretton. The right ovary, 
 wliich had adhered to the outer surface of 
 the tumour, was cut away. The uterus 
 left was \cry small, and its cavity was not 
 
UTERINE TUMOUES 
 
 opened. The tumour was a solid mass of 
 dense wliite fibrous tissue, and after tlie 
 greater part of it had been cut away its 
 base was shelled out from a layer of 
 i;terine tissue about a third of an inch 
 in thickness, showing that the fundus 
 had been expanded over an intra-mural 
 fibroid. This patient recovered with as 
 little illness as after an ordinary ovario- 
 tomy, and has remained Avell. 
 
 Amputation; cavil ij not opened; extra- 
 peritoneal compression; recovery. — I ob- 
 tained an equally successful result after 
 removing a solid fibroma, weighing 30 
 pounds, nearly circular, measuring 40 
 inches in the longest and 08 in the shortest 
 circumference, but by extra-peritoneal 
 treatment. I operated in November 1884, 
 assisted by Mr. Meredith and Mr. Jen- 
 nings, The incision measured 11 inches. 
 Extensive parietal adhesions were sepa- 
 rated ; two pieces of adherent omentum 
 and one of small intestine were also sepa- 
 
 rated. A broad attachment of the fundus 
 iiteri was first surrounded by an elastic 
 ligature. The tumour was then cut 
 through about 2 inches beyond the liga- 
 ture, and after the abdominal wall had 
 been nearly closed by sutures, the base of 
 the growth was shelled out from the ute- 
 rine wall. Doubting Avhether extra, or 
 intra, peritoneal treatment of the stump 
 
 would be preferable in this case, I re- 
 moved tlie elastic ligature. Such very 
 free bleeding came on from the whole of 
 the surface from which the growth had 
 been shelled out, that I put on a wire 
 compressor, and fixed the stump in the 
 lower angle of the wound. I also fixed 
 
 the peritoneal coat of the uterus, close to 
 the compressing wire, to the peritoneal 
 coat of the abdominal wall on each side of 
 the incision. The uterus as left was 
 rather large and irregular in outline. The 
 ovaries and Fallopian tubes were not 
 touched. Daily tightening of the wire 
 compressor, paring aAvay portions of the 
 stump, and applying perchloride of iron, 
 made a very tedious contrast with cases 
 treated intra-peritoneally ; and it Avas not 
 until the 28th day that the w^ire could be 
 removed. I saw this patient in March 
 1885. She Avas quite Avell. 
 
 Amputation ; cavity not opened ; intra- 
 peritoneal ligature ; recovenj. — The next 
 case is one of almost unexpected, but 
 complete, recovery. In May 1876 a 
 married lady, aged 38, called on me Avith 
 a letter from Dr. Birch, of Hazaribagh, 
 in India, imder Avhose care she had 
 been since May 1875. She Awas married 
 in 1871, Avent to India in the same year, 
 had never been pregnant, but remained 
 in good health until sne suffered from 
 lever in September 1874. In February 
 
154 
 
 UTEIIINE AND OTHER ABD031INAL TUMOURS 
 
 1875, Dr. Ewart, of Calcutta, discovered 
 an abdominal swelling which he thought 
 might poi'sibly be early pregnancy, al- 
 though there had been no irregularity 
 in menstruation. The SAvelling increased 
 rapidly in 1875, and when I saw her 
 in May 187 G the uterus was evidently 
 enlarged to the size in the fifth or sixth 
 month of pregnancy. As there were 
 no ui-gent symptoms, she returned to 
 India, and I did not see her again 
 until May 1877. There had been 
 some slight increase in the size o£ the 
 uterus, and menstruation was becoming 
 rather profuse ; but she remained in fairly 
 good health till July 1878, when her 
 general health suffered after much anxiety 
 and over-exertion ; but she got over this, 
 and went through 1879 pretty well. In 
 June 18S0, the tumour having consider- 
 ably increased in size, Sir W. Jenner saw 
 her with me in cons»;ltation as to the 
 question of operation, and it was decided 
 that there should be further delay, but 
 that the tumour should be removed as 
 soon as it became intolerable. IMenstrua- 
 tion became still more profuse, size in- 
 creased, she lost fle.'-h, became imable to 
 take any but very short walks, the feet 
 swelled, and purpuric spots appeared on 
 the legs. In December 1880, at another 
 consultation with Sir W. Jenne::, we 
 found a large solid tumour, reaching quite 
 up to the ensiform cartilage, and an ovary 
 could be felt and moved in each iliac 
 region. The uterine cavity was slightly 
 elongated, but I thought the tumour and 
 part of the fundus uteri might probably 
 be removed without opening this cavity. 
 It was agreed tliat I should attempt to 
 remove the tumour ; but that, if the difli- 
 culty proved to be greater than I expected, 
 I should then remove both ovaries in the 
 hope of thus leading to atrophic change 
 in the tumoui-. We waited Tuitil after 
 the cessation oi" another menstrual period, 
 and I then wont into Gloucestershire, and 
 operated on February 12, 1881: After 
 making an incision i'rom 2 inches above 
 to G inclu's below the umbilicus in the 
 median line, the enlarged solid uterus was 
 exposed, free from adhesions, but covered 
 by very large veins, and there was no 
 distinct neck to the tumour or fundus. 
 The left ovary was large, and both were 
 easily separable from the tumour. My 
 first intention, accordingly, was to be 
 satisfied with removal of both ovaries, and 
 leave the uterus alone. On drawing up 
 
 the left ovary, a cyst, or corpus rubrum, 
 in it burst, and much black clot was 
 pressed out. I then transfixed, tied the 
 connecting tissues between the ovary and 
 the enlarged uterus, and cut the ovary 
 away. Very free bleeding followed, and 
 successive ligatures cut through a soft 
 venous plexus. Itherelbre felt compelled 
 to remove the tumour, and, after applying 
 on each side, before and behind, 4 
 pairs of large pressure-forceps, I ampu- 
 tated the tumour, cutting through the 
 fundus uteri diagonally from the right 
 Fallopian tube, downwards and to the 
 left of the bleeding surface, where the leit 
 ovary had been attached. The uterine 
 cavity was not opened. Part of the fundus 
 and the body lel't Avith the cervix were 
 normal in size and consistence. The left 
 Fallopian tube was removed with the 
 tumour. The right remained ; and the 
 right ovary, although rather large, was 
 not disturbed. Theoretically, it might 
 have been better to remove it ; but I was 
 very unwilling to prolong a serious opera- 
 tion by anything not absolutely necessary. 
 Several very large arteries and veins were 
 secured, some by ordinary ligature of 
 carboliscd silk, some by ligature after 
 transfixing the uterine tissvie ; and then 
 the peritoneal edges of the divided 
 fundus Avere brought together by suture. 
 Although a great deal of blood was lost, 
 the lips never lost their colour, and there 
 was no vomiting. The patient was exactly 
 an hour imder the influence of the anics- 
 thetic, and Dr. Day told me that he had 
 never given so much methylene before at 
 any of my operations. Nearly two ounces 
 were used. I did not make any provision 
 for drainage, as I had carefully sponged 
 away all blood and clot; and the wound 
 was -united in the usual Avay by silk 
 sutures. Phenolised spray was used, 
 phenolised sponges, ligatiu'cs, and instru- 
 ments, and dry dressing. The tumour 
 was a solid fibroma, with several projec- 
 tions or outgrowths from the peritoneal 
 surface. It weighed llv> lbs. 
 
 The patient was left in charge of Dr. 
 Forty, of Wotton-under-Edge, and re- 
 covery was not interrupted by any bad 
 symptom. The temperature reached 101°, 
 and the pulse 104, on the third day; but 
 the convalescence may be said to have 
 been without fever. I saw the lady in 
 London on April 28th, quite well, and 
 with nothing but the linear cicatrix in the 
 abdominal wall to be detected as showing 
 
UTEEINE TUMOURS 
 
 155 
 
 that there had ever been any disease of 
 the iiterus. The cervix was mobile, and 
 nothing abnormal could be discovered 
 anywhere. The catamenia appeared as 
 usual the fii-st Aveek in May, after an 
 interval of three months, and passed olF 
 normally. The lady called on nie in 
 London in September 188-1, having con- 
 tinued in excellent health, menstruating 
 regularly luitil the end of 1883. 
 
 Amptitation ; cavity not opened; intra- 
 j)eritoneal treatvient ; recoi'>ery. — In the 
 following case, operated on June 27, 
 18S1, the operation might have been 
 described in exactly the same terms, 
 except that the left ovary v/as left 
 Avith the remnant of the uterus in this 
 case, while the right ovary was left un- 
 touched in the preceding case. Both may 
 be described as supra-vaginal amputation 
 of the uterus with removal of one ovary. 
 The lady was a widow, 52 years of age, 
 but still menstruating regularly and pro- 
 fusely, mother of 4 children, the youngest 
 of whom was 2G years old. She was sent 
 to me by Dr. Kidd on account of severe 
 flooding at every monthly period, which 
 went on to faintness, and was' followed by 
 extreme exhaustion. Sir W. Jenner saw 
 her with me ; and, on the risk of the 
 operation for the removal of the large 
 uterine tumour being explained to her, 
 she decided to wait. She went to Switzer- 
 land, and almost died at Berne from very 
 alarming haemorrhage. As soon as she 
 Avas able to travel she returned to Eng- 
 land, determined to submit to the opera- 
 tion which I have already alluded to. 
 The recovery was i;n interrupted except 
 by a very troublesome irritation of the 
 bladder. She Avas obliged to travel to 
 Davos-Platz in October 1881 Avith an 
 invalid relative, and although she suffered 
 at first from living at such an elevation, 
 she Avrote to me on December 15, 1881, 
 saying, ' The pain in the bladder scarcely 
 gives me any trouble, and I have seen 
 nothing at the monthly periods. Indeed, 
 the only inconvenience arising from the 
 operation is the necessity for Avearing a 
 belt ' in consequence of the threatening of 
 a ventral hernia at a Aveak part of the 
 cicatrix in the abdominal Avail. This 
 annoyed her so much that in the summer 
 of 1882 I removed the bulging part of 
 the cicatrix, Avhich Avas very thin, thus 
 opening the peritoneum for about 2 
 inches, and brought the edges of the 
 opening together by several sutures. No 
 
 bad symptom folIoAved, but firm union. 
 No truss Avas afterwards necessary, and 
 I saw this lady in November, 1884, in 
 excellent health. 
 
 Av^putation ; cavity not opened; death. 
 — In one other case of removal from a 
 married lady 35 years of age, of a large 
 solid uterine fibroma, Aveighing betAveen 
 15 and IG pounds, and Avliich had been 
 surrounded by ascitic fluid, I have to 
 record an almost sudden death from shock 
 and haemorrhage. The patient died a fcAv 
 minutes after being placed in bed. Na 
 very great amount of blood was lost, but 
 the patient took methylene very badly, 
 and I think she was injuriously affected 
 by the cooling influence of the spray. 
 
 Solid outgroivth from fundus ; cavity 
 not opened ; intra-peritoneal treatment ; 
 recovery. — Among the solid tumours re- 
 moved, not on account of their size, but be- 
 cause of the extreme suffering they caused ^ 
 I may mention the case of a married lady 
 40 years of age, from Avhom I removed, in 
 July 1882, a solid outgrowth from the fun- 
 dus Avhich Aveighed only a pormd and a 
 quarter. She was married Avhen only 22 
 years of age, and had never been pregnant. 
 The catamenia had been quite regular, but 
 very abundant, and lasting about 7 days. 
 She had suffered for many years from ex- 
 cessive pain in the right side of the abdo- 
 men and right loin, which had been attri- 
 buted to pressure on the right kidney or 
 ureter, so that for many months she had 
 been obliged to take on an average 150 
 minims of Squire's Solution of Bimeconate 
 of Morphia daily. In the intervals between 
 the menstrual periods there Avas a constant 
 discharge of offensive viscid greenish secre- 
 tion, accompanied by great depression of 
 spirits. No tumour could be felt by the 
 vagina, but a solid tumour was felt in the 
 right iliac region and in the loin, all 
 movements of Avhich immediately caused 
 corresponding movements in the cervix 
 uteri. The uterine cavity Avas not 
 elongated. After exposing this tumour 
 as in ovariotomy, I found that it Avas an 
 outgrowth from the fundus uteri toAvards 
 the right side above the Fallopian tube. 
 Temporarily compressing the neck by tAVQ 
 pairs of large forceps, as shoAvn in the 
 Avoodcut, the tumour Avas cut aAvay about 
 half an inch above the forceps. Trans- 
 fixing between the points of the tAVo 
 forceps with a large needle carrying a 
 double strong silk ligature, each ligature 
 Avas tightened beloAV the forceps, and as 
 
106 
 
 UTERINE AXD OTIIEll ABDOMINAL TUMOURS 
 
 the forceps were siiccessi%'^ely removed the 
 ligatures were still further tightened be- 
 fore the second knot was made. A third 
 ligature was then applied close behind 
 the other two. The peritoneal edges 
 of the stump were then brought to- 
 gether by a few points of uninterrupted 
 suture of fine silk. The uterus, Fallopian 
 tubes and ovaries appeared then, with the 
 exception of the sutured spot, to be cjuite 
 normal. Eecovery was uninterrupted at 
 first. The sutures were removed on the 
 7th day, and the wound appeared to be 
 firmly united, but on the following day she 
 made some straining effort during defeca- 
 
 tion, the wound partly reopened, and there 
 was a considerable escape of intestines. 
 I replaced them within an hour o£ the 
 accident, inserted fresh sutures, and re- 
 covery hardly seemed to be delayed. All 
 the old symptoms disaj)peared, and the 
 health greatly improved. The catamenia 
 appeared regularly, but there has been fre- 
 quent suffering from a troublesome neural- 
 gic affection of the bladder. Neither has Sir 
 Henry Thompson, who carefully examined 
 her, nor have I been able to discover any 
 cause for this condition. It was greatly 
 
 relieved this summer by a visit to Ems, 
 and though still coming on frequently after 
 passing water, she has been able entirely 
 to give up the use of morphia. 
 
 Fibroma of fundus ; cavity not 
 opened; extra-peritoneal treatment ; death 
 IHtli day. — On February 2, 1885, assisted 
 by I\Ir. Hough and Mr. Green, of Derby, 
 chloro-methyl being administered by Dr. 
 Lathbury, of Breaston, I removed from 
 a single lady, 43 years of age, a myo- 
 fibroma containing a cystlike cavity at 
 the upper part, which had caused great 
 suffering for many years, much increased 
 latterly. There Avas no pedicle. The 
 tumour was a prolongation of the fundus 
 uteri above the right Fallopian tube. Two 
 pins were passed, as shown on page 153, 
 but instead of the wire and compressor, an 
 indiarubber ligature was tied behind the 
 pins, and the stump and peritoneal coat 
 of the abdominal wall were fastened to- 
 gether by sutures. The patient went on 
 remarkably well for several days under 
 Dr. Lathbury's care, but on the day after 
 the sutures were removed the wound 
 partly reopened and intestines escaped. 
 Dr. Lathbury reapplied the sutures, and 
 the accident did not appear to have done 
 much harm ; but death occurred on the 
 LSth day. The stump had separated 
 three or four days previously. 
 
 SUPKA- VAGINAL AMPUTATION OF UTERUS ; 
 CAVITY OPENED 
 
 Solid ahdomiaal tumour ; part of litems 
 and both ovaries re7noved ; cavity opened ; 
 long ligatures ; death 4 days afterwards. 
 — On September 9, 18G1, 1 was consulted 
 by a married lady from Liverpool, re- 
 specting an abdominal tumour which gave 
 her the appearance of being quite at the 
 end of pregnancy. It appeared to be solid. 
 The girth at the umbilicus was 41 inches, 
 the measurement from pubes to umbilicus 
 was 10 inches, and irom umbilicus to 
 sternum 9 inches. The tumour moved 
 freely beneath the abdominal wall. Pro- 
 fessor Pirrie, of Aberdeen, called on me 
 during the first visit of this patient, and 
 saw her with me. She told us she was 
 33 years old, had been married 14 years, 
 but had never been pregnant, and had 
 never menstruated before her marriage, 
 nor until 10 years after it. Yet for the 
 last 4 years she had been tolerably re- 
 gular, the quantity and character of the 
 discharcre beino: normal. For about a 
 
UTERINE TUMOURS 
 
 ■J I 
 
 week before each period, she was accus- 
 tomed to suffer pain in the back, which 
 lasted during tlie fiow, but after it ceased 
 she was always decidedly better for two 
 or three weeks. She remarked that she 
 was larger about the time menstruation 
 commenced, but attention was not called 
 to the abdomen for another year. Then 
 she began to lose flesh and colour, and 
 Dr. Battle, of Liverpool, saAV her. For 12 
 or 18 months increase was slow. In 
 January 18G1, she became seriously ill, 
 and in May went to Dr. Clay, of Man- 
 chester, who told her that she had ovarian 
 disease in an advanced stage, but advised 
 delay on account of the solidity of the 
 tumour. I also thought the tumour was 
 ovarian, biit its extreme solidity led me 
 to explain to the patient that a large in- 
 cision would be necessary for its removal, 
 and that therefore the operation would be 
 additionally hazardous. Professor Pirrie 
 concurred with this opinion. She re- 
 turned to Liverpool, but suffered so much 
 that she returned to town in October 
 detei-mined to have the tumour removed. 
 I then became more doubtful as to its 
 nature, but even more convinced than 
 before from its mobility that it could be 
 taken away, and I operated on October 14, 
 1861. Mr. Cooke, of Charlwood. Street, 
 gave chloroform, and I was assisted by 
 Mr. Henry Smith and Dr. Rogers. By an 
 incision 10 inches long, from 2 inches 
 above the umbilicus, a solid non-adherent 
 tumour was exposed and. turned out 
 without difficulty. It proved to be a 
 fibroid outgrowth from the fundus of the 
 uterus, and I passed, the chain of an 
 ecraseur around a sort of stem just where 
 the body of the uterus becomes continu- 
 ous with the cervix. As the chain was 
 tightened, the shaft of the instrument 
 bent, and it became useless. I therefore 
 substituted for it a very large clamp, and 
 cut the tumour away. Some oozing of 
 blood from the cut surface of the stump 
 led to a further tightening of the clamp, 
 when the instrument broke, and we had 
 copious haemorrhage from very large 
 vessels. But they were all tied, and the 
 wound was closed by pins and sutures, 
 the ligatures being iDrought out at the 
 lower angle. 
 
 The tumour was quite solid, and 
 weighed 27 pounds. It consisted of the 
 fundus uteri greatly enlarged, with both 
 Fallopian tubes, and with both ovaries, 
 about twice the natural size, adherinor one 
 
 on each side of the uterus, and contain- 
 ing clots. The growth of tlie fundus, while 
 the cervix remained of the natural size, 
 had led to a sharp line of demarcation, or 
 deep sulcus, in (he body of the uterus. 
 It was here that the separation had been 
 effected, .so that the os and cervix felt 
 perfectly normal after the operation. 
 
 The patient rallied tolerably well 
 after the operation, and became fairly 
 comfortable in the afternoon after 2 opiate 
 enemas, and passed a pretty good night. 
 
 On the first day after operation she 
 was pretty well all day ; warm and per- 
 .spiring; the pulse from 110 to 120; 
 some tympanites, but no vomiting, and 
 having a natural quantity of urine re- 
 moved by catheter. Towards evening 
 the p;dse became feebler, and there was 
 some dyspnoea with somnolence, althouo-h 
 no opium had been given since the morn- 
 ing. Beef-tea was injected into the 
 rectum. On the second day she was said 
 to have had a good night, sleeping a 
 good deal, but the pulse was 130, and 
 occasionally intermitted. She had also 
 vomited 2 or 3 times during the night. 
 Her aspect was good, the skin comfortably 
 warm, and she had no pain, but com- 
 plained of great Aveakness. In this state 
 she continued, most assiduously supported 
 by Mr. Cooke, but continuing to get 
 weaker and weaker, until she died 4 days 
 after the operation. No post-mortem ex- 
 amination Avas permitted. 
 
 Amputation ; cavitij opened ; death 6 
 months after. — In one case I removed 
 the fundus and body of the uterus, en- 
 larged to the size of an adult's head, by 
 Avhat we believed at the time to be an 
 innocent myoma. The patient recovered 
 Avell from the operation, but died 6 months 
 afterwards of cancer of the cervix. The 
 operation Avas performed in May 1869. 
 
 Amputaiion; clamp and ligatv7-e ; re- 
 covery. — The next case Avas treated extra- 
 peritoneally by the clamp. I operated at 
 the Samaritan Hospital in April 1874. 
 Dr. Keith, of Edinburgh, and Dr. Made- 
 lung, of Bonn, Avere present. The patient 
 had been married 7 years, Avas 33 years, 
 of age, but had never been pregnant. 
 The operation Avas begun as an ordinary 
 ovariotomy. A solid tumour Avas covered 
 by omentum, the veins of Avhioh Avere 
 very large. On pushing this aside the 
 peritoneum Avas seen to be studded all 
 over Avith small hard bodies like mustard 
 seeds. After separating, tying, and 
 
158 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 dividing the shreds of omentum, the 
 tumour was brought out entire. Its base 
 or neck was secured in the largest size 
 clamp, which was fixed outside. On 
 cutting away the tumour just above the 
 clamp, I found that I had cut through 
 the uterine cavity, which was in the 
 centre of the fibroid mass. The right 
 ovary Avas just below the clamp. This, 
 with the tube, was secured by a double 
 ligature, which was tied to the arc of the 
 clamp. Part of the stump which pro- 
 jected above the clamp was then cut 
 away, and was found to include the uterine 
 cavity quite down to the neck, so that the 
 clamp must have compressed part of the 
 cervix uteri. The tumour was a fibro- 
 myoma which weighed 11-^ pounds. The 
 clamp did not come off till the 15th day, 
 and part of the double ligature not till the 
 oOth day after the operation. The patient 
 went home well in 6 weeks, and Mr. 
 Soper, of Dartmouth, wrote to me in 
 July 1.S78 that she had enjoyed good 
 health since the operation. 
 
 Amputation; cavitij opened ; death. — 
 In one case which I operated on in July 
 1877, removinga uterine fibroid, weighing 
 12 pounds, and both ovaries, the uterine 
 cavity being in the middle of the tumour 
 the treatment was extra-peritoneal, a long 
 needle with an ecraseur chahi behind it 
 acting as a clamp. The patient died on 
 the 3rd day, of septicaemia. 
 
 Between 1H78 and 1880 I adopted 2 
 important modifications in the operative 
 procedure — first, the more complete use 
 of antiseptic precautions ; and, secondly, 
 the ' union by suture of the peritoneal 
 edges of the divided viterine wall. I also 
 contrived better pressure-forceps for se- 
 curing divided blood-vessels before tying. 
 In a paper read at the Cambridge meet- 
 ing of the British Medical Association, in 
 August 18,S0, and published in the Joiu-nal 
 of the Association, September 4, 1880,1 
 said,- ' Whatever doubt some may entertain 
 as to the value of my experiments on 
 animals, and practice on women, in leading 
 most operators in the present day to bring 
 divided edges of peritoneum together 
 whenever they have been separated by 
 wound or by operation, I myself have no 
 doubt whatever about it ; and just as 
 strongly as I assert that it is, .and must be, 
 better Avhen theal)dominal wall is divided 
 to bring the ])eritoneal edges and surfaces 
 of the opening together, restoring the 
 complete closure of the peritoneal cavity. 
 
 than to leave the cavity free to the ad- 
 mission of fluids oozing from wounded 
 muscle, fat, and cellular tissue, and to 
 allow contact of intestine and omentum 
 with anything more than peritoneum ; so 
 strongly — more strongly if I could — would 
 I insist that the peritoneal edges of the 
 divided uterine wall, or of the connecting 
 part of the outgrowth Avith the uterine 
 wall, should also be carefully brought 
 together ... by many sutures, or by un- 
 interrupted suture along the whole extent 
 of the gap.' In concluding that paper I 
 alluded to a case then under observation, 
 wliich I brought forward partly to illus- 
 trate the advantage of completely uniting 
 by suture the divided edges of the peri- 
 toneal wall, and partly to argue that, when 
 the uterine cavity has been opened, it is 
 better not to close the raucous surfaces 
 also by sutures, after the method of 
 Schroder, as the opening left for some oozing 
 of blood through the vagina may some- 
 times be useful. A few more details of 
 this case may be now given. 
 
 Amputation; cavitij opened; i^eritoneum 
 sewn over stump ; recover//.— On June 9, 
 1880, I saw a married lady, aged G2, in 
 consultation with Dr. Richard Smith, of 
 TIaverstock Hill, who had been called 
 in about a fortnight before, on account 
 of uterine hemorrhage. This, alter 12 
 years' absence, had come on at the end of 
 1879, and had recurred since every 3 
 weeks, lasting 1 week. She had consulted 
 an obstetric physician 4 years before, who 
 said that there was 'ovarian enlargement.' 
 She had been married twice, had 1 child 
 by her first husband 29 years ago, and 
 had never been pregnant since. With the 
 return of the uterine ha;morrhage there 
 occurred 'enlargement of the abdomen, 
 Avhich increased rapidly, loss of flesh, 
 shortness of breath, and very obstinate 
 constipation. The girth of the abdomen 
 at the most prominent part was 42 inches. 
 Tlie uterine cavity only measured 2^ 
 inches, but the cervix moved in all direc- 
 tions with a large semi-solid tumour, 
 which filled the whole abdomen quite up 
 to the ensiform cartilage. I removed the 
 tumour on July 21, 1880, cutting away 
 nearly all the supra-vaginal portion of the 
 uterus, and after tying all bleeding vessels, 
 carefully sewing together the peritoneal 
 edges of the divided uterine wall. For 
 about 3 days afterwards a little bleeding 
 went on through the vagina, but the 
 patient recovered Avilhout any iebrile ele- 
 
UTERINE TUMOURS 
 
 159 
 
 vation of temperature, was in excellent 
 health in iSHl, and so remains. The 
 doubt as to the tumour being ovarian was 
 accounted for by the fact that a large cyst- 
 like cavity in the centre of the tumour 
 contained 13 pints of bloody fluid, while 
 the solid portion weighed only a little 
 more than 2 pounds. I am much indebted 
 to Dr. K. Smith for his assistance at this 
 operation, and for his care of the patient 
 afterwards, as she remained in his charge 
 during my absence irom London, 
 
 Supra-vnr/inal amputation ; peritoneum 
 sewn over cut surface ; death on dth day. 
 — The relative value of extra-peritoneal 
 and intra-ppritoneal treatment of the pedi- 
 cle of uterine tumours, or of the divided 
 
 vessels as they were divided in cutting 
 away the uterus. The vessels were after- 
 wards tied as the forceps were removed. 
 The uterine cavity had been cut through 
 about the level of the os internum, but 
 the peritoneal surfaces were so sewn to- 
 gether by uninterrupted silk suture as to 
 perfectly shut off communication between 
 the peritoneal cavity and the vagina. 
 The patient died on the 9th day, of 
 septicaemia. 
 
 Supra-vaginal amputation of the uterus 
 ivith 2 tumours ; extra -peritoneal treat- 
 ment ; recovery. — In March 1884 I ope- 
 rated upon a lady 34 years of age, who 
 had been married 2 years, but had not 
 been pregnant. She was in extreme suffer- 
 ing from 2 solid tumours, 1 of Avhich was 
 freely movable in the abdomen, extended 
 over the left side up to the left false ribs, 
 
 surface from Avhich the tumour has been 
 cut away, or of the body of the uterus 
 itself in cases of supra-vaginal amputa- 
 tion of the enlarged uterus, with or 
 Avithout one or both ovaries, cannot yet 
 be estimated with anything approaching 
 to certainty. Cases, both tatal and suc- 
 cessful, may be adduced in favour of both 
 methods, and of different modes of carry- 
 ing out the details of each method. In 
 one case, whei'e I removed tbe whole of 
 the supra- vaginal portion of an enlarged 
 uterus with fibroid outgrowths, both Fal- 
 lopian tubes and ovaries, in Jul}'' 1873, 
 Dr. Martin Sims and his son being present, 
 I secured by forceps all the bleeding 
 
 and could be felt in the pelvis between 
 the uterus and the bladder. The other, 
 much smaller, was low down in Douglas's 
 pouch, considerably encroaching upon the 
 rectum. The larger tumour to the left 
 I found was formed by the fundus uteri 
 irregularly eidarged. The smaller tumour 
 behind and to the right was an outgrowth. 
 Both were drawn out together ; a wire 
 was passed round the uterus, just below 
 the outgrowth but above the bladder, and 
 tightened by a screw. Two long pins 
 were pushed through the neck of the 
 tumour above the Avire, and the tu- 
 mours were cut away. The incision 
 went through the uterine cavity, near the 
 
IGO 
 
 UTErJXE AND OTHER ABDOMINAL TUMOURS 
 
 internal os. I did not disturb the ovaries. 
 In uniting the incision in the abdominal 
 wall, the lower suture wag passed through 
 the peritoneal coat o£ the uterus, close to 
 the constricting wire. The mass removed 
 weighed 5 pounds 7 ounces. The patient 
 recovered, but it was more than a fort- 
 night before the pins and wire came 
 away, and whenever the wire was tight- 
 ened she complained of extreme pain. 
 Before the cicatrisation of the wound was 
 complete, a uterine sound could be ea.sily 
 passed from the lower angle of the un- 
 clo.sed wound through the os uteri into 
 the vagina. I saw this lady in September 
 1884, well and strong, not having had 
 any return of menstruation or periodical 
 trouble of any kind, although neither of 
 her ovaries had been interfered with, and 
 
 there Avas nothing in the condition of the 
 cervix uteri, nor anything which could be 
 Ifelt by vaginal examination, which would 
 have led anyone ignorant of what had 
 been done to suppose that the pelvic 
 organs were other wiso than perfectly 
 normal. 
 
 EXUCLEATIOX 
 
 Retro-peritoneal turanur ; enucleated; 
 recovery. — A remarkable case was that of 
 a lady whom I saw in consultation with 
 Mr. Symonds, oE Oxford, in February 
 1878. She was single and 3G years of ase. 
 Her abdomen was enormously enlarged 
 by a solid tumour, which extended up- 
 ward behind the lower ribs on both sides, 
 pressing them outwards, and passed down- 
 
 wards into the pelvi.=, filling up the hollow 
 of the sacrum and causing prolapsus of 
 the posterior wall of the vagina. There 
 was considerable oedema of the feet and 
 legs, which was said to disappear for a 
 time after the cessation of each monthly 
 period. The cervix uteri could not be 
 reached, and it was impossible to ascer- 
 tain where the uterus was situated. The 
 catamenia were regular in time and normal 
 in quantity. Mr. Symonds had advised 
 removal of the tumour in 187G when it 
 was much smaller, but the patient and 
 her friends steadily objected. The first 
 .symptom of illness was in 18G8, when 
 backache became troublesome, and soon 
 after a small tumour was discovered in 
 the left side of the abdomen. The growth 
 went on slowly for some years, but in 
 1877 was much more rapid. When the 
 patient came under our observation in 
 February 1877, I expressed my opinion 
 to Mr. Symonds that, as the tumour Avas 
 quite solid, not fluctuating, and as the 
 uterus could not be found, an accurate 
 diagnosis was impossible, and that only an 
 
 ' exploratory incision could determine as to 
 the possibility of removal. I thought the 
 j tumour more likely to be uterine than 
 I ovarian, and probably some such rai-e 
 I form of abdominal fibroma as I had once 
 ; removed in Germany, and which has been 
 I described by Virchow as fibroma molliis- 
 cum, not necessarily connected with either 
 ' uterus cr ovaries. The decision as to 
 operation being left to the patient, she at 
 first declined, but suffering became daily 
 greater, and it Avas arranged tiiat I should 
 make an exploratory incision on IMarch 7, 
 four days after the cessation of the cata- 
 menia. 
 
 The sketch above, although made of 
 another patient, gives an excellent idea of 
 the appearance of this lady at the time, 
 except that it hardly shows how much the 
 tumour encroached on the thorax, and not 
 at all the oedema of tlie legs. 
 
 Mr. Symonds and Mr. Hill being pre- 
 sent, an incision Avas made in the median 
 line between the umbilicus and pubes, 
 and I cut into the substance of a solid 
 tumour Avhich was closely adherent to the 
 
UTERINE TUMOURS 
 
 IGl 
 
 abdominal wall. After separating some 
 adhesions, I passed my hand into the 
 peritoneal cavity and found the tumour 
 to be free from adhesions on the left side, 
 also behind and above, but to be closely 
 l)Ound down on the right side. In i'ront, 
 the bladder was so high that the incision 
 could not be carried within about 4 to 5 
 inches of the pubes. So it was extended 
 upwards, about 5 or G inches above the 
 umbilicus, as soon as I had convinced my- 
 self that it would be possible to remove 
 the tumour. A large piece of adhering 
 omentum was detached from the upper 
 part and behind. Towards the left side a 
 broad mesenteric attachment was divided 
 by the knife, large vessels being tempo- 
 i-arily secured by torsion-forceps. I was 
 then able to shell out the tumour from a 
 sort of vascular capsule, formed by two 
 layers of the right broad ligament, and 
 separate it, but only by the knife, from 
 the posterior surface of a uterus of normal 
 size, after forcibly pulling the tumour up 
 out of the pelvis and separating it from 
 the rectum, to which it adhered closely. 
 The right ovary (although normal) was 
 cut away because the Fallopian tube had 
 been divided and the broad ligament was 
 much torn. The left ovary and Fallopian 
 tube were not disturbed. Several silk 
 ligatures were applied to the right of the 
 uterus, and also to open vessels on its 
 posterior surface Avhere the tumour had 
 been cut away. Two large pieces of 
 omentum Avere cut off after securing 
 them by ligature. I then found that the 
 two opposite sides of the remnant of the 
 capsule of the broad ligament (out of 
 Avhich I had enucleated the tumour) could 
 be brought together behind the uterus, so 
 as to complete the union of the divided 
 peritoneum from the lower angle of the 
 opening in the abdominal wall, over the 
 elevated bladder and the fundus uteri, 
 all down the back of the uterus to the 
 rectum. I did this by an uninterrupted 
 suture of fine silk, making about 20 
 points of suture, and finishing close to 
 the vagina and rectum. In this way the 
 peritoneal sac was completely shut off 
 from the torn cellular tissue of the pelvis. 
 A good deal of spongmg Avas necessary to 
 remove clots of blood from the peritoneal 
 cavity ; but very little blood was lost 
 considering the great size of tiie tumour 
 and the extent of its attachments. The 
 opening in the abdominal wall was closed 
 by 25 silk sutures. The patient was 
 
 placed in bed exactly an hour fiom tlie 
 minute Avhen she began to inhale methy- 
 lene. She was faint and very chilly, a 
 spray of a solution of thymol (1 in 1,000 
 of water) having played upon the abdo- 
 men all through the operation; and, al- 
 though sponges moistened with warm 
 thymol solution protected the abdominal 
 cavity to some extent, the chilling effect 
 of the spray was manifest. 
 
 Upon examining the tumour it was 
 found that about 2 pounds of blood had 
 drained from the vessels divided in its 
 capsule, and at its line of separation from 
 the uterus. Its circumference, in o 
 different directions, was 52 inches at the 
 smallest, 57 inches at the largest, and 53 
 inches in a third. A small piece was cut 
 out for microscopical examination, and 
 the tumour Avas then Aveighed in the 
 museum of the JMiddlesex Hospital, and 
 found to be G8 pounds 6 ounces. The tu- 
 mour Avas ' chiefly composed of cells Avith 
 relatively large nuclei, many containing 
 several nucleoli of the type difficult to 
 distinguish as distinctly muscular; but 
 in some parts cf the tumour imstriped. 
 muscle-ceils Avere manifest.' (J. K. 
 Thornton.) I have A^ery little to add. 
 as to the progress after operation, except 
 that the temperature seldom rose above 
 99°, only reaching 101-2° (the highest 
 noted) once. Only 4 opiates Avere given. 
 There Avas never any distension of the 
 abdomen. Six days after operation, the 
 bandage and dressing Avere removed for 
 the first time. The 4 or 5 layers of 
 thymol gauze next the skin were damp 
 with serum; the outer layers were quite 
 dry. The wound A\-as united, from top to 
 bottom. All the 25 sutures were removed, 
 and the line of union Avas almost imper- 
 ceptible. The dressing Avas only changed 
 twice after this; and, except a feAV drops 
 of pus from one of the central stitchholes, 
 union Avas perfect by first intention. 
 
 For a few days in the 2nd and 
 3rd Aveek after operation the patient 
 occasionally vomited, Avas Aveak and low- 
 spirited, and there was a considerable 
 swelling in the pelvis, as if from a ha?ma- 
 tocele in front of the rectum, to siich an 
 extent that the uterus could not be felt. 
 Thei e were frequent A^ery offensive Avatery 
 motions, but never any purulent discharge. 
 When the SAvelling in the pelvis began to 
 subside, and after washing out the rectum 
 with thymol solution, rapid amendment 
 set in a-^.d Avent on. Two days before she 
 
162 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 left London by rail for Oxford, on April 8, 
 just a month after operation, I carefully 
 examined the pelvis by vagina and rectum, 
 and really could not find any ti-ace of an 
 operation having been performed. The 
 uterus was in its normal position, was 
 movable, and of ordinary size and weight. 
 She wrote herself in May, saying ' I am 
 able to wallc a little, and get out in the 
 air as much as possible.' But improve- 
 ment did not continue ; a pelvic abscess 
 formed, which was not opened, and she 
 died in August. 
 
 Mural fibroid, removed ivith the r/)/Jit 
 ovarij and Fallopian tube ; enucleation 
 from right broad lifiament, a)idthin capsule 
 of uterine fhres; death. — In May 1882 Ire- 
 moved a very large uterine fibroma from a 
 patient of Dr. Grabham, of Madeira, 50 
 years of age, without opening the uterine 
 cavity, only cutting away a thin slice of 
 the uterus close to the fundus, Avith the 
 right Fallopian tube, and the right ovar}', 
 which was attached to the tumour. The 
 anterior surface of the tumour was first ex- 
 posed covered by broad ligament, which 
 contained many very large veins. On 
 dividing the broad ligament, avoiding the 
 veins as much as possible, white fibroid 
 structure was seen, covered by a very thin 
 layer of uterine fibres, forming a sort of 
 imperfect capsule. Cutting away the 
 tumour from the fundus, and applying 
 forceps to the bleeding vessels, the uterus, 
 after the tumour w^as cut off, appeared 
 almost normal in size, shape, and consist- 
 ence. Some bleeding vessels on the 
 surface of the divided fundus were secured 
 by fine ligatures. Other ligatures were 
 applied to vessels in the divided broad 
 ligament. The edges of the ligament 
 were afterwards sewn together by an un- 
 interrupted suture, so as to cover the cut 
 surface of the fundus. The left tube and 
 ovary were not disturbed. The patient 
 died 4 days after the operation, with 
 symptoms of obstructed intestine. No 
 post-mortem examination could be made. 
 
 r..\I'I.Ol:.\TOKY INCISIONS 
 
 In addition to the cases Avhich I have 
 related, where the whole of a tumour has 
 not been removed, or where an outgrowth 
 has been removed and an interstitial 
 growth not interfered with, I have met 
 with cases wliero fibro-cystic tumours 
 have been punctured, the cyst emptied, 
 and nothing more done. In one case, a 
 
 uterine cyst was drained successfully, the 
 patient dying 5 years afterwards of kidney 
 disease. In another similar case, a 
 uterine cyst was successfully drained, but 
 the patient died 4 years afterwards of 
 malignant disease. In 1881, I emptied a 
 very large uterine cyst of blood-clot in a 
 patient of Dr. Burd, of Shrewsbury, and 
 drained it. The patient recovered and is 
 still in good health. 
 
 In another case, a patient of Dr. 
 Andrews, of Hampstead, a single lady, 
 aged GO, I was only able to remove part 
 of a fibroma, after emptying a large cyst- 
 like cavity. The patient died on the ord 
 day. In a patient of Dr. Monro, of New- 
 town, Montgomeryshire, where I could 
 only remove a projecting outgrowth from 
 the main part of the tumour, the patient, 
 who Avas in an extremely feeble condition 
 before the operation, died on the 8th day; 
 and in February 188a, in a lady from 
 Newfoundland, I made an unsuccessful 
 attempt to enucleate a fibroma which in- 
 volved the left side of the fundus and 
 body of the uterus, and was covered by 
 the left broad ligament. I only removed 
 a small part of a very large tumour, but 
 the patient died on the 5th day of septic- 
 aemia. I did not use the spray in this 
 case, but adopted all other usual anti- 
 septic precautions. 
 
 In a table of 31 cases of exploratory 
 incision and partial removal of uterine 
 tumours, published in 1882, in my book 
 on ' Uterine and Ovarian Tumours,' in 
 IG cases nothing more was done than 
 incision of the abdominal wall and re- 
 moval of peritoneal fluid. In 3 cases 
 solid tumours Avere simply punctured. 
 In 1 a uterine vein was Avounded. In 1 
 the bladder Avas Avounded, but with only 
 temporary inconvenience to the jiatient. 
 In 1 case a nodular outgroAvth Avas re- 
 moved, the greater part of the groAvth not 
 being disturbed. In this case the patient 
 Avas much more benefited by the operation 
 than could have been reasonably expected. 
 In the cases Avhcre an incision only Avas 
 made, no harm seems to have been done, 
 and Avhen peritoneal fluid Avas removed 
 the patients were neither better nor Avorse 
 than after a simple tapping. I think it 
 very probable? that if, Avith my present 
 knoAvledge and experience, I had to treat 
 similar cases now, I should do more than 
 I did then. Tiie progress of the opera- 
 tion has been that of gradual development 
 during the last 25 years, and there can be 
 
UTERINE TUMOURS 
 
 163 
 
 iio doubt, as experience increases and the 
 published records of cases carefully ob- 
 served and truthfully recorded increase in 
 number, that quite as certain rules for 
 our guidance "will be established as for 
 any other great surgical operation. As 
 in the history of ovariotomy, so in tliatof 
 myomotomy, there have been periods 
 when the general principles of intra- peri- 
 toneal and extra-peritoneal treatment 
 have by turns fallen into discredit, and of 
 late we have been coming to a sort of 
 understanding that when the tumour can 
 be removed without opening the uterine 
 cavity, intra-peritoneal treatment is pre- 
 ferable ; and that the extra-peritoneal 
 treatment gives better results whenever 
 the uterine cavity is opened. Still more 
 recent experience, especially that of 
 Schroeder and Olshausen, since the elastic 
 ligature has been frequently iised, appears 
 to favour the belief that as in ovariotomy, 
 so in myomotomy, intra-peritoneal treat- 
 ment will be the rule, extra-peritoneal 
 the exception. Here again I Avould 
 repeat that this question can only be 
 settled by careful observation, larger ex- 
 perience, and truthful record. 
 
 SUBMUCOUS INGROWTHS 
 
 towards or into the uterine cavity are 
 quite as common as subserous outgrowths 
 into the peritoneal cavity, or as intra- 
 mural growths. It is not uncommon to 
 see all 3 varieties in the same uterus, but 
 occasionally the ingrowth is the only form 
 of the disease. It, is more commonly 
 attended with serious haemorrhage than 
 either of the other forms, and the hgemor- 
 rhage is generally the symptom which 
 leads to the examination and the discovery 
 of the tumour. Sometimes the os is more 
 or less dilated, and if the growth is pedi- 
 cled, it may be pulled by a hook, or 
 corkscrew, through the os into the vagina. 
 When. the os is not dilated, a sound may 
 sometimes be passed more or less com- 
 pletely round the growth, showing that 
 we have to do with an intra-uterine 
 polypus. In other cases the cavity is 
 more or less blocked up by a mural 
 growth surrounding it, or projecting into 
 it, from one side, or developed in the 
 «ervix, one or other lip of Avhich may 
 project downwards into the vagina. 
 
 Where fibroid ingrowths, or polypi, 
 have a distinct pedicle, the old plan of 
 tying the pedicle and allowing the polvpus 
 
 to slough away is now completely aban- 
 doned. Where the pedicle is hard, and 
 not very large, it may be divided by the 
 scissors, or polyptome, Avith very little 
 risk of bleeduig, and the polypus removed 
 by forceps, hook, or corkscrew. In the 
 larger and softer pedicles I know of 
 nothing which answers so Avell as crush- 
 ing with an ordinary lithotrite, or with 
 Aveling's polyptrite, cutting away the 
 polypus, and leaving the lithotrite tightly 
 screwed on for a few minutes afterwards. 
 I have occasionally put on 1 or 2 pairs of 
 pressure-forceps to a pedicle, either before 
 cutting away the polypus, or when bleed- 
 ing occurred after cutting away, and have 
 left the forceps hanging out of the vagina 
 ibr several hours ; and 1 prefer this 
 method to the more conmion one of 
 applying perchloride of iron and plugging 
 the vagina. 
 
 Where ingrowths projecting into the 
 uterine cavity are covered by the mucous 
 membrane, but have no pedicle, and have 
 been exposed after dilatation of the 
 cervix ; or when they occupy one lip of the 
 cervix, Avhich is thus enlarged and pro- 
 jects into the vagina, the mucous mem- 
 brane over the projecting portion may be 
 divided, either with the knife or with 
 Paquelin's cautery, and ergot may be 
 given. Occasionally in this way a sort of 
 spontaneous expulsion of the growth is 
 obtained. Sometimes the effect of the 
 uterine contractions may be assisted by 
 drawing the growth down by forceps, or 
 hook, while by the finger, or some blunt 
 instrument, the growth is separated from 
 the uterine tissue in which it has been 
 imbedded. In this way I have removed 
 very large solid uterine ingrowths. In 
 one case the growth Avas so large that 
 after I had separated it. Dr. West put on 
 an ordinary pair of midwifery forceps, 
 and in removing the growth the perineum 
 Avas ruptured completely through. I 
 applied 4 sutures immediately, and union 
 Avas' so perfect that the patient knew 
 nothing of the injury. I have twice had 
 to cut up these growths into several pieces 
 before they could be removed from the 
 vagina, and I have several times had 
 difficulty, after separatmg an intra-uterine 
 fibroid from its attachments, in getting it 
 through the os. Once Avith Dr. Lips- 
 combe, Of Tring, Avho had fully dilated 
 the cervix by tents before my arrival, I 
 had succeeded in separating the uterine 
 attachments of an intra-uterine growth as 
 
1G4 
 
 UTERINE AND OTHER ABDOMIXAL TUMOURS 
 
 large as nn infant's head, but could not get 
 it through the os, which appeared to have 
 been stimulated to contraction by my mani- 
 pulation. Fearing to keep up the action 
 of chloroform very long, -\ve allowed the 
 patient a few hours' sleep, and next 
 morning, under a very deep anaesthesia, I 
 cut the tumour into several pieces with 
 strong scissors, and thus removed the whole. 
 Recovery Avas most satisfactory, but I 
 know of nothing that is more trying to 
 the patience of a surgeon, or more fiitigu- 
 ing, than the performance of one of these 
 operations. In 1884 I removed m.ore than 
 
 00 pounds of a solid fibroid mass in this 
 Avay, from a Spanish lady, a patient of 
 Dr. Leeson, of Dorset Square. She Avas in 
 the very lowest state of prostration from 
 loss of blood before the operation, and 
 the proceeding occupied fully 2 hours. 
 In this case the result was fatal, 
 but I feel certain that in this way there 
 was a better prospect of saving life than 
 there would have been by abdominal 
 section. In May 1884, with Dr. Walker, 
 of Maida Vale, I removed one of these 
 ingrowths almost as large as the last- 
 mentioned, in a similar manner, after a 
 great part of it had become gan- 
 grenous. The gangrenous portion was re- 
 moved one day, antiseptic injections used, 
 and the remainder of the growth was 
 withdrawn a few days afterwards. This 
 patient is now in excellent health, and I 
 attribute her recovery in a great measure 
 to Dr. Walker's assiduous care in keeping 
 up constant irrigation of the vagina and 
 uterine cavity Avith a solution of per- 
 chloride of mercury — 1 in 2,000 — which, 
 after many others had been tried, was 
 found to be the only di.sinfectant that 
 freed the room, or even the house, from 
 the almost insufferable odour. 
 
 Professor Olshausen says that he has 
 performed myomotomy in 3G cases, of 
 whom 12 died. Nine of these cases were 
 pedunculated, of Avhich 8 recovered, and 
 
 1 died. There were 8 cases in Avhich, 
 although there was no pedicle, the uterine 
 cavity was not opened ; of these 4 re- 
 covered and 4 died. Out of 17 cases 
 Avhere the uterine cavity Avas opened, 
 10 recovered and 7 died. Two retro- 
 peritoneal cases, enucleated, both rocoA'ered. 
 Jn 8 cases the pedicle or the cervix uteri 
 Avas secured by elastic ligature, which 
 was left in. In 1.') cases the broad 
 ligament av;is also .secured Avith elastic 
 lijjatiu'es. Jn 2 cases the tiunour.s were 
 
 fibro-cystic ; in all the other cases, .solid. 
 SeA^eral tumours Avere very large: 18, 
 20, 28, 44, and one 50 pounds. The 
 cause of death in 1 case was urcemia, 
 1 ureter having been tied ; in 1, obstructed 
 intestine; in 4, shock; in 1, pulmonary 
 embolism ; in 5, peritonitis and septicemia. 
 
 To sum up shortly the result of my 
 OAvn operative Avork in cases of uterine 
 tumours from I860, when the operations 
 Avere, Avith fcAv exceptions, undertaken 
 unexpectedly in place of the ovariotomy 
 prepared for, or in cases of diagnosi;^ 
 confessedly doubtful before operation, 
 down to the later years when an accurate 
 diagnosis has been made in almost every 
 case, it appears that 50 uterine tumours 
 have been removed Avith the result of 27 
 recoveries and 24 deaths. 
 
 Of the outgrowths, 20 recovered, 17 
 died. Where the uterine cavity AA'a.s 
 opened, G recovered, 3 died. Cases 
 treated extra-peritoneally, 10 recovered, 
 10 died. Cases treated intra- peritoneally, 
 16 recovered, 10 died. 3 cases wherc- 
 the tumour was enucleated died. The 
 notes of 1 case are missing, but I 
 believe it Avas a fibroid Avith a large base, 
 and one ovaiy Avas removed at the same 
 time. The Avoman died of peritonitis. 
 
 The largest tumour Avas retro-peri- 
 toneal, and Aveighed 70 pounds — the 
 patient recovering. 
 
 COMPLICATION OF UTERINE TUMOURS WITH 
 rREGNANCY 
 
 It is not an iinfrequent subject of con- 
 sultation, Avhen an unmarried patient or a 
 Avidow has a uterine tumour, Avhether or 
 not she should marry. Of course the 
 question is much simplified if the patient; 
 has passed the child-bearing age. Wlien 
 under that age two questions arise. The 
 pelvis may he so blocked by the lower 
 segment of the tumour as to be an impe- 
 diment to marital intercourse. When thi.s 
 is not the case, two further questions arise : 
 the 1st, is pregnancy probable ? 2ndly, if 
 it occur, Avould it be dangerous to the 
 mother, or the l)irth of a living child be 
 improbable? All these questions have 
 frequently come before me in consulta- 
 tion. I have known a case Avhero an in- 
 tending husband Avas not stopped by the 
 a.ssurance that not even a catheter could 
 be passed into the vagina; just as, in 
 another case, a young couple insisted on 
 marrvii^.g, although Dr. Farre and I gave 
 
UTERINE TUMOURS 
 
 1G5 
 
 a. written certificate that tlie case was one 
 <i£ congenital absence of the uterus, and 
 ])robably of both ovaries. On the other 
 hand, I have known engagements broken 
 off as soon as one of the parties was 
 informed that a uterine tumour existed. 
 Ill one case, which I attended with Dr. 
 Farre, a widower was informed by us that 
 tlie young lady he proposed to marry 
 had a large uterine tumour, Avhich partly 
 blocked up the pelvis. As he persevered 
 in his desire to marry, she was placed 
 very fully under tlie influence of chlo- 
 rof"orm, and while tlie hips were raised, 
 J)r. Farre succeeded, after very great 
 difficulty, in pushing up the lower part 
 of the tumour above the brim of the 
 pelvis. She married soon afterwards, 
 and Dr. Playfair attended her exactly 9 
 months later, delivering her of a living 
 child without much difficulty. Consider- 
 able diminution in the size of the tumour 
 followed delivery ; the lady went to China, 
 and I have heard that there has certainly 
 been one child, and I believe more, since. I 
 have known other cases Avhere pregnancy 
 has gone on to the full term in patients 
 suffering iirom uterine tumours, even of 
 considerable size, and I do not remember 
 one where there was any great difficulty 
 in consequence, nor any very unusual 
 ha3morrhage. I have notes of 2 cases 
 where tumours of considerable size dimi- 
 nished very rapidly after delivery, almost 
 disappearing in a few weeks — cases so 
 carefully noted by myself and others, 
 that I could have no doubt whatever as 
 to the fact. 
 
 In one case I was called hurriedly to a 
 lady in great pain, and found labour so 
 far advanced that I could not leave her. 
 I sent for Dr. West, but the child was 
 boi'n and the placenta expelled before 
 he arrived. So large a tumour remained 
 in the abdomen that we thought it was a 
 twin, but it proved to be a large uterine 
 tumour, which did not retard the con- 
 valescence of the patient. This tumour 
 Avas very much smaller a few months 
 afterwards. 
 
 The question as to whether pregnancy 
 is likely to occur must be answered in 
 reference to the situation of the tumour, 
 and whether the uterine cavity is much 
 altered in its size and form. But, speak- 
 ing generally, without much statistical in- 
 formation by Avhich one can be guided, 
 and doubting whether Simpson's calcula- 
 tion of a diminished proportion of sterile 
 
 to fertile women fiom 1 in 10 to 1 in 8, as 
 a consequence of the presence of uterine 
 tumours, can be based upon a sufficient 
 number of cases, my own experience 
 would certainly lead me to believe that 
 these tumours not ordy interfere with 
 conception, but frequently lead to abor- 
 tion — and that when pregnancy goes on, 
 delivery Avill not be free from unusual 
 dangers. The surgeon may be content 
 with giving this information, and leave 
 those who are interested in the question to 
 act according to their own judgment. 
 
 The histoiy of one patient whom I saw 
 in 1862, in consultation with Dr. Madge, 
 illustrates the difficulty which may arise 
 when fibroid tumours low down in the 
 pelvis impede delivery. The particulars 
 were laid before the Obstetrical Society 
 by Dr. Madge, and I quote portions of his 
 report. 
 
 'Mrs. II., ajt. 27, primipara, well- 
 grown, in robust health, and who had 
 gone her fall time, was taken with slight 
 labour pains on the morning of May 28. 
 On making an examination in the after 
 part of the day, I found the pelvis occu- 
 pied by a large round tumour, Avhich 
 at first appeared to me to be the child's 
 head. It seemed, however, to be lifting 
 up, as it were, and pushing forwards the 
 posterior wall of the vagina. It was low 
 down, and came lower, but receding again, 
 with every pain. It appeared to fill up 
 every niche in the pelvis, so that the 
 finger could not be passed round it. The 
 OS uteri could not be felt. Next day the 
 tumour was occupying precisely the same 
 position. The pains Avere still slight and 
 not frequent, and, as the patient Avas in 
 her usual health and spirits, it Avas con- 
 sidered advisable to Avait. In the evening, 
 Avith considerable difficulty, by hooking 
 my finger high up behind the symphysis 
 pubis, I Avas enabled to reach the os uteri ; 
 it Avas directed forwards, dilated to about 
 the size of a crown piece, and, as Avell as 
 I could make out, some part of the breech 
 presented. On the following day Dr. 
 West, Mr. Spencer Wells, and Mr. NcAvton 
 met me in consultation. Pains getting 
 more frequent. As some parts of the 
 tumour felt soft and yielding, a trocar 
 Avas introduced, and a small portion of 
 fluid draAvn off. Vain attempts had been 
 made previously to push the tumour 
 above the brim of the pelvis. Chloroform 
 having been administered, and the cathe- 
 ter used, the opening in the tumour Avas 
 
166 
 
 LTEKINE AND OTHER ABDOMINAL TUMOURS 
 
 enlarged, i\Ir. Spencer "Wells was then ' 
 enabled to push the tumour upwards, 
 and, with the aid of a blunt hook, tiie 
 child was brought down by the buttock. ! 
 "When born it had some iaint signs of life, ' 
 but could not be made to breathe. In 
 the early part of the following day the 
 patient seemed, to be doing Avell ; as the 
 day advanced, by fits and starts she 
 became very excited, and could not be 
 persuaded to lie still. Peritonitis set in 
 in the afteruoon, and she died on the oid 
 day after confinement. 
 
 '■ Autopsi/, 18 hours after death. — 
 There was a little effused lymph; and 
 underneath the viscera about a pint of 
 bloody serum. The tumour Avas lying 
 above and in a line with the uterus, 
 nearly reaching by its upper border the 
 epigastrium. It was attached to the pos- 
 terior aspect of the fundus uteri by a 
 long pedicle, and had thus been allowed 
 to drop into the pelvis at or before the 
 commencement of labour. The Aveight of 
 the tumour was between 1 and 2 pounds, 
 its diameter 6j inches, and it consisted 
 throughout of Avhite fibrous tissue. Six 
 small tumours, of the same character, 
 were studded about the external surface 
 of the uterus.' 
 
 It will be observed that in this case a 
 trocar had been passed through the vagina 
 into the substance of the timiour before 
 the tumour was pushed up. In a case 
 where the tumour was certainly known to 
 be solid this, of course, would not be done. 
 In any similar case, where the tumour was 
 detected at an earlier period of preg- 
 nancy, either so low in the pelvis as to 
 be an impediment to delivery, or high up 
 in the abdomen, the question Avhetlier 
 pregnancy should be allowed to go on to 
 the full term, or Avhether premature 
 labour should be brought on, or the 
 uterine tumour should be removed, or 
 the prrgnant organ amputated, must be 
 decided by the conditions in each case. I 
 haA'e just alluded to cases Avhere, with 
 very considerable tuujcurs, natural deli- 
 very, at the full term, of a living child 
 Avas recorded. But other cases have l)een 
 related by Schroeder, liegar, and Kalten- 
 bach, Avhere in the early months of preg- 
 nanc3' the tumour increased with such 
 great rapidity, and the sufferings of the 
 patients became so distressing, that inter- 
 ference Avas necessary in order to save 
 life. The induction of premature labour 
 under such conditions has proved to be 
 
 so dangei^ous, and the emptying of the 
 uterine cavity can be of so little use, that 
 the removal of the tumour, so far as our 
 present knowledge can guide us, Avould 
 seem to be the better practice ; and the 
 fact of the uterus being pregnant does not 
 seem to have added much to the difficul- 
 ties and dangers of the operation Avhen it 
 has been performed. In one case, Avhere a 
 myoma about double the size of a child's 
 head between the uterus and the liver, 
 and several other smaller myumas, Avere re- 
 moved firom the gravid uterus by Schroe- 
 der, the patient Avent on to the end of 
 pregnancy, and had a liA'ing child. In 
 another case, Avhere he amputated a uterus 
 Avith a myoma in the fundus, about 
 the size of an adult's head, Avith several 
 smaller growths as large as an apple, or 
 the fist, in the Avails of the organ, and Avith 
 a 3 months' foetus in the cavity, the patient 
 recovered Avithout any fever. In a very 
 similar case, performed at the 10th week 
 of pregnancy, the patient also recovered, 
 in spite of a seA'ere bronchial catarrh. In 
 Hegar's case, the removal of the tumour 
 only was folloAved by the death of the 
 patient. In Kaltenbach's case, tumour, 
 uterus and foetus were all removed, the 
 stump Avas treated extra-peritoneally, and 
 the patient recovered. In a similar case 
 by Wasseige, treated intra-peritoneally, 
 the patient died. Schroeder's cases Avere 
 treated intra-peritoneally. 
 
 in April, 1884, Dr. Bantock operated 
 on a lady Avho had been some time under 
 notice, and Avhose case Avas diagnosed as 
 one of multiple uterine fibroids. He 
 found the uterus encumbered Avith 2 
 tumours, 1 large cystic tumour from the 
 left angle of the fundus, and another, more 
 solid, but also partially cystic, from the 
 right angle of the fundus. The uterus 
 contained a foetus of 3 months.. Supra- 
 vaginal amputation and extra- peritoneal 
 treatment resulted in the complete re- 
 covery of the patient, Avho at the end 
 of the year Avas known to be in good 
 health. 
 
 Two cases illustrating this subject 
 have also come under the management 
 of my colleague, ]\Ir. Thornton, in the 
 Samaritan Hospital. The first patient 
 Avas a married Avoman, 39 years of age, 
 in an advanced stage of pregnancy. In 
 May, 1.S79, he removed a tumour, attached 
 by a pedicle to the right side of the 
 uterus, and otherwise slightly adherent 
 to it, and not only Avedged in the pelvis, 
 
UTERINE TUMOUnS 
 
 167 
 
 complete removal, the rule is that 
 menstruation is stopped, and not only 
 excessive loss of blood at the men- 
 Labour came on about 9 hours , strual periods, but bleeding from the 
 and the cliild Avas still-born [ uterus at other times, supposing there to 
 
 be no polypus, is also stopped, and dimi- 
 nution of the tumour goes on more or 
 less rapidly. In Jul}'', iSS'j, I operated 
 upon a patient of Dr. Macintosh, of 
 Brompton, who had a A'ery large, solid 
 uterine tumour, and was extremely en- 
 
 but lirmly fixed to the brim and the 
 ■whole of the pouch of Douglas. The 
 pedicle was first clamped, then tied, and 
 returned, 
 afterward 
 
 without any difliciilty. The woman sur- 
 vived till the 5 th day. 
 
 The second ojieration was in July, 
 18ft2. Patient married, o8 years of age, 
 had carried a large tumour for 7 years, 
 and was very ill, with no chance of going 
 
 on to the full term. Extensive adhesions j feebled and pallid from repeated hamor- 
 
 had to be separated. An elastic ligature 
 was passed round the cervix, and large 
 forceps were placed on each broad liga- 
 ment. The uterus, aj^pendages, and tu- 
 mour Avere all cut away, the elastic liga- 
 ture was replaced by Kaberle's serre-nceud 
 and the stump fastened in the lower corner 
 of the wound. The patient made an 
 excellent recovery, was up on the ISth 
 day, left the hospital about the middle of 
 August, remained under care for another 
 fortnight, aud then went into the country. 
 She, however, died about 3 weeks after 
 her return home, with obscure symjDtoms 
 of renal or intestinal obstruction. 
 
 EEMOVAL OF THE OVARIES IN CASES OF 
 UTERINE TU.AIOUKS 
 
 The alternative proposal of removal of 
 the ovaries in order to lead to premature 
 cessation of menstruation in cases of 
 uterine tumour attended Avith much 
 bleeding, should alwaj's be considered 
 during consultation, Avhere surgical treat- 
 ment is called for. And it is occasion- 
 ally advisable to recommend that an 
 operation should be begun with the 
 understanding that if the tumour can 
 only be removed with great difficulty and 
 danger, it should be left alone, and the 
 ovaries removed. Whereas if the tumour 
 can be removed Avithout any unusual 
 hazard, Avith or Avithout one or both 
 OA'aries, it should be taken away. In one 
 of the cases Avhich I have just related, 
 finding that there Avould be unusual 
 difficulty, I intended to remove the ova- 
 ries, but there Avas so much bleeding 
 after removing one and such difficulty 
 in stopping the bleeding, that I removed 
 the tumour. Sometimes the ovaries are 
 so situated in these cases that they can be 
 easily remoA^ed ; in others they are so 
 confounded Avith the tumour that it is 
 difficult even to find them. After their 
 
 rhage. I took away both ovaries Avith a 
 most satisfactory result; ha3morrhage never 
 reappeared after the operation, and a con- 
 siderable diminution in the size of the 
 tumour has been observed. Dr. Mackin- 
 tosh saAv his patient in the summer of 
 1 884 in excellent health, there having been 
 no return of menstruation, and scarcely any 
 abdominal tumour to be felt. In a similar 
 case, but smaller tumour, in a young lady, 
 a patient of Dr. Priestley, Ave decided, after 
 consultation, upon the alternative extir- 
 pation of the enlai-ged uterus, or of removal 
 of the ovaries. After making an ex- 
 ploratory incision, removal of the ovaries 
 appeared to present the fcAver difficulties, 
 and to offi^r the best chance of safety to 
 the patient. This AA^as done, and the 
 result has been most satisfactory. The 
 operation Avas performed in 1 88 1. I saAV 
 the patient in the summer of ISHi in 
 excellent health, and I could scarcely 
 find a trace of the tumour, Avhich, at the 
 time of operation, had extended some 
 inches aboA^e the umbilicus. 
 
 We must have further experience, and 
 a larger number of cases carefully re- 
 corded, befoi'e Ave can arrive at a fair 
 estimate of the relative value and danger 
 of the two courses of action in cases of this 
 kind. The question Avhether the o\'aries 
 only, or the ovaries and Fallopian tubes 
 should be removed, must be decided by 
 the condition of the tubes. If healthy, it 
 Avould be absurd to remove them ; but if 
 diseased they should with equal certainty 
 be taken aAvay, Avhether free or adherent. 
 It is very important that every frag- 
 ment of both ovaries should be completely 
 cleared aAvay. If adherent, and one or 
 both are twisted or scraped aAvay from 
 their connections, if only some very small 
 portion be left, menstruation may after- 
 Avards occur quite regularly, and the 
 operation prove more or less a failure, 
 even though both Fallopian tubes may 
 have been totally removed. 
 
1G8 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 It is to be hoped that, in recording 
 cases, surgeons will be as careful as 
 possible in giving the dimensions of the 
 tumour before the ovaries were removed, 
 and the dimensions at certain definite 
 periods afterwards. In September 1884, 
 Ur. Harvey brought two interesting cases 
 before the Calcutta INIedical Societ)', in 
 which ho had renioved both ovaries, which 
 were quite licahhy, on account of uterine 
 tumour?. One of these tumours was ac- 
 companied by excessive menorrhngia, the 
 other by dypmenorrhoia and interference 
 Avith action of bladder and bowels. In tlie 
 first case the tiimoxu* was about 5 inches 
 across between the Fallopian tubes. The 
 tumour ' practically disappeared within G 
 months.' In the .second case the uterus 
 at the time of operation Avas as large as at 
 the end of 7 months' pregnancy. Within 
 3 months ' the iiterine tumour had shrunk 
 to half its former size.' Dr. Harvey does 
 not appear to have touched the Fallopian 
 tubes in either of these cases. In a third 
 case, where tlie uterus reached within ^ an 
 inch of the umbilicus, both ovaries were 
 removed, the right 'with difficulty along 
 with the thickened tube.' The patient died 
 on the 9th day, of peritonitis and septic- 
 aemia. Dr. Harvey adds, ' The objection 
 to the operation that it unsexes the woman 
 and makes it impossible for her to have 
 children, is sufficiently met by the fact 
 that in the cases when the operation is 
 justifiable the woman is in the last degree 
 unlikely to conceive, and it v/ould be very 
 unfortunate should she do so.' 
 
 In August 188-^, at the meeting of 
 the International Congress at Copenhagen, 
 Dr. Wiedow, of Freiburg, showed that of 
 149 cases of castration for uterine growths, 
 15 died — a mortality of about 10 per cent. 
 Comparing this Avilli the much larger 
 mortality of myomotomy, he argues that 
 castration must be the' better practice if 
 the results are proved to be good; and 
 he shows, by an analysis of the cases, 
 that the results, both as regards stopping 
 of the bleeding and shrinking of the 
 tumours, have been generally satisfac- 
 tory, and that removal of the Fallopian 
 tubes has little or no influence upon the 
 results. He insists that complete removal 
 of both ovaries is of the utmost import- 
 ance ; for, when any portion of either 
 ovary has been left, even if both Fallo- 
 pian tubes have been removed, menstrua- 
 tion has recurred quite unmodified by tlie 
 operation. 
 
 TUMOURS OF THE FALLOPIAN TUBES 
 
 Another class of abdominal tumoura 
 is found in the form of enlargement of 
 the Fallopian tubes. Tumours of the 
 Fallopian tubes, though generally taking 
 the form of distended sacs, are not 
 always cyst-like. They are sometimes 
 solid. When the contents are fluid, they 
 vary as to their nature. We may range 
 tumours of the Fallopian tubes in the 
 following order : 
 
 1 . Dilated tubes containing clear 
 fluid. 
 
 2. Dilated tubes with pundent con- 
 tents. 
 
 3. Dilated tubes containing blood or 
 menstrual fluid. 
 
 4. Tubes enlarged by papillomatous 
 growths. 
 
 5. Tubes enlai-ged by fibrous deposit. 
 
 6. Tubes including the products of 
 conception. 
 
 Numbers 4,571 and 4,572 in the Museum 
 of the College of Surgeons are specimens 
 of these tumours, formed by dilatation of 
 the Fallopian tubes, Avhich I removed in 
 1877. These tubes were both distended 
 with fluid. The patient, single, 23 years 
 of age, Avas admitted into the Samaritan 
 Hospital in July 1877, with an abdominal 
 tumour, which extended midway betAveen 
 the umbilicus and ensiform cartilage, and 
 under the left false ribs, drawing the 
 bladder upAvards, and pushing the uterus 
 downwards. Douglas's pouch Avas filled 
 by a solid mass which moved Avith the 
 abdominal tumour. The catamenia Avere 
 regular. The tumour had only been 
 noticed about 9 months before, but 
 steadily increased. It Avas supposed to 
 be a nudtilocular ovarian cyst. On open- 
 ing the peritoneum, 2 tumours separated 
 by a deep fin-row Avere seen. That to the 
 right Avas first turned out Avithout being 
 opened. A ligature Avas applied upon a 
 very narrow neck, Avhich proved to be 
 the closed uterine end of the right Fallo- 
 pian tube. This Avas divided beyond the 
 ligature. A very similar dilatation of 
 the left Fallopian tube Avas treated in 
 the same manner. Both Fallopian tubes, 
 closed at both ends and dilated into 
 cj'st-like tumoiu's, Avere removed without 
 being tapped or opened. The right ovary 
 Avas removed Avith the right tube. The 
 left ovary Avas not disturbed. The weight 
 of one tumour Avas 4 pounds 1 1 ounces, 
 
UTERINE TUMOURS 
 
 169 
 
 of the other, 1 pound G ounces. There 
 was nothing in the fkiid contained in 
 either cyst to distinguish it from ordinary 
 ovarian fluid. The woman recovered 
 well, left the hospital weeks after opera- 
 tion, married in A\ni[ 1878; and I saw 
 her in September 1S81, in good health, 
 the catamenia having been quite as 
 regular as before oi)eration, but more 
 ■copious. In Mr. Doran's account of the 
 preparations in the Museum of the College 
 of Surgeons, he says : ' Several pedun- 
 culated cysts sprang from tlie broad 
 Jigament. Some of the cysts contained 
 vegetations similar microscopically to the 
 papillomatous growth from the interior 
 of the Fallopian tube which will shortly 
 be described.' Mr. Doran is here refer- 
 ring to the following vei-y remarkable 
 case. 
 
 In the autimm of 1877, a maiden 
 lady, a patient of Mr. Bickersteth, of 
 Liverpool, began a long illness with tume- 
 faction of the abdomen and an attack of 
 right ovaritis. She was tapped. This was 
 followed, in the spring of 1878, by pleural 
 effusion on the right side. 120 ounces 
 of clear fluid were removed by tap- 
 ping. Then the ascitic fluid re-collected 
 at the end of 2 or 3 months. Tapping 
 to the extent of 24 ounces. In another 
 3 months the right pleura again required 
 tapping, 100 ounces of fluid being re- 
 moved. Three months more, tie abdo- 
 men had a third time become swollen, 
 and 16 pints were drawn off. But 
 throughout the period of these alternating 
 pleiiritic and peritoneal effusions, and 
 ever since the subsidence of the original 
 symptoms of pelvic inflammation, there 
 had been neither acute disturbance of the 
 system, nor even a rise of temperature; 
 and after each tapping recovery appeared 
 for a time to t)e complete. No signs of 
 heart or liver disease. The last tapping 
 was done in January, and in INIarch, 
 1879, as the case was as obscure as ever, 
 the patient was referred to me. Mr. 
 Bickerstcth had detected a dull note on 
 percussion in the flanks, most marked on 
 the right side. The abdomen Avas again 
 full, and there was also some fluid in the 
 thorax. So I advised an exploratory 
 incision. This Avas objected to, and the 
 abdomen was simply tapped. The fluid 
 had a sp. gr. of 10 o2, Avas charged Avith 
 idbumen, and the scanty deposit gave 
 evidence of vacuolated cells, indicating 
 some proliferating disease. The tap- 
 
 ping, however, enabled me to detect a 
 hard, nodular mass behind the uterus, 
 Avhich organ Avas freely moA'able, and so 
 low in the pelvis that the cervix lay close 
 to the vulva. An operation Avas impera- 
 tive, and I opened the peritoneum in 
 April 1879. Seventeen pints of opalescent 
 fluid escaped. The left ovary was normal. 
 To the right of the uterus, not larger than 
 natural, a tumour Avas found the size of 
 an orange, and consisting of the greater 
 part of the right Fallopian tube, Avith the 
 ovary behind it. A ligature av;is applied 
 between the tumour and the uterus, and 
 the tumour Avas cut away. The ovary 
 Avas also removed after ligature. No 
 secondary deposits Avere found on the 
 peritoneum. The patient made a rapid 
 recovery. 
 
 A small, thin-Avalled cyst projected from 
 the surface of the ovary, Avhich Avas not 
 otherwise diseased. Aboitt an inch of the 
 innermost portion of the Fallopian tube 
 remained itndilated and quite pervious. 
 The other part formed an elongated 
 tumour, 3^ inches Iong,Avith the fimbriated 
 extremity quite open, and the fimbrise, 
 although thickened and shortened, re- 
 mained quite distinct. The distended 
 section of the tube Avas filled Avith cauli- 
 flower excrescences, Avhich grcAV from all 
 parts of the mucous membrane. Several 
 cysts, Avith thin Avails and smooth exteriors, 
 rose by narrow pedicles from amidst the 
 excrescences, and contained papillary out- 
 groAvths. The caulifloAver groAVths Avere 
 covered Avith countless secondary off- 
 shoots, and on the free surfaces there Avas 
 a single layer of columnar epithelium, a 
 feAV of the cells being ciliated. The blood 
 supply was scanty, and in some parts of 
 the stroma chondrification had taken 
 place. The disease had begim with local 
 inflammation, causing hyperplasia of the 
 tubal mucous membrane, developing into 
 the Avarty and papillary growths, and 
 accompanied Avith an acrid mucous secre- 
 tion. This escaping by the open end of 
 the tube, caused the morbid effusion of 
 the peritoneum, and the abundant ascitic 
 fluid. The cells found in the fluid Avere 
 epithelial, the growth Avas epithelial, con- 
 fined to the free surfaces, and there was 
 nothing in it of a cancerous character. 
 
 The patient had another attack of 
 pleurisy in the foUoAving autumn, has 
 ceased to menstruate, and in 1884 still 
 lives in good health, Avithout any signs ot 
 the reappearance of the papillary growth 
 
170 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 in other parts, or of any fresh formation 
 of ascitic or pleural fluid. 
 
 This is the only case of papillomatous 
 tumour of the Fallopian tube that I have 
 CA'er removed, and the case previously 
 related is the only one in which I have 
 removed tubes dilated into cyst-like 
 cavities during my 20 years' practice at 
 the Samaritan Hospital. I saw one case 
 in consultation in 1884, which Avas after- 
 wards operated on by Mr. Thornton, and 
 another which I removed myself in October, 
 LS84. The tube in this case was qi:ite 
 closed at both ends, and the central por- 
 tion of the tube was dilated into a thin- 
 walled, cylindrical, cyst-like body, which 
 liad a remarkable resemblance to intestine. 
 A single ligature at the uterine end of 
 the tube was all that was required before 
 cutting away the tumour. The uterus, 
 the other tube, and the ovaries appeared 
 to be quite normal. The cavity contained 
 about 2 pints of fluid, closely resemb- 
 ling some variety of ovarian fluid. It also 
 contained a great deal of cholesterine. 
 The dilated tulje is now in the Museum 
 of the College of Surgeons. The patient 
 recovered Avithout any fever, menstruated 
 ireely from the 4th to the 8th day after 
 the operation, left for Yorkshire on the 
 21st day, and I have had grateful letters 
 irom her since. 
 
 Considering how very frequently I 
 have performed the operation of ovario- 
 tomy, it seems remarkable that these four 
 cases are the only examples I have met 
 Avith Avhere either one or both Fallopian 
 tubes have been so diseased as to lead to 
 their removal. I have reported many 
 cases Avhere, in connection with ovarian 
 tumours, a Fallopian tube has been con- 
 siderably elongated, and its canal closed. 
 In one case it Avas dilated and formed a 
 channel of communication between a 
 bleeding ovarian cyst and the uterine 
 cavity and the vagina; but I have never 
 seen anything su])porting the opinion that 
 disease of the Fallopian tubes occur.s Avith 
 anything approaching the extraordinary 
 frequency Avith Avhich by some it is 
 alleged to occur. AVhen treating the 
 pedicle as formei-ly by the clamp, and 
 recently by the ligature, I have been 
 guided, as to including the tube or not, 
 simply by the ease Avith which one or the 
 other could be done. When the Fallopian 
 tube is closely attached to the cyst I 
 usually include it in the clamp or ligature. 
 But if the pedicle can be readily secured 
 
 withoiit including the tube I leave it. I 
 have scarcely ever been decided in this 
 matter by observing signs of disease in 
 the tube itself, although I remember oc- 
 casionally, though not very often, having 
 removed it because it appeared unusually 
 red or swollen, elongated or tortuous. 
 
 No doubt the tube occasionally be- 
 comes the seat of gonorrheal inflamma- 
 tion ; but, whateA'er may be the experience 
 of others, my OAvn observation Avould lead 
 me to believe that these and other cases 
 of so-called salpingitis, or pyo-salpinx, 
 usually recover under ordinary care and 
 rest, Avithout surgical treatment. It would 
 appear to me as rational to perform 
 castration in every case of gonorrheal 
 orchitis, as to remove the Fallopian tubes 
 simply because they are inflamed or the 
 seat of suppuration. 
 
 Those who Avish to knoAv more about 
 the diseases of the Fallopian tubes, since 
 the time of their discoverer — Fallopius, 
 1550- — and of Haller, Bartholine, Ruysch, 
 Morgagni, Cruveilhier, Avill do Avell to 
 consult Hennig's Avork on ' Diseases of the 
 Fallopian Tubes and Tubal Pregnancy,' 
 published in 1876. They Avill there find 
 a great deal of A'aluable information as 
 to congenital and other defects, dilata- 
 tion, atresia, adhesions, abnormal con- 
 tents, catarrh, inflammation, and neAV 
 Ibrmations; Avhile the chapter on tubal 
 pregnancy contains a very complete 
 bibliography, and some historical notices 
 of recorded cases from KiOl doAVUAvards. 
 The section on the pathological anatomy 
 includes notices of interstitial, tubal, tubo- 
 ovarian, and tubo-abdominal pregnancy. 
 The sections on diagnosis and treatment 
 are less .satisfactory, and do little more 
 than confirm the conclusion to Avhich 
 experience here has been leading, that, 
 Avhenever the diagnosis of tubal preg- 
 nancy can be made out Avith tolerable 
 certainty, the risk of rupture as preg- 
 nancy advances, and of death from internal 
 haemorrhage, is so great, that the removal 
 of the dilated tube by abdominal section 
 is the safest and best practice. But here 
 again my OAvn experience is very small. 
 With the exception of one case, recorded 
 by ]\Ir. Cooke, in the 5th volume of the 
 ' Obstetrical Transactions,' where an intra- 
 uterine and an extra-uterine pregnancy 
 Avent on together to the full term ; and an- 
 other case recorded by Mr. Doran, where 
 a ruptured tube containing an ovum Avas 
 found after the death of the patient, I 
 
UTERINE TUMOURS 
 
 171 
 
 am not sure that I have ever seen any 
 variety of extra- uterine foitation, either 
 in my own practice or in consultation. 
 
 The last work on tubal pregnancy, by 
 Dr. J. Veit, of Berlin, published in 1H<S4, 
 contains interesting observations on the 
 connection of tuljal pregnancy with hajma- 
 tocele, and upon the diagnosis and treat- 
 ment of tubal pregnancy. The general 
 conclusion he comes to is, that in uncom. 
 plicated tubal pregnancy the sac should 
 be extirpated ; but when a lia3matocele 
 has formed, or the foetus is dead, that rest 
 and expectation are to be recommended. 
 When ru[)ture into the peritoneal cavity 
 has taken place, he advises compression of 
 the aorta, and only under extreme neces- 
 sity, direct stoppage of haemorrhage by 
 laparotomy. IMy own feeling would be 
 that, in any case of hcemorrhage from 
 rupture, although compression of the aorta 
 might be useful in temporarily stopping 
 bleeding while the necessary preparations 
 for laparotomy Avere being made, this 
 operation had better be resorted to as 
 soon as possible. 
 
 TUMOUKS OF THE ROUND LIGAMENT 
 
 I have only twice seen the round liga- 
 ment, as it passes along the inguinal 
 canal, so enlarged as to form a solid 
 tumour ; and by a curious accident both 
 patients came to me in the same year. I 
 never saw a case before that time, and I 
 have never seen one since. Both were 
 on the right side, and both had led to 
 great difFereiace of opinion among men of 
 large experience, the majority looking 
 upon them as malignant tumours. About 
 the first, I was myself very doubtful ; but 
 I felt confident that it could be removed 
 without difficulty ; and the patient was 
 otherwise so healthy that I would not 
 believe it possible that the tumour could 
 be malignant. A linear incision throuQ;h 
 
 the integuments exposed a fibroid tumour 
 considerably larger than an orange, which 
 was very easily removed, and proved to 
 be the round ligament enlarged just after 
 it passed through the internal ring. It is 
 now in the Museum of the College of 
 Surgeons. The structure precisely re- 
 sembled that of a uterine fibro-myoma. 
 The patient rapidly recovered, and is still 
 after many years in good health. 
 
 The second case occurred very soon 
 after the first, and I was able to give a 
 correct diagnosis. This tumour was 
 rather larger, of the same structure, and 
 is also in the College Museum. The 
 patient recovered without difficulty. 
 
 Much more commonly than solid tu- 
 mours of the round ligament, cystic 
 tumours are found in the inguinal canal 
 of women, and are known as hydrocele of 
 the round ligament. I have seen them of 
 various sizes, from that of a walnut up to 
 a cyst capable of holding 10 or 12 ounces 
 of fluid. I have no notes of these cases, 
 but I must have tapped at least 20, and 
 the fluid has always resembled that of 
 hydrocele in the male. I have once 
 known the fluid collect again. In that 
 case I injected iodine -with complete suc- 
 cess. In all the others, so far as I know, 
 simple tapping was followed by a cure. 
 Anatomically the cystlike cavity in which 
 this fluid forms is supposed to be a dila- 
 tation of the tubular process of perito- 
 neum into the inguinal canal, which in 
 the foetus is called the canal of ISTuck. 
 These cases are frequently mistaken for 
 oblique inguinal hernia, but the diagnosis 
 is easy. There may be impulse on cough- 
 ing, but the tumour is not altered by the 
 position of the patient, and it cannot be 
 reduced ; there is no gurgling on pressure, 
 and the percussion note is dull. When 
 large, fluctuation is perceptible, and in 
 thin Avomen transparency may sometimes, 
 be made evident. 
 
 CHxiPTER II 
 
 ON PARTIAL AMPUTATION AND ON COMPLETE EXCISION OF THE UTERUS 
 
 The removal of fibroid tumours of the 
 uterus and the partial amputation of the 
 hypertrophied uterus, have led on to its 
 more or less complete extirpation in cases 
 
 of uterine cancer. The names of Blun- 
 dell and Freund are associated Avith these 
 operations. More recentl}'' Poi'ro has 
 supplemented the Ca^sarean section by 
 
UTERINE AND OTHER ABDOxMINAL TUMOURS 
 
 the removal of the upper part of the 
 uterus leaving the vaginal portion after 
 amputation at abotit the division between 
 the neck and the body of the organ. The 
 case which I am about to describe is not 
 identical with any of these proceedings. 
 It was not a supra-vaginal amputation, 
 but a complete taking away of the whole 
 gravid uterus and its appendages. Even 
 if I had followed Porro's example it 
 would have been the first case of the kind 
 in Great Britain, But cutting round the 
 neck into the vagina and leaving no 
 stump makes the I'ollowing case of exci- 
 sion of a gravid cancerous uterus not 
 only the first excision of the entire 
 gravid uterus in this country, but an 
 operation xmicjue in its mode of perform- 
 ance, completeness, and success. 
 
 Bischoff, of Basle, in 1S79 removed a 
 uterus, the cancerous cervix of which 
 impeded delivery, from a patient 41 years 
 of age, and at the 34th week of preg- 
 nane}'. She, however, died 11 hours 
 after, the lelt ureter having been tied. It 
 thus seems that my own case at present is 
 the only one of the kind followed by 
 recovery and a temporary restoration to 
 health. 
 
 The patient was a farmer's v?ife, 
 37 years of age, pregnant G months Avith 
 her Gth child, and suffering from epithe- 
 lioma of the cervix uteri. IShe was 
 brought to me for consultation at my 
 house by Dr. Goldsworthy Tucker, of 
 Farningham, on October 5, 1881. She 
 had borne a child IG months previously, 
 had nursed it ibr 3 months, became weak 
 and troubled with vaginal discharge, but 
 again became pregnant, and aborted at 
 weeks, towards the end of 1880 ; again 
 menstruated in March, April, and May 
 1881. The exact date of the last concep- 
 tion is doubtful, but the calculation must 
 be made from tlie month of May. At her 
 first visit to me she was quite conscious 
 of the movements of the child, ballotte- 
 ment was distinct, and I could hear the 
 sounds t)f the fuctal lieart. The cervix 
 uteri was long and enlarged, the os admit- 
 ting one finger easily for 1 inch, and 
 the cervical canal was surrounded by a 
 mass of epithelioma, which everted the 
 lips of the OS and projected downwards 
 into tlie vagina. Proposals for the in- 
 ducing of premature labour and for the 
 removal of the diseased cervix had already 
 been discussed in previous consultations 
 ■with Dr. Playfair ; but it seemed to me 
 
 that the disease was so distinctly limited 
 to the cervix that if all the morbid tissue 
 were scraped away and chloride of zinc 
 applied to the denuded surface, preg- 
 nancy might go on to the full term. 
 And this procedure was decided upon. 
 A few days more, however, reduced the 
 patient to such a state of pain and weak- 
 ness, with great increase of the discharge, 
 that we were called to review with Dr. 
 Graily Hewitt the various objections and 
 advantages of the different courses open 
 to us. Our deliberations ended in the 
 decision that it would be better to re- 
 move the Avhole uterus and its contents, 
 and I accordingly performed the opera- 
 tion on October 21, with the assistance 
 of Mr. Thornton and Mr. Doran ; Dr. 
 Graily Hewitt, Dr. Tucker, and Mr. 
 Cadge of Norwich being present. 
 
 The patient was secured as for ova- 
 riotomy ; bvit, as it was necessary to keep 
 a catheter in the bladder, an opening was 
 made expressly for it in the waterproof 
 covering. The vagina was plugged with 
 thymol cotton, wetted with warm water 
 containing about 1 per cent, of phenol. I 
 divided the abdominal wall in the middle 
 line to an extent of about 8 inches, from 
 2 inches above to G inches below the 
 umbilicus. The uterus thus exposed was 
 about the size of a large adult head. 
 After turning it out I inserted 4 sutures 
 in the upper part of the wound over a 
 large iJat sponge, so as to keep back the 
 intestines and protect the abdomen from 
 needless cooling by the spray. I found 
 the ovaries at a higher level and nearer 
 to the fundus than was expected, and it 
 was cpiite easy to secure the spermatic 
 artery, first on the left and then on the 
 right side, by transfixing the broad liga- 
 ment below each ovary and tying with 
 strong silk. I took the catheter as my 
 guide in dissecting the bladder from the 
 anterior surface of the uterus. The ex- 
 panded uterine coats were very thin, like 
 a tense cyst, and they were soon acci- 
 dentally ruptured. I punctured the pro- 
 truding membranes and a quantity of 
 liquor amnii escaped. The next thing 
 was to draw out the foetus, and tie and 
 cut the cord ; but I did not interfere with 
 the placenta. I then separated the attach- 
 ments between uterus and vagina, com- 
 pletely circumcising the neck, and securing 
 by pressure-forceps all bleeding vessels 
 as they were divided. The entire uterus, 
 with all the diseased parts about the os 
 
PARTIAL AND COMPLETE EXCISION OF UTERUS 
 
 and cervix, was thus removed. The for- 
 ceps were then taken off successively, and 
 every bleeding vessel tied with carbolised 
 silk. Then, taking out the vaginal pings, 
 I brought together the opening into the 
 vagina, and the edges of the divided broad 
 ligaments, with silk sutures. The pelvis 
 was carefully cleansed, the wound closed 
 as usual with silk sutures, and the ordinary 
 dressing applied as after ovariotomy. 
 
 The patient was under the influence 
 of methylene for about 75 minutes, but 
 the operation from beginning the incision 
 to closing the wound was completed 
 within an hour. 
 
 Mr. Cadge kindly noted the time 
 occupied by the different stages of the 
 operation as follows : 
 
 2.35 r.M. Patient began to inhale me- 
 thylene. 
 
 2.11 ]'.M. Cathefrr and I'higging va- 
 gina. 
 Incision in abdominal wall. 
 Uterus drawn out. 
 Sutures in upper part (<f 
 abdominal wall, dividing 
 broad ligaments and va- 
 gina, removing fcetus and 
 securing vessels, till 
 Uterus removed. 
 Ligature of vessels and su- 
 tures of vagina and broad' 
 ligaments. 
 Closing of wound and dress- 
 ing. _ 
 
 0.55 ,, Patient in bed. 
 Tlie uterus has been preserved in the 
 Museum of the Royal College of Sui-geons, 
 and the accompanying drawings are back 
 and front views of the preparation. 
 
 2.50 
 2.5)5 
 2.5G 
 
 r.io 
 
 oAO 
 
 3.50 
 
 Tlie first of these drawings shows tlie 
 posterior aspect of the entire uterus and 
 ovaries as they were removed. The shi'ed 
 of peritoneum seen hanging near the cen- 
 tral part ot the diseased cervix was stripped 
 from the anterior surface of the rectum. 
 
 The second drawing is a view of the 
 anterior siu-face, showing where the peri- 
 toneal covering of the uterus was divided, 
 just where it is reflected on to the bladder. 
 
 Just below the line of divided peritoneunx 
 a darker line shows the opening into the 
 uterine cavity through which the foetus 
 was drawn out. Btdow, in both drawings, 
 the cervix altered by epithelioma is very 
 well depicted. 
 
 Mr. Doran reported that the uterus 
 and its appendages, when removed, 
 ' weighed 25 ounces exclusive of the 
 foetus, and measured G inches in lenTth.* 
 
174 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 ' The upper part of the uterus pre- 
 sented no abnormal appearance; ante- 
 riorly, immediately below the line of 
 reflexion of the peritoneum on to the 
 bladder, was a perfectly horizontal 
 lacerated wound, about 2 inches in -width, 
 opening into the uterine cavity. The 
 cut ends of the uterine artery could be 
 seen, on each side, entering the iiterus at 
 its lateral and inferior part, between the 
 anterior and posterior peritoneal coverings. 
 The OS was completely encircled by a 
 cauliflower growth which extended very 
 
 little into the uterine cavity, but invaded 
 the cellular tissue to the right of the 
 cervix. The portion of vaginal -wall 
 removed formed a complete but very 
 narrow fringe round the new formation. 
 This growth, when examined microscopi- 
 cally by Mr. Eve and myself, showed all 
 the characteristics of epithelioma. The 
 right ovary contained a large corpus 
 luteum of pregnancy, the left showed two 
 corpora lutea in process of atrophy ; the 
 stroma of both was normal and free from 
 dilated follicles. 
 
 'The foetus weighed 22^ ounces, 2.'j 
 ■ounces lighter than the uterus and its 
 appendages; it measured 11 inches and 
 was ill-nourished, its body covered with a 
 fine down, its eyelids gummed together, 
 and its nails not extending to the tips of 
 the fingers; the cord was 9}; inches in 
 length. The conclusion Avould be that it 
 was about a week over the Gth month 
 after conception.' 
 
 The condition of the patient after the 
 operation was pretty much what we sec 
 in cases of ovariotomy ; rather more pain 
 and sickness than in a simple case, 
 but less than in very complicated cases. 
 Three small opiates were given within G 
 hours alter the opeiation. Sickness re- 
 
 mained troublesome during the first week, 
 and the patient was nourished with injec- 
 tions of beef- tea and port- wine, with a 
 little laudanum occasionally. The highest 
 tempei'ature was 101 '2°, and the most 
 rapid pulse 12S. During the night 
 between the 2Sth and 29th, S days alter 
 the operation, opening of the wound 
 happened from frequent vomiting ; but 
 the stitches Avere carefully replaced by 
 Mr. Thornton in my absence, and, though 
 the temperature rose soon after a degree 
 higher than it had been, the sickness 
 ceased in the afternoon. 
 
 After this, though some of the stitches 
 once more cut through, and the patient was 
 kept in a state of irritation by an accidental 
 
PARTIAL AND COMPLETE EXCISION OF UTERUS 
 
 175 
 
 scald on the leg by a hot-water cushion, 
 there was not much to remark beyond 
 a rather free discliarge of serum from the 
 vagina, which afterwards became puru- 
 lent, and ceased within the third week. 
 Twenty-eight days after operation she 
 was moved into another room, but before 
 this the pulse, temperature and digestive 
 functions had been quite normal. Urine 
 passed freely ; slie had neither pain nor 
 sicknes«, and she slept well. She returned 
 to her home in Kent, by road, on 
 November 21. When asked in v;hat 
 respect this confinement differed from 
 those of her 5 children, she said she 
 had always suffered from vomiting, but 
 more this time than ever before; that the 
 chief difference was that she had no 
 trouble this time with her breasts, and 
 that the most pain was from the scald on 
 her leg. Her husband called on me in 
 the first week of 1 1SN2 and told me that 
 she was in good health, gaining strength, 
 enjoying life, and had no vaginal dis- 
 charge, pain, or irritation. This case 
 then distinctly proves that a patient may 
 recover after complete excision of a gravid 
 uterus and both ovaries, and Mr. Doran's 
 inspection and report of the specimen in 
 the College Museum encouraged us to 
 expect that as the diseased part had been 
 completely removed, there might be a 
 considerable jirolongation of life, as in 
 cases of epithelioma of the lip or anus, 
 where many years often elapse v/ithout 
 any new morbid growth, and to be hope- 
 ful that the patient might escape a recur- 
 rence of the disease. But she came up 
 to see me 3 times, at intervals of a fort- 
 night, in February and March 1(S82, 
 with a very suspicious thickening of the 
 vaginal cicatrix, although the general 
 health was steadily improving. I saw 
 her again in London in the summer, the 
 disease evidently recurring and extend- 
 ing upwards. At length a considerable 
 mass formed in the left iliac fossa, and 
 she died 13 months after the operation. 
 
 If I were to perform such an operation 
 again I should modify its successive steps 
 according to the gravid or non-gravid 
 state of the cancerous uterus. When 
 non-gravid, recent experience serves to 
 prove that extirpation by the vagina is 
 the safer method. "Wlien gravid, it is 
 possible that dilatation of the cervix and 
 emptying the uterine cavity as a prelimi- 
 nary measure might still enable the 
 operator to act through the vagina. No 
 
 case so treated, as far as my knowledge 
 goes, has been recorded, and it is not 
 easy to estimate the amount of risk 
 which would have to be encountered. It 
 seems probable that in nearly all cases of 
 gravid cancerous uterus, either the abdo- 
 minal, or a combined vaginal and abdo- 
 minal, operation would afford the greatest 
 chance of success. In either case a lai-ge 
 elastic catheter or a canula, through the 
 end of which diverging wires expand, 
 like, but shorter than, those figured on 
 page 44, would serve as a guide and 
 saft'guard in separating the uterus from 
 the bladder ; and if the abdominal opera- 
 tion should be selected, a large ring 
 pessary, or a modified Zwancke's pessary, 
 in the vagina, would afford better help in 
 making the section of the vaginal wall 
 round the neck of the uterus than the 
 cotton plugs which I used. Of course 
 the vagina ought to be thoroughly 
 cleansed by sulphurous acid or som.e 
 other disinfectant. 
 
 The position of the patient during the 
 abdominal operation should be the same 
 as ibr ovariotomy, but for a combined 
 vaginal and abdominal operation it would 
 be convenient to separate the thighs and 
 flex the legs, carefully protecting them 
 from cold. In any case a strong reflecting 
 lamp should be provided and ready for 
 use — say, for example, a good carriage 
 lamp or a policeman's bull's-eye, until a 
 cool, glowing electric light is perfected, 
 such as we may obtain by means of an 
 accumulator, and one of the incandescent 
 lamps recently described and used by 
 Dr. Felix Semon. Something of this 
 kind, particularly if the spray be u?ed, 
 would aid greatly when vessels are being 
 tied or sutures passed, unless the light in 
 the room is unusually strong. 
 
 The length of the incision in the 
 abdominal Avail need not be so long as 
 that which I made, if, after exposing the 
 uterus, the liquor amnii were evacuated 
 by a trocar. The uterus might still 
 further be diminished in size by dividing 
 its wall and removing the foetus, but it 
 would be very desirable to avoid any 
 interference Avith the placenta. In Porro's 
 supra-vaginal amputation an elastic liga- 
 ture passed round just above the vagina 
 might be used Avith advantage, but this of 
 course is out of the question if the cervix 
 has to be removed. 
 
 After AvithdraAving the uterus from 
 the abdominal cavity a few sutures should 
 
176 
 
 UTERLNE AND OTHER ABDOMINAL TUMOURS 
 
 be inserted so as to bring together the 
 edges of the upper part of the opening in 
 the abdominal wall, and close it over a 
 flat sponge. This prevents the intestines 
 from escaping, and protects them from the 
 cooling of the spray when it is used. I 
 do not think I need say more about the 
 suppression of hfcmorrhage by tying the 
 spermatic arteries or the use of pressure- 
 forceps than will be found in my narrative 
 of the case. By careful dissection, and 
 the guide of a catheter, tlie uterus may 
 be separated from the bladder without 
 mucli danger, but I do not yet see any 
 mode of certainly providing against the 
 mischance of tying or dividing one or 
 both ureters. I fear that, with all possible 
 care, it is an accident which may occa- 
 sionally prove unavoidable. 
 
 Mr. Nunn suggested to me last year 
 that removal of the entire uterus would 
 be more easy if the organ were first 
 divided into two parts by cutting it 
 through in the median line and removing 
 first one half and then the other. He 
 founded this proposal on his anatomical 
 observations brought before the Patho- 
 logical Society in 1S57, and published in 
 the ninth volume of the ' Transactions.' 
 Professor Mliller, of Berne, has more 
 recently made a similar recommendation, 
 as a modification of total extirjsation of 
 the uterus by the vagina. He has not 
 carried his proposal into practice ; but he 
 thinks that the necessary ligatures would 
 be more easily applied and be much less 
 likely to slip if, after drawing down the 
 uterus, it can be 'split into two symmetri- 
 cal halves in a vertical direction. Then 
 each half of the uterus with its ligament 
 could be drawn backwards,' the ligatures 
 applied, and the uterus cut away (' Cen- 
 tralblatt fur Gyniikologie,' 1882, No. 8). 
 
 When the abdominal operation is 
 performed, my own present ieeling is in 
 tavour of the intra-peritoneal method of 
 securing the vessels, with suture of the 
 peritoneal edges, and complete closure of 
 the incision in the abdominal wail. Ols- 
 hausen's recent experience Avith the 
 elastic ligature, proving that the ligature 
 and the parts compressed by it may be 
 left within the abdominal cavity with most 
 encouraging results, strengthens my im- 
 pression in favour of the intra-peritoneal 
 ligature. But I iireely admit, at the same 
 time, tliat recent cases by Dr. Bantock, 
 Mr. Thornton, and Mr. Meredith prove 
 that the extra-peritoneal treatment of the 
 
 pedicle, or of the root of outgrowths from 
 the uterus, or portions of the uterus 
 included in a ligature or compressing wire, 
 may be very safely and successfully 
 efTected by Koeberle's serre-noeud, which 
 is ixsed as a clamp, and prevented from 
 being drawn inwards by two strong pins 
 passed through close to the wire loop, 
 as shown in the preceding chapter. The 
 edges of the wound are then carefully 
 closed around the stump. 
 
 Most operators have thought it neces- 
 sary to arrange for drainage after sepa- 
 rating the uterus from its vaginal attach- 
 ments all round. But I do not see that 
 drainage can be more necessary in this 
 operation than after the removal of uterine 
 or ovarian tumours, where I have almost 
 completely abandoned it. I believe it to 
 be more important effectually to close the 
 opening between the peritoneal cavity 
 and the vagina by sutures, than to use 
 a drainage-tube. Indeed, I should A'ery 
 much fear that the latter course would be 
 hazardous. It has also been proposed to 
 use two sets of sutures, one for the 
 vaginal mucous membrane and one for 
 the peritoneum and broad ligaments. 
 My present feeling is that the vaginal 
 sutures are unnecessary, and may pos- 
 sibly be injurious by leading to collec- 
 tions of blood or serum in the pelvic 
 cellular tissue. 
 
 As I have never performed either a 
 vaginal or a combined vaginal and abdo- 
 minal operation for the removal of a non- 
 gravid uterus, I hesitate to say much 
 about the details of the procedure ; but 
 I think it extremely probable that the 
 operation as hitherto practised might be 
 very much simplified by drawing down 
 the uterus, separating its attachments to 
 the vaginal wall all round as near to the 
 uterine substance as possible, or exactly 
 where the peritoneum is reflected off Irom 
 its walls, securing any bleeding vessel as 
 it is divided by pressure-forceps, not 
 using any ligatures, but leaving the 
 forceps hanging out of the vagina tor 2 or 
 3 days until all danger of hajmcrrhage 
 has ceased. Since I first published this 
 suggestion, it has been successfully 
 tested by more than one operator; not 
 altogether superseding ligatures, but 
 supplementing them where ligatures 
 could not be easily applied. The tbrceps 
 might be so arranged or tied together as 
 to serve the double purpose of stopping 
 bleeding and of bringing the opposite 
 
rARTIAL AND COMPLETE EXCISION OF UTERUS 
 
 177 
 
 ■sides of tlie vagina together, to render 
 peritoneal sutures superfluous. It is 
 very unlikely that if the forceps were left 
 untouched for 2 or 3 days any bleeding 
 would take place] and if it did, there 
 would be no more difficulty in applying 
 ti ligature than in the first instance. 
 Further, it appears to me that sufficient 
 iittcntion has not been paid in any of 
 these operations to preliminary compres- 
 sion of the abdominal aorta by tourniquet 
 as a safeguard or preventive of bleeding, 
 or to compression of the aorta by the 
 fingers of an assistant when bleeding 
 occurs during the progress of the opera- 
 tion. It is also probable that Mr, 
 Davey's plan of compressing the iliacs by 
 a sound passed up the rectum might also 
 ■occasionally prove useful. I can imagine 
 it to be quite possible in persons where 
 the abdominal wall is lax, either by a 
 modified tourniquet or by the hand of an 
 assistant, so to force the parietes back- 
 wards and below the brim of the pelvis, 
 as to push the uterus downwards, keep 
 the intestines in the upper part of the 
 abdominal cavity, and at the same time 
 to check the circulation in the aorta or 
 the iliacs, and thus render the operation 
 ■almost bloodless. 
 
 More than 50 years ago, Blundell, 
 ^fter long consideration, based upon a 
 t^eries of experiments to show the effect of 
 peritoneal section and manipulation, and 
 fully aware of the difficulties and risks of 
 the operation, proposed excision of the 
 cancerous uterus. He brought forward 
 his views with no very sanguine expecta- 
 tions, and simply advocated the extirpa- 
 tion as a last resource, which might 
 perchance restore a measure of life to a 
 few of the many women who were menaced 
 with speedy and inevitable death. He 
 carried out his proposition for the first 
 time in September 182S. He did 4 cases, 
 3 of wdiich proved fatal — 2 within 6 
 hours of the operation, 1 after 39 hours — 
 and 1 lived a year, when on examination 
 cancerous masses were found in the pelvis. 
 All Blundell's operations were performed 
 through the vagina. A very interesting 
 •account of them, and of the thoughts and 
 experiments which led him to attempt 
 them, may be found in his work on 
 ■^ Obstetric Medicine,' published in 1840, 
 from page 752 to page 784. 
 
 Three deaths out of 4 cases, and a re- 
 currence of the disease within a year in the 
 only patient who recovered, will account 
 
 for the fact that the idea of extirpation 
 of the cancerous uterus was not revived 
 in England until 1878, when, in the 
 Hunterian Lectures at the College of Sur- 
 geons, I made known Freund's operation 
 of excision through the abdominal wall. 
 It has not yet been done in England with 
 any good results. In 2 instances of which 
 
 1 heard, death followed after a short inter- 
 val ; and it cannot be said to have proved 
 successful in Germany and Italy, The 
 experience of Freund himself and other 
 operators up to the end of 1880 has been 
 collected, and Olshausen has 'commented 
 on the particulars of 94 cases. Of these 
 24 survived the operation ; but in nearly 
 every case there was a return of the 
 disease, and in some of them after a very 
 short time — an experience corresponding 
 almost exactly with that of Blundell. 
 Among the fatal cases some died of shock, 
 some from bleeding, and others from septic 
 peritonitis. Six times one of the ureters 
 was divided. In 2 other cases the same 
 accident befell both ureters, and 4 of the 
 operations were never completed. Imme- 
 diate consequences so discomfiting, and 
 results so negative, led to other modes of 
 excision, Delpech had a long time before, 
 in 1830, indicated a combined hypogastric 
 and vaginal operation, and excision by 
 the vagina came again to be adopted. 
 Olshausen has accumulated the history 
 of 44 such operations, showing an out- 
 come of 29 recoveries, 12 deaths, and 3 
 incomplete operations. We have here 
 an advance of more than 40 per cent, in 
 favour of this procedure, the relative 
 mortality being for the abdominal section 
 about 75 per cent. ; that for the vaginal 
 extraction not quite 30 per cent. In his 
 own practice Olshausen informs me that 
 he has had 34 cases of total extirpation 
 of the uterus by the vagina up to the end 
 of 1884, with 7 deaths — 3 from sepsis, 
 
 2 of shock, 1 carbolic poisoning, and 1 
 iodoform poisoning. Besides these, 1 pa- 
 tient, after a rapid recovery, died quite 
 suddenly on the 26th day, of pulmonary 
 embolism. Three cases could not be com- 
 pleted on account of firm adhesions be- 
 tween the uterus and rectum or bladder. 
 Among the cases where there has been no 
 reappearance of disease, 2 years have 
 elapsed in 2 cases, in 1 case 2^ years, and 
 in 2 cases 3 years ; but in a larger pro- 
 portion there has been reappearance in 
 between 1 and 2 years. 
 
 Professor Billroth of Vienna, in a letter 
 
 N 
 
178 
 
 UTEKINE AND OTHER ABDOMINAL TUMOURS 
 
 to me, dated Vienna, November 18, 1881, 
 
 ' Your Porro-Freixnd case has in- 
 terested me very much, as a similar case \ 
 occixrred to me 3 months ago. A strong \ 
 woman, about 37 years of age, 4 months \ 
 pregnant, had extensive carcinoma ol: the 
 whole cervix and part of the vagina. The 
 whole viterus was extirpated by the vagina, j 
 Bleeding was considerable, but recovei-y 
 Avas rapid. Unfortunately it was necessary 
 to cut away part of the bladder, leaving 
 a hole in the bladder, and a large hole 
 (Rt'esenloch) in the peritoneum. I stopped 
 up both with plugs of iodoform gauze. 
 These were left for 8 days, and were then 
 removed. There Avas no sepsis, but heal- 
 ing. The A'esical fistula remains for future 
 treatment. In another case, similar except 
 that the uterus was not gravid, one ureter 
 was wounded. The large peritoneal 
 opening was plugged with iodoform gauze, 
 and the patient recovered. But I cannot 
 heal the ureter fistula. Still the disinfect- 
 ing power of iodoform is by these cases 
 clearly established. By no other means 
 could the decomposition of the woTind 
 secretion and of the urine flowing through 
 the fistula have been prevented, and death 
 would have been certain. 
 
 ' Unfortunately my very successful 
 results of total extirpation of the carcino- 
 matous uterus per vaginam are very dis- 
 appointing so far as regards relapse. Even 
 in the 2 cases just described, where I 
 extirpated up to the extreme limits of 
 anatomical possibility, there is already 
 recurrence. Of what use are all our pains 
 and art! ' ('Was nutzt da alV unsre Millie 
 und Kunst ! ') 
 
 The question of the extirpation of the 
 cancerous uterus has a very different 
 aspect during pregnancy and in the non- 
 gravid state. For a pregnant woman 
 something must be done to save her life. 
 When not pregnant the question is one of 
 expediency, not of necessity, and it seems 
 probable that there will be very few cases 
 in which a positive diagnosis can be made 
 before the disease has extended so far 
 as to put excision beyond all reasonable 
 hope of success. In the early stages 
 diagnosis is often doubtful, and so serious 
 an operation would not be submitted to if 
 recommended. At a later stage, when a 
 more positive opinion is attainable, and 
 the disease is apparently confined to the 
 cervix, destruction by caustics, or the 
 actual cautery, or cutting or .«crapingaway 
 
 of the diseased parts, followed by the 
 application of the chloride of zinc or some 
 other corrosive agent, or arapiitation of 
 the cervix, are all methods of treatment 
 which would have to be considered before 
 proposing total extirpation. And although 
 the results of these proceedings have not 
 been very satisfactory so far as extension- 
 or recurrence of the disease is concerned, 
 yet the immediate danger to life is very 
 small compared with that attending re- 
 moval of the whole uterus. In many 
 cases great relief is obtained for a time, 
 loss of blood and offensive discharges are 
 stopped, pain is lessened, and the general 
 health improved. I have known 2 cases 
 in which, after removal of the diseased 
 cervix and the use of the actual cautery, 
 the patients died about 5 years later on ot 
 some other disease, no return of that of the 
 uterus having been observed. But in no 
 other case Avhich has been subjected to 
 the same treatment by me has the relief 
 lasted many months ; and of course it can 
 only be expected to be at all useful when 
 the disease is confined to the lower segment 
 of the uterus. 
 
 In cases where the fundus or body is 
 affected, if any surgical measures are ad- 
 missible, excision by the vagina Avould be 
 the resource to wliich our present know- 
 ledge inclines us. And if it be done suf- 
 ficiently early by operators who have made 
 themselves masters of all the details of 
 manipulation by practice on the dead body, 
 and by carefully stiidying the records of 
 the cases hitherto published, we need not 
 despair of establishing for excision of the 
 cancerous uterus, a higher scale of success 
 with fewer failures and more recoveries, 
 and of being able to rescue from their 
 misery as large a proportion of our patients 
 as any surgeons can claim to do wlien they 
 exercise their art for the removal of cancer 
 from other parts of the body. 
 
 I have nothing to add as a result of 
 m}^ own observation or practice to the 
 above sentences published in 1S81, and 
 all I can gather from the published re- 
 ports of others confirms me in the belief 
 that whether a cancerous uterus is excised 
 by the abdomen or the vagina, recurrence 
 of disease is the rule : and it becomes a 
 very serious question if any patient should 
 be advised to take the risk of shortening 
 life — considering that it is about 80 per 
 cent, when tlie abdominal operation is 
 performed, and from 20 to 30 per cent, 
 after the vaginal operation — wlien the 
 
PARTIAL AND COMPLETE EXCISION OF UTERUS 
 
 179 
 
 gain, even in the most favourable cases, 
 may not be very great, perhaps not even 
 greater than by the less formidable treat- 
 ment proposed in the preceding paragraph. 
 
 PORRO'S OPERATIOX 
 
 The operation now commonly Icnovvn 
 as Porro's is an extension of the Ca3sarean 
 section, and mvist replace it in most of the 
 cases requiring surgical interference of 
 the kind. It is the result of reasoning and 
 experimental vivisection. The fatality of 
 the Cccsarean section to the mother was 
 only too well known, and its causes were 
 not doubtful. The idea that tlie danger 
 would be lessened if the uterus itself as 
 Avell as the contents were taken away, was 
 first suggested by Cavallini, of Florence, 
 in 17G8. He proved the possibility oi 
 doing so, as well as the fact that the uterus 
 is not necessary to the life and health of 
 animals, by successfully operating on dogs 
 and sheep. Michaelis of Marburg, in 
 1809, argued that, as the constitutional 
 effects were less after the gravid uterus 
 had in ignorance been cut away than in 
 cases of Cajsarean section, and as the 
 uterus was an organ worse than useless to 
 a Avoman who had to submit to any such 
 risk, the question of amputation might be 
 entertained. Blundell and others, a few 
 years later, satisfied themselves that it 
 might be done in the case of animals with 
 a large proportion of recoveries ; and 
 Storer of Boston, in 18G9, to save a patient 
 from immediate death by hasmorrhage 
 during a Ca3sarean section, was forced to 
 cut off the uterus as well as a large fibroid 
 rumour .which sprang from it. The 
 woman had been 3 days in labour with a 
 l^utrid fo3tus, and died 68 hours after the 
 operation. This sufficed to show that the 
 operation itself was not directly fatal in 
 the human subject. Porro did the first 
 premeditated uterine amputation in con- 
 nection with the Cesarean section in 1876, 
 and saved the lives of both mother and 
 child. With these facts, confirming the 
 justice of the philosophical suggestion, 
 the question of adopting the operation 
 came before the profession for decision. 
 Opinion was divided, but the days of 
 blind opposition were over, and judg- 
 ment was more calm than Avhen pre- 
 judice swayed men to denounce ovario- 
 tomy. The practice has since so rapidly 
 and Avndely spread that Dr. Clement God- 
 son, at the end of 1884, Avas able to tabu- 
 
 late 152 cases, with (JG recoveries and 86 
 deaths, reported from 11 different coun- 
 tries and by no fewer than 90 operators. 
 This table of Dr. Godson's is a marvel of 
 exactness and amplitude, and is a useful 
 appendix to the report of a case which he 
 himself conducted to a successful end 
 under very difficult circumstances. The 
 patient Avas a dAvarf, 24 years of age, and 
 Cesarean section Avould haA'e been the 
 only means of saving the lives of mother 
 and child if this operation had not been 
 undertaken. It was performed on Novem- 
 ber 22, 1882. Precisely similar arrange- 
 ments as for ovariotomy Avere made. An 
 incision from just below the imabilicus 
 to about 2 inches above the symphysis 
 pubis exposed the uterus. As Ioav doAvn 
 as possible on its anterior Avail, or about 
 the junction of the lower Avith the middle 
 third, a small incision Avasmade just large 
 enough to admit a finger. A gush of 
 venous blood occurred, and the membranes 
 Avere seen. Dr. Godson inserted the tip 
 of each forefinger and tore the uterus 
 open transversely. The membranes were 
 not ruptured by this manipulation. He 
 thrust his hand through them, extracted 
 the child, tied the cord in tAvo j^Iaces, and 
 divided it. "While he Avas thus engaged 
 Mr. Thornton, Avho Avas assisting him, 
 grasped the neck of the uterus Avith his 
 left hand and applied the wire of Kceberle's 
 serre-no2ud Avith the right, so as to include 
 both ovaries and tubes as Avell as the 
 uterus, at about the level of the internal 
 OS. The Avire Avas then tightened, and 
 the uterus with the contained placenta 
 cut aAvay. Solid perchloride of iron was 
 then applied to the raAV surface of the 
 stump. Two guarded pins were passed 
 through it above the wire, and a strong 
 silk ligature Avas passed, round beneath 
 them for greater security. The abdominal 
 Avail Avas then closely united around the 
 pedicle, as in ovariotomy. The serre- 
 nosud Avas not detached till the loth day. 
 The patient regained perfect health, her 
 abdomen shoAving hardly any scar, and no 
 depression Avhere the pedicle Avas secured. 
 All I need to say noAv about the Avay 
 of performing Porro's operation is, that 
 it is not advisable to make an inci.sion 
 sufficiently long to admit of the uterus 
 being turned out entire before opening 
 it. The opening in the uterine Avail 
 should be out of the A\'ay of the placenta, 
 and Dr. Godson's mode of opening the 
 uterus transversely, just above the 
 
 N 2 
 
180 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 internal os, is probably the best-. The 
 child should be extracted in the readiest 
 ■way possible, and without any attempt to 
 separate the placenta. The operator 
 should firmly grasp the neck of the 
 uterus with his left hand, aiid carry an 
 elastic ligature round it with his right. 
 Perhaps this might in some cases be 
 advantageously done before tlie uterus is 
 opened, as soon as any bleeding in the 
 abdominal wound has been stopped, but 
 without making any strong constriction 
 until after the child has been removed. 
 The tying of the cord, and any necessary 
 attentions to the child, should be entrusted 
 to an assistant. The elastic ligature may 
 then be fastened by a simple knot, or by 
 being passed through a leaden ring, which 
 is compressed, or by compression with 
 my forceps. The uterus, with its placenta 
 undisturbed, and the parts inclosed in 
 the ligature, may then be cut away. Of 
 course all the precautions described in 
 ihe chapters on Ovariotomy and Uterine 
 Tumours, for preventing the escape and 
 exposure of intestines, and for holding 
 the edges of the opening in tlie abdominal 
 Avail together during the manipulation of 
 the uterus and pedicle, should be observed. 
 The uterus having been cut away, and a 
 few sutures passed through the edges of 
 the upper part of the wound in the 
 abdominal wall, supposing the extra- 
 peritoneal treatment of the stump to be 
 preferred, two strong guarded pins are 
 made to transfix the stump from side to 
 side, about ^ an inch above the elastic 
 ligature. If the operator is unwilling 
 to trust to this ligature alone, the wire of 
 Kdiberle's serre-noeud may be passed im- 
 mediately behind the pins, and as it is 
 tightened, the india-rubl)er may be cut 
 through, or left as an additional precau- 
 tion, at the option of the operator. My 
 own belief is that the elastic ligature 
 alone will be quite sufficient. In either 
 case perchloride of iron should be applied 
 freely to the stump, as soon as the peri- 
 toneal edges of the opening in the abdo- 
 minal wall have been sewn closely round 
 the peritoneal coat of the stump. One 
 suture below the stump, and the lowest of 
 those above it, should pass through not 
 only both edges of the abdominal wound, 
 but also the peritoneum of the stump. 
 When these sutures are tightly tied, it 
 is almost impossible for any product of 
 the decomposition of the stump, or any 
 liquefied perchloride of iron, even if 
 
 applied in excess, to run down beside the 
 stump into the abdominal cavity. The 
 skin and the lower part of the wound 
 should be protected by careful packing 
 with iodoform wool, and the dressings 
 applied as in ovariotomy. Careful daily 
 dressings, changing the iodoform wool, 
 tightening tlie Avire if one is used, re- 
 moving portions of dead tissue, and the 
 fresh application of perchloride of iron 
 or iodoform, are required until the pedicle 
 separates. 
 
 Dr. Godson's table is arranged chro- 
 nologically. It enables us to trace the 
 quick and universal adoption of the opera- 
 tion, and gives a vivid idea of the changed 
 condition of the profession when we note 
 how general is the diffusion of surgical 
 skill and aptitude equal to dealing with 
 emergencies so pressing and an under- 
 taking so difiicult of execution. 
 
 The details and references of 152 
 cases of true Porro's operations are given 
 in the table. It covers the time from the 
 date of Porro's first, on May 21, 187G, to 
 the end of 1884. A calculation of the 
 results shows a mortality of 56"57 per 
 cent, of mothers, and a gain of 124 living 
 children. We learn from the table three 
 lessons : first, that as some form of septic 
 peritonitis was the cause of 56 out of 
 the 80 deaths, it is chiefly to ths suppres- 
 sion of this danger that we are to look 
 for a diminution of the mortality among 
 the mothers ; secondly, that Ave ought not 
 to regard the operation as a last resource 
 for dying mothers; thirdly, that, as a 
 major operation of surgery, it compares 
 favourably with some others of the 
 same or even less importance, and that it 
 contrasts A'ery advantageously Avith the 
 Cesarean operation. 
 
 I have great pleasure in quoting some 
 of the remarks added by Dr. Godson, and 
 in taking the opportunity of congratulat- 
 ing him upon being the first in Great 
 Britain Avho has succeeded in saving the 
 lives of both mother and child by the 
 operation. 
 
 Dr. Godson says, in reference to the 
 number of deaths after the operation, that 
 ' in performing it only as a dernier rcssort 
 lies one great reason for such a high 
 mortality. Out of the 152 cases you 
 Avill find 80 only in Avhich the patients' 
 condition Avas " favourable," in which the 
 pedicle Avas not dropped in, and in which 
 the success of the operation itself Avas 
 not prejudiced by any avoidable accident. 
 
PAraTAL A^^D COMPLETE EXCISION OF UTERUS 
 
 ISl 
 
 or these SO cases, 52 recovered, 28 
 died, a mortality of about 1 in 3. The 
 question of selection should be based on 
 these figures; not upon a summing-up of 
 total results without regard to the cir- 
 cumstances, so far as Ave can investigate 
 them, which in each case in/Iuence the 
 result. It is manifestly unreasonable to 
 include in the same category, as cases 
 undertaken under fair conditions, opera- 
 tions performed when tlie patient was 
 almost moribund from disease, or ex- 
 hausted from days of labour, during 
 which the soft parts had been bruised, or 
 lacerations had occurred in the attempts 
 to deliver by means of the forceps or 
 cranioclast.' 
 
 And again, speaking of the advantages 
 of Porro's operation : * Looking at the 
 table, and taking from it the results, the 
 first idea will probably be not altogether 
 favourable, for out of the 152 operations, 
 86 deaths are recorded against 66 re- 
 coveries. 
 
 ' In comparing these results with those 
 of the old Caisarean operation, I would 
 call attention to the following astound- 
 ing facts : In the Vienna Hospital, for 
 100 years there had not been a re- 
 covery after a Csesarean section; whereas 
 recently, in 3 cases of Porro's opera- 
 tion performed in one week by Professor 
 Carl Braun, the whole of the patients 
 recovered. In Italy, the old Cesarean 
 operation was almost always fatal. Pro- 
 fessor Chiara, of Milan, writes that out of 
 62 cases operated upon by Porro, Lazzati, 
 Billi and himself, only 3 recovered. On 
 the other hand, nearly half (23 out of 53) 
 of the Porro's operations have been ruc- 
 cessful, notwithstanding that the operation 
 has been performed by as many as 35 
 different surgeons. Again, up to May 
 20, 1879, when Professor Tarnier per- 
 formed his first Porro's operation at the 
 Maternite in Paris, ever}'' Cassarean case 
 had proved fatal there since 1787. The 
 condition of the patient was most \ni- 
 favourable, nevertheless she recovered. 
 In our own city, I know that my late 
 colleague. Dr. Greenhalgh, performed 
 Cajsarean section 10 times, with only 1 
 
 recovery ; while I have myself seen it 
 performed by 4 different operators, every 
 case proving fatal. In Prague, Professor 
 Breisky has performed Porro's operation 
 4 times; in each case the woman has re- 
 covered and the child has been saved. 
 
 ' The advantages claimed for Porro's 
 
 operation over the old Caisarean section 
 
 are these : 
 
 I '1. The uterus being removed, and 
 
 j the stump of it being outside, there is no 
 
 I danger of bleeding within the peritoneum, 
 
 or of exudation of lochia, as before, 
 
 through the incised uterine Avail. At the 
 
 time of operation, the risk of haemorrhage 
 
 is much less, for as soon as the cervix is 
 
 constricted, it ceases, and this may be 
 
 very promptly done. 
 
 '2. Should bleeding occur from the 
 pedicle, being outside it is under control 
 — an advantage which is, hoAvever, sacri- 
 ficed by the intra-peritoneal method. 
 
 '3. The uterus and ovaries having 
 been removed, the dangers arising from a 
 subsequent pregnancy are avoided.' 
 
 In the above summary by Dr. Godson 
 of the advantages claimed for Porro's 
 operation, it is assumed that the uterine 
 stump is fixed outside — that the supe- 
 riority of the extra over the intra-peri- 
 toneal method is established — and it is 
 quite true that an examination of the 
 cases tabulated by Dr. Godson tend to 
 confirm this conclusion. Only 14 cases 
 Avere treated intra-peritoneally, and of 
 them only 5 recovered, Avhile of the extra- 
 peritoneal cases there Avere 59 recoveries 
 to 79 deaths. But, in my opinion, it is 
 not at all improbable that further trials 
 of the intra-peritoneal method, by elastic 
 ligature and peritoneal suture, may modify 
 this conclusion, or even reverse it. 
 Whether the necessary experimental trials 
 of both methods are in this country to be 
 made upon Avomen only, or upon females 
 of some of the lower animals, must 
 depend upon the manner in which British 
 physiologists are limited in their re- 
 searches by the officials Avho administer 
 the Act of Parliament 34 & 35 Vict, c, 
 98 (187G), knoAvn as the 'Vivisection 
 Act.' 
 
182 
 
 UTERINE AND OTHER ABDOmNAL TUMOURS 
 
 CHAPTER in 
 
 EXTIPvPATION OF THE SPLEEN 
 
 One of the main cliaracteristics of modern 
 surgery is its boldness and success in 
 dealing with the organs of organic life. 
 Although in former times the three great 
 cavities were punctured, excision of the 
 organs therein was scarcely thought of as 
 a means of saving life. The Ca^sarean 
 operation was done with more regard to 
 the rescue of the child than that of the 
 mother. The current phrases, 'cutting 
 for the stone,' ' tapping,' ' trephining,' 
 mark the limitations of the efforts of 
 ancient art. Relieving pressure, letting 
 out fluids, and getting rid of a foreign 
 body were the ends accomplished. Tu- 
 mours of the brain and gangrenous lungs 
 brought about death without any attempt 
 to avert it, and the abdomen was a sort 
 of Alsatia for every organ it sheltered. 
 But the day that INIcDowell ventured into 
 the peritoneal cavity for an ovarian tumour 
 was the last of its immunity. He, indeed, 
 little thought to what his act would lead ; 
 and I believe, if the truth were told, the 
 generation of sui-geons now vrorking out 
 the sequel of his daring are not a little 
 astonished at the lengths to Avhich it has 
 inspired them to go. A short summary 
 of Avhat has been done in abdominal sur- 
 gery for the extirpation of diseased organs, 
 or parts of oi'gans, I propose for the fol- 
 lowing chapters, as Ave may fairly trace 
 the whole extension up to the starting- 
 point of the peritoneal invasion by ovario- 
 tom)^ 
 
 I have enlarged upon tumours of the 
 uterus and its appendages, and have 
 shown that even evisceration, as far as 
 regards those parts, is a justifiable and 
 life-saving proceeding. Sir Henry 
 Thompson has written upon the new 
 surgery of the bladder, and other operators 
 have proved how successfully they are 
 able to rectify the occasional injuries to 
 that organ and to the ureters. 
 
 But in order of time, the spleen was 
 the first abdominal viscus that was brought 
 under notice as capable of being dealt 
 with like an ovarian tumour. I think 
 we may look upon the case of extirpa- 
 tion of the spleen attributed to Zaccarelli, 
 in 1549, as apocryj)hal. We do not find 
 anything authentic tiJl 182G, in which 
 
 year Quittenbaum, of Rostock, removed a 
 diseased spleen from a woman, who died 
 of shock in G hours. Then, in 1855, 
 Kuchler, of Darmstadt, reported that he 
 had done the operation on a man who 
 had enlarged spleen from ague. He en- 
 countered no special difficulty in his 
 undertaking, but lost the patient from 
 ha3morrhage 2 hours after operation. 
 
 INIy attention was first drawn to the 
 subject by a specimen of enlarged spleen 
 exhibited at a meeting of the Pathological 
 Society in 1862, by Mr. Nunn. 
 
 At that time I did not know that the 
 operation of extirpation had been per- 
 formed on the human subject. I believed 
 that it had not been attempted in Great 
 Britain. But in reasoning about the 
 matter, I could not doubt the possibility 
 of safely accomplishing in man that which 
 presented no fatal difficulty in dogs. I 
 saw that, in such cases as Mr. Nunn's, it 
 was the enlarged spleen Avhich directly 
 killed the patient, in spite of all remedies; 
 and so, putting together the facts of the 
 fatality of the disease, the proved possi- 
 bilities of living without the organ in 
 question, and of getting rid of it by 
 operation, the conclusion could not be 
 evaded that a surgeon who, after due pre- 
 paration, refused the responsibility of 
 such an extirpation was failing in his duty. 
 Recent expeiience in ovariotomy lent force 
 to the conviction that it was a thing to be 
 done, and a earful study of the elaborate 
 treatise. * Die Extirpation der Milz am 
 jMenschen,' by Simon, of Restock, con- 
 firmed my resolution to make the at- 
 tempt. I had to wait for the occasion, 
 but in the autumn of 1863 I was con- 
 sulted by a lady who had a spleen en- 
 larged to 3 or 4 times its natural size. 
 There had been no attack of ague. The 
 face was very pallid, and there was a con- 
 fiidcrable excess of white corpuscles in the 
 blood. The spleen rapidly enlarged. Sir 
 W. Jenner and Sir Ranald Martin con- 
 sulted with me in the spring of 18G4, but 
 the state of the 1 ilood set aside any serious 
 consideration of the question of operation. 
 The patient died in March 18G5, and Mr. 
 Mitchell Clarke, of Clifton, examined the 
 body at my request, with the express 
 
EXTIRPATION OF THE SPLEEN 
 
 183 
 
 object of ascertaining wLat would have 
 been the mechanical difficulties encoun- 
 tered if the large spleen had been removed. 
 He reported that 'it was very easily- 
 drawn through a long incision in the 
 linea alba, and the vessels having been 
 tied in 3 or 4 bundles, it was detached. 
 There was not the slightest adhesion to 
 ixny organ, nor to any other part.' Then 
 came other patients who v/cre not so 
 seriously affected by the tumour as to 
 make a dangerous operation advisable. 
 
 At length a woman, 34 years of age, 
 who had been married at the age of 19, 
 placed herself under my care, evidently 
 dying from a large spleen, Avithout, so far 
 as I could discern, any other disease. She 
 had 3 children, the youngest of whom was 
 born 1 1 years before. She had never mis- 
 carried. The catamenia had been regular. 
 Though weak and of a frail family, she 
 had been as well as usual till the latter 
 part of 1864, when she began to flag, but 
 it was not till April 18C5 that any swell- 
 ing in the abdomen was noticed. It was 
 first observed beneath the lelt false ribs, 
 and grew downwards and to the right. 
 At my first visit, in October 18G5, 1 found 
 the spleen extending as high as the 7th 
 rib, and so low in the pelvis that it could 
 be felt by the vagina in front of the litems. 
 The notch was distinctly perceptible a 
 little above the umbilicus. On the right 
 side, beloAv the umbilicus, it extended 
 within 3 inches of the anterior superior 
 spine of the ilium. On the left side the 
 posterior border was felt free and well 
 defined in the loin. It Avas impossible to 
 ascertain by palpation or percussion Avhere 
 the enlarged spleen and left lobe of the 
 liver met, nor could any enlargement of 
 the liver be detected. Some dilated 
 superficial veins ran over the tumour 
 and left; side of the thorax to the left 
 axilla. There was no oedema of the legs, 
 nor any sign of dropsical effusion nor 
 glandular enlargement. The complexion 
 was rather pallid, but the lips, gums, and 
 conjunctivae Avere of a good colour — in- 
 deed rather liorid. She had been con- 
 fined to her bed for nearly a month, 
 owing to the pain in the abdomen and 
 general uneasiness ; but the appetite Avas 
 tolerably good. There Avas a tendency 
 to constipation. I explained the nature of 
 the disease to the husband, and said that 
 nothing but an operation — which had 
 never been done in England, and only 
 twice abroad, unsuccessfully — offered a 
 
 hope of saving life. I saAv her at intervals 
 until November 14. During three Aveeks 
 .she had been trying to take quinine, 
 iron, and bromide of potassium. The 
 quinine produced headache. The cata- 
 menia had appeared twice Avithin the last 
 month. Her nights had been more dis- 
 turbed by pain ; she had a little cough, 
 but air entered both lungs freely. The 
 heart Avas pushed a little upwards and to 
 the right. The urine Avas acid, deposited 
 urates, and Avas free from albumen. The 
 spleen Avas now rapidly increasing in size. 
 In consultation Sir W. Jenner observed a 
 soft anemic cardiac murmur, and a small 
 tumour just above the umbilicus, to the 
 right of the notch in the spleen, Avhich Ave 
 supposed to be either a splenculus or a 
 part of the pancreas. The blood Avas care- 
 fully examined and a slight excess of white 
 corpuscles Avas noted, but not greater 
 than is often observed in pale persons. 
 
 Sir W. Jenner expressed liis opinion 
 that the patient could not live long if left 
 to medical treatment only, but that ex 
 cision of the spleen did give ' the shadow 
 of a chance ' of saving life. The patient 
 and her husband considered the matter, 
 and I performed the operation, by their 
 desire, on November 20. Mr. Clover ad- 
 ministered chloroform, and I Avas assisted 
 by Drs. Bowen, Ritchie, and Wright. 1 
 made an incision Avhich extended 5 inches 
 above and 2 beloAV the umbilicus, along 
 the outer border of the left rectus. Tavo 
 arteries Avere tied before the peritoneum 
 Avas opened. In opening the peritoneum 
 rather a large arteiy Avas cut across in a 
 piece of omentum Avhich Avas loosely 
 adherent between the surface of the 
 spleen and the abdominal Avail. The 
 vessel Avas tied. The adhering portion of 
 omentum Avas separated, and by putting 
 in my hand and turning the loAver edge of 
 the spleen first through the opening, the 
 Avhole of it Avas easily removed. The in- 
 testines Avere prevented from escaping by 
 Dr. Wright, Avho kept the edges of the 
 opening carefully together behind the 
 spleen, Avhich avus held only by the ves- 
 sels and the gastro-splenic omentum. I 
 Avas beginning to tAvist the spleen round 
 to bring the vessels into a sort of cord, 
 preparatory to applying a ligature, Avhen 
 the splenic vein, Avhich Avys as large as a 
 small finger, gave Avay, and blood ran 
 freely fi-om the spleen ; but none was 
 alloAved to enter the abdomen, and I at 
 once inclosed the vessels in a large clamp 
 
184 
 
 UTERI>^E AND OTHER ABDOMINAL TUMOURS 
 
 and cut away the spleen. Before tying 
 the vessels, temporarily secured by the 
 clamp, I passed eight silk sutures to keep 
 the edges of the incision well together. 
 The peritoneum wns thus protected and 
 the viscera retained while 1 was dealing 
 with the vessels. These Avere tied in 2 
 bundles above the clamp, which was then 
 loosened, and 2 arteries and a vein were 
 also separately tied before it was finally 
 removed. On taking it off I found that 
 part of one end of the pancreas, as large 
 as the end of a thumb, had been bruised 
 by it. All the ligatures, except those on 
 vessels in the abdominal walls, were cut 
 off clcse and returned with the included 
 tissues. The sutures were then tied, and 
 the abdomen was well supported by 
 plaster, pads of lint, and a bandage. The 
 patient was 35 minutes under chloroform, 
 had shown less evidence of shock than 
 was often seen during ovariotomy, and her 
 pulse throughout was between SO and 00. 
 
 The spleen is now in the Museum of 
 the College of Surgeons. It weighed, on 
 removal, G pounds 5 ounces, but 9 ounces 
 of blood drained out of it, leaving the 
 weight 5 pounds 12 ounces. It measured 
 11 inches in length, (S in breadth, and 
 between 3 and 4 in thickness. 
 
 Reaction was .4ow. There Avas not 
 much pain, but the stomach was irritable 
 and the kidneys secreted abundantly. 
 Twelve hours after the operation the 
 pulse rose to 100, and the patient became 
 restless. There was some vomiting, no 
 lympanites, and flatus passed readily both 
 by mouth and rectum. The s^kin con- 
 tinued warm and moist, and there was 
 plenty of urine; without albumen. The 
 patient was fed by the rectum, but at times 
 retained in the stomach some milk and 
 soda-wattr. 
 
 On the morning of the 2nd day there 
 was a violent spasm of the diaphragm. 
 The pulse rose to 112, with hot, dry skin, 
 chest oppression, and some abdominal 
 pain. This was relieved by oDium, given 
 internally, and there was quiet sleep for a 
 few hours till 3.30 of the 3rd day, only 
 waking up occasionally. At that time 
 there Avas a violent rigor, commencing 
 suddenly Avith a feeling of cold in the 
 back. The rigor only lasted for a feAv 
 minutes, but reaction did not take place 
 for half an hour, and Avas followed by 
 profuse perspiration. During the day the 
 patient was able to take milk and soda- 
 water, but at 4 o'clock in the afternoon a 
 
 second rigor, in every respect similar to 
 the former one, took place. The rest ol" 
 the evening the pulse remained at 120 to 
 130, and the urine continued to be secreted 
 in large quantities, notwithstanding the 
 violent perspiration. 
 
 On the morning of the 4th day 6 
 grains of quinine Avere given before the 
 expected attack. There Avas no rigor and 
 the patient slept Avell. The pulse Avas 
 only 96. During the day, egg beaten up 
 and mixed Avith milk Avas given and re- 
 lished. In the afternoon I removed the 
 stitches, and found the Avound was per- 
 fectly united. Some more quinine was 
 given, but as it produced buzzing in the 
 head, it Avas discontinued. 
 
 During the 5th day the patient was 
 remarkably well. She Avas able to enjoy 
 the milk and rusk. Pulse continued about 
 103, rising at night to 120. Some fluid 
 freces Avere passed. The patient also 
 continued Avell during the Gth day. 
 Urine in abundance Avas secreted, and the 
 bowels acted naturally in the morning. 
 Milk given freely. In the afternoon the 
 bowels began to be irritable, and port- 
 wine Avith 10 drops of laudanum Avas in- 
 jected into the rectum. A good deal of 
 flatus passed. At night she Avas very 
 cheerful and comfortable, and there Avas 
 some colour in the cheeks. About 10 
 o'clock she Avas fed moderately and slept ; 
 but about 1 in the morning of the 7th 
 day she aAvoke, complained of cold and of 
 a pain in the back, Avhich .she had felt at 
 each of the previous rigors. The bowels 
 acted very freely. The pulse Avas very 
 feeble, and rose to 150, and the respira- 
 tion to 44. She rapidly became Aveaker, 
 and died about 4 hours after the sudden 
 change — 158 hours after the operation. 
 
 We examined the body 12 hours after 
 death. Decomposition had advanced Avith 
 unusual rapidity. Fluid blood and air 
 bubbled from the superficial veins as they 
 were opened. The Avouud Avas perfectly 
 united, but the cutaneous edges were 
 separated Avithout difficulty. Tlie peri- 
 toneal edges adhered much more firmly. 
 Two ligatures on superficial vessels came 
 away with a very slight pull. A few 
 drops of pus Avere observed in the track 
 of one of the ligatures. There Avere no 
 signs of general peritonitis ; scarcely any 
 serum, and not a trace of blood being 
 found in the abdomen. Redness and 
 effusion of lymph Avere entirely limited to 
 the seat of operation. The ligatures on 
 
EXTIRPATION OF THE SPLEEN 
 
 185 
 
 the blood-vessols were found Avidi diffi- 
 culty, being overlapped by the pancreas, 
 which was large. The liver also was 
 large. The kidneys were healthy. Both 
 pleural cavities and the cavity of the peri- 
 cardium contained a large quantity of 
 dark red serum. The lungs were healthy, 
 although there Avere old pleural adhesions 
 at each apex. The heart was large and 
 flabby, and contained soft clots, which 
 extended along the pulmonary artery to 
 the second divisions. These were the 
 only clots found in the body, the blood 
 elsewhere being thin and fluid, and air 
 bubbling out wherever a vein was opened. 
 
 I did not remove another spleen until 
 1873. The patient Avas a married lady, 
 42 years of age, who had observed a small 
 tumour nearly 20 years before. It had 
 not affected the general health, and she 
 was in no way incommoded, till 1870, 
 when more rapid enlargement took place. 
 Even then she chiefly complained of lassi- 
 tude and weakness of the legs. But in 
 September 1872, when I was first con- 
 sulted,, her condition was such as to bring 
 forward the question of operation, as it 
 was clearly a case of enlargement of the 
 spleen. By May 1873 all repugnance to 
 the proposition had given Avay, and the 
 patient was desirous to run even a serious 
 risk of losing her life, rather than go on 
 in her then miserable state. The cata- 
 menia had been irregular for some time, 
 but had recently reappeared. No notes 
 were furnished to me as to any blood ex- 
 aminations, but there was no history of 
 malarial influence. 
 
 I went to Birmingham to do the opera- 
 tion on IMay 24, and was assisted by 
 Mr. Goodall, Mr. Bartlett, and Mr. G. B. 
 Evans. Dr. Day administered methylene ; 
 and there were present Dr. Tracy of Mel- 
 bourne, Dr. Maxwell of Formosa, China, 
 and Dr. Chadwick of Boston, U.S. 
 
 I have little to say about the operation, 
 which only differed from that in the first 
 case in the incision being along the linea 
 alba instead cf to the left, and that I tied 
 the splenic artery nearer to the aorta. 
 The tumour was nearly double the size of 
 the first, weighing 16 pounds 3 ounces 
 soon after removal, and 12 pounds after 
 all the blood had drained from it. 
 
 There was much sickness and restless- 
 ness after the operation, bvit some hours 
 of sleep during the night, with the skin 
 freely acting. Next day the perspiration 
 was profuse ; sickness continued, but there 
 
 was no restlessness. The vomit on the 
 2nd day ' assumed a coffee-ground cha- 
 racter,' and the abdomen was tympanitic, 
 with some cessation of sickness. The 
 dark vomit reappeared, and on the 3rd 
 day the pulse quickened, and she began 
 to sink, dying about 70 hours after the 
 operation. These symptoms evidently 
 indicate septictcmia. They were much 
 more frequently observed before the 
 adoption of the antiseptic precautions 
 now so much more strictly enforced than 
 in 1873. 1 have little doubt this patient 
 would have been far more likely to have 
 recovered if the operation had been done 
 with all the safeguards that would now 
 be used. 
 
 No post-mortem examination was per- 
 mitted. Mr. Kichards, of the General 
 Hospital, Birmingham, examined the 
 tumour and made drawings. Tumour 
 and drawings were sent to the Museum 
 of the College cf Surgeons, and the fol- 
 lowing is the report which I received 
 li-om Mr. IJichards : 
 
 ' The enlarged spleen, of which the 
 size and colour are accurately represented 
 in the painting, weighs 12 pounds, and is. 
 of the consistency of healthy human liver. 
 The surface is smooth. The finger, passed 
 over the surface, is found to ride over hard 
 nodules which are pretty uniform in size, 
 each nodule being about the size of a 
 cob-nut. One of these nodules, together 
 with a small amount of intervening tissue, 
 is enucleated for minute examination. 
 
 ' The internodular tissue presents the 
 character of ordinary splenic pulp. The 
 nodule has neither capsule nor limiting- 
 membrane, nor large vessels going to it. 
 It is almost as firm and tough as cartilage. 
 On section, the central portion is yellow- 
 like tissue undergoing caseation ; the 
 periphery is purple, like splenic pulp. 
 The two blend insensibly. Fresh scrap- 
 ings show splenic cells, with many large 
 cells the size of human liver cells, con- 
 taining a little granular matter and one 
 small eccentric nucleus. The cells are 
 nearly imiform in size and shape, and 
 nearly spherical. 
 
 ' Microscopical sections of the nodule 
 show it to be composed of splenic cells, 
 with abundant irregular stroma ; here and 
 there are racemose alveoli, containing the 
 large before-named cells. The large cells 
 are in greatest abimdance at the centre of 
 the nodule. I am satisfied that the affec- 
 tion of the organ is not cancerous, nor 
 
188 
 
 LTERINE AND OTHER ABDOMINAL TUMOURS 
 
 sarcomatous, nor any form of amyloid 
 disease.' 
 
 The 3rd and Jast time of my remov- 
 ing an enlarged spleen was in June 1876. 
 The patient was a married woman, 27 
 years of age, sent to me in the previous 
 February by Mr. Jenkins, of Oxford, who 
 in the August of 1875 thought he heard 
 the foetal heart sounds, but as they were not 
 distinguished afterwards, he advised her 
 to see me. She was then about the size 
 of a woman near the end of pregnancy. 
 No fluctuation could be detected in the 
 tumour, and after a too hasty examina- 
 tion, I said it was a case where tapping 
 would be useless, and advised removal of 
 the tumour as soon as she was willing to 
 submit to operation. I did not see her 
 between February and June. In June 
 the tumour was somewhat, but not much, 
 larger than in February, filling the whole 
 of the lower part of the abdomen, extend- 
 ing upwards under the left false ribs, but 
 on the right side only half way between 
 the umbilicus and the right false ribs — 
 not reaching qiiite across to the right 
 superior spinous process of the ilium. 
 The OS and cervix uteri were normal ; 
 the tumour could be felt by the vagina, 
 and when pressed up on the right side 
 moved the cervix. The movements of 
 'the tumour Avere not much influenced by 
 respiration. No distinct fluctuation could 
 be detected, but in some directions it was 
 doubtful. Lumbar sounds were clear on 
 percussion on the right side, dull on the 
 left. A depression, suggestive of the 
 splenic notch, was felt about o inches to 
 the right of the umbilicus. She was a 
 healthy-looking woman, of clear com- 
 plexion, and not emaciated. The cata- 
 menia were regular, neither excessive nor 
 deficient. I have not much to say about 
 the operation, except that Dr. Marion 
 Sims Avas present, and that the tumour 
 weighed 11 poimds, or 7| pounds after 3:^ 
 pounds of blood had drained out of it. 
 This was the only one of my 3 cases in 
 which loss of blood was the cause of death. 
 The reason why the bleeding escaped my 
 notice at the time of operation is explained 
 by the account of the post-mortem exa- 
 mination ; and the obvious lesson of the 
 case is, that the splenic artery should be 
 tied before it divides into its branches, and 
 as near the aorta as it can be done, 
 without cutting off blood supply to the 
 pancreas and left side of the stomach. 
 Probably Franzolini's method of tying 
 
 both artery and vein separately, with two 
 silk ligatures, and dividing the vessels 
 between the ligatures will prove to be the 
 best. 
 
 Eight hours after death the body ap- 
 peared perfectly white and bloodless, and 
 so did the muscles of the abdominal wall 
 when cut into. After taking out the 
 sutures the incision was extended upwards 
 nearly to the ensiform cartilage, and a 
 .short incision carried outwards on the left 
 side, just above the umbilicus, so that a 
 good view of the parts might be obtained 
 without in any way disturbing them. 
 
 The intestines and stomach looked 
 perfectly Avhite, and the latter was much 
 distended Avith gas. No blood nor clot 
 to be seen. The stomach Avas turned up 
 and held on one side so that the liga- 
 tures could be seen, and they Avere found 
 to be holding firmly. The one Avhich Avas 
 applied by transfixion, and tied in tAvo 
 halves, included in each half a large branch 
 or division of the splenic artery and the 
 corresponding veins. The one Avhich Avas 
 applied separately, afterAvards, included 
 nothing but some loose cellular tissue, 
 found to be a part of the gastrosplenic 
 omentum. Close to this Avas a piece of the 
 spleen, about the size of a Avalnut, also 
 held merely by loose cellular tissue. A 
 considerable quantity of bright red fluid 
 blood was sponged out, and at least a 
 pound of dark coagulum Avas then re- 
 moved, and a large dark mass brought 
 ijito view, Avhich proved to be a quantity 
 of coagulum, inclosed in a bag formed by 
 the connections of the pancreas, duodenum, 
 and parts included in the first two liga- 
 tures. On incising this and removing 
 the clot — of Avhich there Avas as much as 
 6 to 8 ounces — the points from Avhich the 
 main ha?morrhage had occurred Avere 
 found. They appeared to be some of the 
 smaller divisions of the splenic artery, 
 including the vasa brevia and a small 
 branch passing to the pancreas. 
 
 The chief haemorrhage liad therefore 
 occurred from divisions of the artery, the 
 main branches of which Avere included in 
 the first two ligatures ; but the trunk, 
 before bifurcation, had not been secured. 
 The posterior part of the peritoneal 
 cavity contained some clot and fluid blood, 
 and the pelvis Avas full of fluid, which 
 appeared chiefly blood. The Avhole of 
 the haemorrhage had taken place origin- 
 ally into the sac named above, formed by 
 the connections of the pancreas, duodenum, 
 
EXTIRPATION OF THE SPLEEN 
 
 187 
 
 and spleen, and when this would hold no 
 more, the blood had escaped from an 
 opening in it posteriorly. Hence, until 
 the parts were turned aside, there was 
 no appearance of the extensive htenior- 
 rhage which had taken place. 
 
 I have only seen one case of a splenic 
 cyst, and that was in a lady whom I at- 
 tended several years ago with Sir W. 
 Jenner. The diagnosis was very doubt- 
 ful, owing to the presence of gas, as well 
 as fluid, in the cyst before I tapped it. 
 The contents were chiefly decomposed 
 blood, with very fetid gas; but by di'ain- 
 age and daily injections of iodised water 
 for more than a month, the patient quite 
 recovered and remained for several years 
 in good health. I have seen 2 other 
 cases of enlarged spleen where operation 
 was contemplated ; one with Dr. Wilson 
 Fox, where the spleen gradually dimin- 
 ished under the influence of reduced iron ; 
 and another, a young lady from Trinidad, 
 for whom I made an exploratory incision 
 in June 1883, but did no more than clear 
 the peritoneum of ascitic fluid, as the 
 spleen was not very large, was intimately 
 connected with the pancreas and the liver, 
 and there was a A'ery clear history of con- 
 siderable variations in its size. She went 
 to Dieppe, and I heard some months 
 afterwards that the splenic tumour could 
 scarcely be detected. I heard lately that 
 she married in 1884, and is now well. 
 
 I arather from the interesting mono- 
 graph on Splenectomy, by Franzolini. of 
 Udine, published in 1882, that, from the 
 first case by Quittenbaum, in 1836, up to 
 Franzolini's own case in 1881, 28 cases of 
 extirpation of the spleen in the human 
 subject had been recorded. Twenty-two 
 of these were in women, 4 in men, and 2 
 doubtful. One was a simple, and one an 
 hydatid cyst of the spleen. Four cases 
 are described as movable spleen ; all the 
 others as simple, malarial, or leuka?mic 
 hypertrophy. Only 5 of the patients re- 
 covered — the 1st, a cyst ; the 2nd, a 
 simple hypertrophy, the tumour weighing 
 less than 3 pounds; the 3rd, a movable 
 spleen, the size a little more than normal ; 
 the 4 th, also movable, measuring 23 
 centimetres in length, 12 in breadth, and 
 G in thickness; the 5th, Franzolini's own 
 case, where the Aveight was scarcely over 
 3 pounds. The tumours in my own 
 cases appear to be the largest yet removed. 
 Nearly all the deaths seem to have been 
 from htemorrhage and collapse. Crede 
 
 has collected 30 cases up to 1881, most 
 of tliem the same as Franzolini's. Of 
 these KJ were leukaimic, and all died ; of 
 the remaining 14, o died and 9 recovered ; 
 of the 9 recoveries, in 1 the spleen it- 
 self was normal and free in a peritoneal 
 abscess, in 4 the spleen was simply 
 hypertrophied, in 2 movable, or what is 
 termed ' wandering spleen,' and 2 were 
 splenic cysts. 
 
 These facts, and the two operations 
 which I performed after my first, do not 
 lead to any important modification of the 
 following remarks, made in commenting 
 on my first case, and published in the 
 ' Medical Times and Gazette,' vol. i. 18G4 : 
 
 ' The cases of Quittenbaum and Kiich- 
 ler had tauglit that a large spleen could 
 be easily removed ; but as 1 patient only 
 lived 2 hours and the other only 6 hours, 
 it was doubtful whether a human being 
 would recover from the immediate efiEects 
 of the operation. The case now recorded 
 does at least make this addition to our 
 knowledge. 
 
 ' It also proves that neither haemor- 
 rhage nor peritonitis necessarily follows 
 the operatiori. Some alteration in the 
 blood, which becomes fluid, and permits 
 of a rapid exudation of serum into the 
 pleural or other serous cavities, may per- 
 haps prove in other cases, as in this, to be 
 the chief danger to be dreaded. 
 
 ' The principal difference between the 
 operative proceedings of Quittenbaum and 
 Kuchler and my own was in the re- 
 moval of the ends of the ligatures which 
 secured the splenic blood-vessels. In their 
 cases the ends of the ligatures Avere left 
 and brought out through the wound. I 
 had found a similar mode of dealing Avith 
 the ligatures which secure the pedicle in. 
 ovariotomy to be so A^ery rmsuccessful — 
 the threads acting as setons and setting 
 up peritonitis — that I determined (if the 
 clamp made much pull upon the stomach) 
 to cut off the ends of the ligatures and 
 return them AA'ith the included tissues — a 
 proceeding Avhich has led to A^ery good 
 results in ovariotomy. In dogs, two ov 
 three turns of the spleen, tAvisting the 
 blood-vessels, are often enough to stop 
 bleeding Avithout any ligature; but al- 
 though this may answer Avith a spleen of 
 natural size in a dog, it could not be 
 thought of, except as a preparative for the 
 ligature, in the case of a large spleen in 
 man. But my trial shoAvs that it Avould 
 be better not to attempt it, for the splenic 
 
188 
 
 UTERINE AND OTHER ABD03IINAL TUMOURS 
 
 vein burst before one turn was completed. 
 If I were to oj^erate again, I would tie the 
 vessels in separate bundles as they enter 
 the spleen, and then cut away the organ. 
 
 ' The parallel between the operation 
 for the removal of an enlarged spleen aud 
 an enlarged ovary ends with the operation 
 itself. The successful removal of one 
 ovary is frequently followed by the most 
 jierfect health of the woman, Avho may 
 bear children of both sexes. Whether a 
 human being would enjoy good health 
 without a spleen is a question still waiting 
 for a satisfactory answer. Experiments on 
 other animals may be objected to, although 
 the impunity with which the organ may 
 be removed and the good health of the 
 animal for years after does seem to imply 
 that the offices it performs cannot be of 
 very great importance, and may be per- 
 formed by the lymphatic glands or some 
 other organs. Dr. Wilks says that the 
 spleen may be " shrunken into so small a 
 compass, and surrounded by so thickened 
 a capsule, that its enlargement seems im- 
 possible, and its appearance would suggest 
 that the functions of such a withered 
 organ had altogether ceased. Yet, if so, 
 there are no symptoms to indicate its loss." 
 (" Guy's Hospital Reports," Third Series, 
 vol. xi. p. 41.) 
 
 ' Many cases have been recorded which 
 prove that after partial or total removal 
 of the spleen by accident life may be pro- 
 longed, but there is little satisfactory in- 
 formation as to the length of life or state 
 of health of the individuals. 
 
 ' In one remarkable case a woman, 30 
 years of age, who had fever in January 
 1711, had swelling and pain in the leit 
 side of the abdomen, followed l)y swelling 
 of the left foot and leg, and in February 
 by a ielid discharge from the uterus. 
 For the next four months she became 
 thinner, and fluctuation Avas detected in 
 the abdominal swelling. Ferrerius then 
 made a puncture 3 fingers' breadth below 
 the umbilicus to the left side, from which 
 a discharge of fetid pus was kept up for 
 many days. A second and larger opening 
 higher up, near the tunbilicus, then oc- 
 curred spontaneously, and the matter was 
 discharged through both. The patient 
 became nuicli emaciated, when the surgeon 
 saw a bluish body at the upper opening 
 and removed it Avithout much trouble. It 
 was H fingers in length, 2 in thickness, and 
 the same in breadth. It was examined by 
 Fantoni, and found to be the spleen. The 
 
 patient began to improve at once, but for 
 several days a portion of her food passed 
 through the opening near the umbilicus, 
 as if the abscess about the spleen had been 
 complicated by a gastric or intestinal fis- 
 tula. But the wound healed, the patient 
 recovered her strength, had a good colour, 
 the catamonia returned regularly, she be- 
 came pregnant, and bore a healthy child ; 
 but from this time the abdomen began to 
 swell again, and during a year different 
 parts of the body, especially the head, 
 Avero attacked. 
 
 ' This is one of the most complete 
 accounts we have as to the state of health 
 after loss of the spleen. It is qi;oted by 
 Hecker and Simon from Fantoni's " Opus- 
 cula iMedica," published at Geneva in 173s. 
 Cases in which, after penetrating Avounds 
 of the abdomen, tlie Avhole of the spleen or 
 portions of it have been removed are on 
 record, but I have only been able to meet 
 Avith tAvo Avell-authenticated cases Avhere 
 the avhole spleen Avas removed. The first 
 Avas in 1G78 by Mathia ; it is related by 
 CrUger and quoted by Simon. A Avatch- 
 man, 23 years old, Avas stabbed. The 
 spleen protrtided. The vessels were tied 
 and the spleen ci;t aAvay 3 days afterwards. 
 There Avas free bleeding, but it Avas stopped 
 by a styptic poAvder, and the man Avas 
 Avell in 3 weeks. The divided A'essels 
 formed a lump of the size of a hazel-nut, 
 and adhered to the cicatrix. The man 
 returned to his duties, and Avas seen in 
 good health 6^ years after the accident. 
 
 ' The second case occurred in 1815, 
 and is recorded by Lenhossek (Ilecker's 
 " Annalen," Berlin, 1 S2S). A youth of 1 !) 
 Avas Avounded in the abdomen. The spleen 
 protruded, and, as it Avas becoming gan- 
 grenous, it Avas cut away after tying the 
 vessels. The Avound healed, and in iSlS 
 the man was quite Avell. 
 
 ' Cases of partial excision of the spleen 
 are much more numerous, but 1 shall only 
 refer to one recorded by Bcrthet, in 1844, 
 Avhere a man lived and enjoyed good 
 healtli for 13 years after a Avound followed 
 by hernia and extirpation of a large portion 
 of the spleen. He died of acute pneu- 
 monia, and after death only a small piece 
 of spleen Avas found, the size of a hazel- 
 nut, Avhich Avas adhering to the stomach. 
 The case is quote I by Gray and Simon 
 from the " Archives Generales de Mede- 
 cine," 1S41. These cases of partial exci- 
 sion are of farlessphysiological importance 
 than cases of total excision ; for Dr. Crisp 
 
EXTIRPATION OF THE SPLEEN 
 
 189 
 
 has shown that if a portion of the spleen 
 be left it may grow, and the organ may be 
 more or less completely reproduced. This, 
 Dr. Wilks observes, is " quite in harmony 
 ,^vilh the simple hypertrophy of the spleen, 
 for if an organ of a given size can grow to 
 several times its normal standard, there 
 appears no reason why a small portion re- 
 maining after an operation should not 
 again grow to the original dimensions " 
 {pp. cit. p. 40). This remark prepared 
 me to leave a portion of the spleen in my 
 patient, if I found it possible to do so, or 
 the splenculus, if, as wc thought probable, 
 it had existed. Possibly it niiglit be ad- 
 visable to act on this principle in a case 
 where it could be done safely. 
 
 ' If it be asked, " In what cases may 
 an enlarged spleen be excised ? " the con- 
 clusion would seem to be that they can be 
 only very few. If a large spleen were 
 wounded, or ruptured, or caused obstruc- 
 tion of intestine, the operation might 
 be the only means of saving life. But in 
 the absence of some such accident imme- 
 diately endangering life, it is not often 
 that a patient has a large spleen and has 
 not some co- existing disease of liver, 
 kidneys, or lymphatic glands, which would 
 •either prevent the success of the operation, 
 or would destroy the patient soon after 
 the recovery from its immediate effects. 
 Where no such disease co-exists, then 
 probably the ill effects of the large spleen 
 nre either too slight to warrant a dan- 
 gerous operation, or the general condition 
 of the patient is too bad to give any reason- 
 tible prospect of recdvery. This is espe- 
 •cially true Avith regard to that form of 
 enlarged spleen wliich follows ague. 
 Either it is amenable to treatment, or, if 
 the patient be ill enough to induce the 
 surgeon to think of an operation, the 
 general health is so broken up and the 
 blood is so altered, rhat a simple cut or 
 ulcer may lead to dangerous bleeding, and 
 a fortiori a serious 0[ieration would most 
 likely be fatal. The relation which the 
 enlarged spleen after ague bears to the 
 accompanying leukaemia, bydra^mia, or 
 melanoBmia, is a prf)l»lem which has still 
 to be solved; and, ev>-n in the leukaemia 
 which occurs independently of ague, it is 
 still a matter of doiii)t whether the en- 
 largement of the spl'en or the alteration 
 
 in the blood bears always the same relation 
 of cause and effect. But as it has been 
 proved experimentally that the blood 
 which issues from the spleen by the splenic 
 vein does contain a much greater number 
 of white corpuscles than the blood in tlie 
 general circulation, and it is known that 
 in simple hypertrophy of the spleen there 
 is a great increase in the proportion of 
 white to red corpuscles in the blood 
 throughout the body, it woidd seem to be 
 a fair presumption that removal of the 
 spleen by cutting off the supply of the 
 white corpuscles which are in excess,- 
 might save the life of persons who would 
 otherwise die of leukaemia.' 
 
 In 1882, Dr. B. Credo brought a case 
 of extirpation of the spleen before the 
 German Surgical Congress at Berlin, and 
 published a valuable paper on the subject 
 in ' Langenbeck's Archiv ' in 1883. He 
 removed in September 1881, from a man 
 44 years old, a spleen which weighed about 
 15 ounces, after about 56 ounces of fluid 
 had been withdrawn from a cyst. He 
 tied all the vessels separately with cat- 
 gut, cutting off the ends close to the knots. 
 The patient recovered, and 10 months 
 after the operation was in good health, 
 working as a mason. His conclusions, 
 after a careful study of the whole subject, 
 agree very nearly with my own in 18G4 
 repeated above, but with additions to the 
 effect that in the animal organism the 
 spleen serves for the transformation of the 
 white corpuscles of the blood into red, 
 and that adults are not injured by loss of 
 the spleen, although its removal may cause 
 transitory disturbance in the formation of 
 the blood, and swelling of the thyroid 
 gland which may, for a time, supply the 
 functions of the spleen. 
 
 The discussions here, which followed 
 the cases of Mr. Hayward in 1882, and 
 of Mr. Spanton in 1883, led to the conclu- 
 sion that, in cases of leucocythajmia, the 
 enlarged spleen should certainly not be 
 removed until after the free use oi:' re- 
 duced or dialysed iron; and that the 
 best results are to be hoped for in cases 
 of simple or malarial hypertrophy. The 
 alternative proposal of tying the splenic 
 artery cannot be tried on the human 
 subject until sufficient experiments on 
 the lov/er animal have been made. 
 
190 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 CHAPTER IV 
 THE OPERATIVE SURGERY OF THE KIDNEY 
 
 KEPHKORAPHY ; TAPPING AND DRAINAGE ; NEPHROTOMY ; NEPHROLITHOTOMY ; NEPHRECTOMY 
 
 Students who have followed the exten- 
 sion of the domain of peritoneal surgery, 
 from the revival of ovariotomy to the 
 removal of uterine and splenic tumours, 
 however great their expectations as to 
 further progress, must still be surprised 
 at the very rapid development, Avithin 
 the last few years, of the surgery of the 
 kidney, even more than that of other de- 
 partments of abdominal surgery. Twenty 
 years ago tapping a renal cyst was a 
 novelty. An abscess occasionally made 
 Avay for the passage o£ a renal calculus ; 
 very rarely a tumour, supposed to be 
 ovarian or uterine, was found to be renal 
 after an operation had been begun, and 
 the operation Avas either left incomplete 
 or the kidney Avas remoA^ed Avith the 
 tumour, after tying the renal A'essels, as 
 the only mode of stopping bleeding; or 
 the fact of the removal of the kidney 
 was not discoA^ered imtil after the com- 
 pletion of the operation. On the last 
 contingency a useful purpose Avas served, 
 as experiments on the loAver animals 
 proving that one kidney might be re- 
 moved Avithout serious ill consequences, 
 and that the remaining kidney fulfilled 
 all the necessary excretory functions, Avere 
 confirmed by the condition of the patients 
 Avho had been subjected to such an unin- 
 tended operation. One such case occurred 
 to me 18 years ago. It has been included 
 in Mr. Barker's, and in other tables; and 
 all I need say of the case noAv is, that, 
 although the patient died of septictcmia, 
 the removal of the kidney did not appear 
 to have had any special influence on the 
 progress of the case. There Avas nothing 
 in the lU'inc after operation unusual after 
 ovariotomy. This Avas very carefully 
 examined, as the Avhole of the left kidney 
 and the ureter Avere known to have been 
 removed, together Avith a solid tumour 
 which Aveighed !]_, pounds, and a cyst 
 which had contained IG pints of fluid. 
 
 Many years before this case, in 1848, 
 I opened a perirenal abscess in the 
 loin of a sailor in II. M.S. ' Tra- 
 falgar,' and finding a renal calculus on 
 probing the abscess, easily removed it; 
 and another a few days afterAvards. In 
 
 185-4, I exhibited at the Pathological 
 Society a calculus found by Dr. Bence 
 Jones to consist of uric acid, which I had 
 removed after opening an abscess by the 
 side of the rectum of a gentleman. It 
 had no doubt been arrested just Avhere the 
 ureter passes through the coats of the 
 bladder, as there Avas free escape of urine 
 for some days after its removal, though 
 this gradually ceased, and there was no 
 further trouble. Twice since I have re- 
 moved a renal calculus from the loin 
 after opening an abscess. 
 
 Fifteen years ago another case taught 
 us to Avhat a large size tumours of the 
 kidney, or closely connected Avith it, may 
 attain. It Avas also illustrative of the 
 difficulties surroimding the question as 
 to the point of origin. A single Avoman, 
 aged 35, Avas admitted into the Samaritan 
 Hospital in December 1870, Avith the 
 abdomen greatly enlarged. There Avas 
 extreme oedema of the abdominal AA'alls. 
 Fluctuation Avas scarcely perceptible, and 
 only doubtful in the loAver part of the 
 abdomen ; there AA^as no crepitus, and the 
 sounds on percussion Avere dull all over 
 the swelling. The uterus appeared to 
 be small, normal in size, and movable. 
 No tumour could be felt in the pelvis. 
 She had gradually attained her very great 
 size since the spring of 1870. The tume- 
 faction of the abdominal Awalls Avas too 
 great to admit of any satisfactory diag- 
 nosis as to the nature of the tumoiir. 
 This could be only ascertained by an ex- 
 ploratory incision, Avhich Avas accordingly 
 made l:)et\veen the umbilicus and sym- 
 physis pubis to the extent of 6 inches. 
 Much serous fluid escaped, and 3 or 4 
 superficial vessels Avere tied. Four or 5 
 pints of clear scrum floAved out Avhen the 
 peritoneal cavity Avas opened, and a solid 
 tumour was exposed, very firmly adherent 
 and Avascular on its surface. One large 
 vein at the upper part bled so freely that, 
 after vainly trying to apply ligatures (for 
 the soft granular tissue gave Avay before 
 the silk), I used the actual cautery and 
 solid perchloride of iron. The Avound 
 Avas closed Avith sutures and long bands of 
 strapping. It did not unite Avell, and 
 
OPERATIVE SURGERY OF THE KIDNEY 
 
 191 
 
 after 2 or 3 Aveeks it opened, and 
 allowed the tumour to protrude a little. 
 There was continued drainage of serum 
 from the gaping incision, and from punc- 
 tures made at various times in the legs 
 and thighs, which relieved the urgent 
 dyspnoea and prolonged life ; but the 
 patient gradually got weaker, and died 
 8 Aveeks after the operation. 
 
 The tumour Avas found adherent to 
 the abdominal Avails, to the liver, omen- 
 tum, and descending colon. Behind, it 
 v/as inseparably connected Avith the right 
 kidney, which had to be removed Avith 
 it. The tumour alone Aveighed 84 pounds. 
 The uterus and both ovaries Averehealth3\ 
 Dr. Wilson Fox reported that the tumour 
 was 'fibro-plastic,' that the right kidney 
 could only be separated from it by cn.reful 
 dissection, and that it probably originated 
 in the kidney, or in the peritoneum 
 covering it. Portions of the tumoiu* are 
 preserved in the Museum of UniA'ersity 
 College. 
 
 In going over tables of operations on 
 the kidney, it is interesting to remark 
 that, Avhile 20 years ago a large proportion 
 of the operations Avere performed after 
 an error in diagnosis, during the last 
 few years a A^ery correct diagnosis before 
 operation has been the rule, and a mistake 
 an exception. 
 
 In 1877 I Avas led into error in a 
 patient Avho Avas admitted into the Sama- 
 ritan Hospital, supposed to be the subject 
 of an ovarian cyst, Avith a history of 3 
 tappings Avithin the preceding 5 years, of 
 44, 46, and 52 pints of fluid, by surgeons 
 Avho had no doubt about the fluid being 
 ovarian. After incision and removing 31 
 pints of fluid, and more than a pound of 
 cyst Avail, it Avas found impossible to get 
 aAvay the" rest of the cyst. A drainage- 
 tube was inserted, and the patient died 
 on the 5th day. The cyst Avas clearly 
 one of the left kidney, the main cavity 
 being formed by one of the calyces. 
 
 Among the affections of the kidney 
 which most frequently come under our 
 notice, I may mention painful, moA^able, 
 or floating kidney, hydronephrosis, pyo- 
 nephrosis, formation of stone in the 
 kidney, cystic degeneration, growth of 
 hydatids, tumours either in the substance 
 of the kidney or closely attached to it. 
 For information on the questions of diag- 
 nosis Avhich come up in connection Avith 
 these cases, I may refer to the chapter 
 on Differential Diaixnosis in Part I. 
 
 MOVAELE OR FLOATING KIDNEY 
 
 forms an abdominal tumour occasionally 
 tender on pressure, and painful itself, but 
 more frequently neither tender nor pain- 
 ful, and only causing uneasiness in 
 patients or anxiety in their medical 
 attendants, because of the uncertainty as 
 to the precif^e nature of the tumour and 
 the possible future consequences. When 
 assured that the tumour is nothing more 
 than a kidney Avhich is too movable, and 
 that nothing more need be recommended 
 than an abdominal belt, most patients 
 are perfectly satisfied. Occasionally the 
 kidney is somcAvhat enlarged and tender, 
 but this is mostly the eifect of iinnecessary 
 handling, and disappears with rest and 
 quietness. Sometimes a mass of hard 
 fgeces in the colon curiously resembles a 
 movable kidney, Avhich may also be 
 simulated by a cancerous groAvth involv- 
 ing some part of the intestines. But I 
 have seen a great many cases Avhere I 
 have excluded these and other sources of 
 fallacy, and have convinced myself that 
 one or both kidneys Avere abnormally 
 mobile. In Avomen, I have almost always 
 found that it Avas the right kidney. I 
 attended a lady Avith Dr. Wilson Fox, 
 seeing her from time to time for several 
 years, on account of a tumour Avhich Ave 
 both believed to be a movable I'ight kid- 
 ney. It could be pushed into the loin, 
 and across the abdomen as far as the 
 umbilicus, and in size and shape exactly 
 resembled the kidney. At length she 
 began to suffer from an ei:ilargement of 
 the left ovary. This attained a consider- 
 able size, and I removed it. Taking the 
 opportunity of examining the supposed 
 movable kidney, I found it AA'as the right 
 ovary, lying just above the right kidney, 
 Avith a slender pedicle at least a foot 
 long. In size, shape, and consistence it re- 
 sembled a kidney, and I removed it. The 
 patient recovered, and is still quite well. 
 In other cases of supposed moA^able kidney, 
 I have found that the tumours were pedun- 
 culated outgroAvths from the uterus, but 
 I have no doubt Avhatever that movable 
 kidneys are not unfrequently met Avith. 
 I have never myself knoAvn them cause 
 sufiicient inconvenience even to raise the 
 question of operative interference. But 
 there are many cases on record where 
 they have led to nephrectomy, or to the 
 operation of fixation, recently styled 
 ' nephroraphy.' Never having yet seen 
 
192 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 the necessity of either removing or fixing 
 a movable kidney which was not enlarged, 
 I must be content with referring those 
 who are interested in the subject to an 
 interesting paper by Professor Ceccherelli, 
 of Parma, published in the 'Rivista 
 Clinica' of April 1H84, entitled 'La 
 Nefrorafia nel Rene Mobile.' 
 
 TAPPING OF RENAL CYSTS 
 
 I have only 3 times tapped renal 
 cysts. These cases were remarkable, and 
 some account of them follows: 
 
 Pjionephrosis of the r/'t/ht kichieij, ivith 
 impaction of two calculi in the ureter. — 
 On May 16, 1865, I was called to see 
 the mother of a patient upon whom I had 
 performed ovariotomy successfully, the 
 daughter telling me that her mother had 
 a tumour like that which I had removed 
 from herself I found the patient in pain 
 all over the abdomen, but greater on the 
 Ti"ht side and in the right loin ; and 
 I felt a hard tumour between the right 
 false ribs and the right ilium, reaching 
 forward to within an inch or two of the 
 umbilicus. 
 
 The patient was r)0 years of age, 
 and had borne 5 children. Her last child 
 was 17 years old. Before the last con- 
 finement her health had been good. This 
 labour was protracted, the presentation 
 having been transverse. Ever since, she 
 had been subject at times to pain in the 
 back and right loin. It used to come on 
 suddenly, increase in violence, and pro- 
 duce shivering and nausea. After 6 or 8 
 hours it would cease. Her urine at the 
 time of the attacks was visually thick, 
 with a yellowish sediment ; at other times 
 it was clear. For 5 years such attacks 
 recurred pretty regularly every G weeks. 
 Then, after a more active life, they re- 
 curred more frequently, scarcely a week 
 intervening from one to another. In 1860 
 the catamenia ceased, and the attacks 
 became milder and less frequent, and she 
 was entirely free for a year or more. In 
 1862 the pains suddenly recurred with 
 more violence than ever. After great 
 suffering for several liours ' a dozen or 
 two of little stones, as large as a pin's 
 head,' were passed with the urine. From 
 that time to the present attack she had 
 been quite well. On May 8, 1865, while 
 out walking, she stumbled and fell upon 
 her abdomen. She was lifted up, com- 
 plaining of great abdominal pain. She 
 
 got home, went to bed, and next day the 
 pain was so great that she was unable to 
 get up. During the next 6 days she 
 passed a good deal of blood in the urine, 
 and she perceived, for the first time, a 
 tumour as large as a cricket-ball in the 
 right side of the abdomen. On the 15th 
 the pain, which had almost ceased, re- 
 turned suddenly with great violence, and 
 I was sent for. She was much relieved 
 by an opiate prescribed ; and I made a 
 careful examination of the tumour. It 
 could be felt below the right false ribs, 
 but its margins could not be made out 
 very distinctly. They appeared to be 
 overlapped, on the right by the caicum, and 
 on the left by small intestine. Wherever 
 the tumour could be distinctly felt, it 
 gave a dull note on moderately strong 
 percussion, but a clear one on deeper 
 pressure and sharper percussion. By 
 pressure forwards with one hand on the 
 right loin, while the other was on the 
 front of the tumour, a trace of fluctua- 
 tion was detected. Pain was kept in 
 check by opiates, and on May 19th there 
 was a prominent point near the middle 
 of the tumour. Fluctuation being distinct, 
 
 1 inserted a very fine trocar at this point 
 (which was midway between the umbilicus 
 and right anterior superior spine of the 
 ilium) and drew off between 2 and 3 
 pints of thin pus, by a syringe attached 
 to the canula by an air-tight joint. The 
 urine, before the tapping, had been clear, 
 but the day after it was found by Dr. 
 De Mussy to be loaded with pus. On 
 the 27th, notwithstanding continued escape 
 of pus through the bladder, the tumour 
 was as large as before the tapping. I 
 therefore tapped again, and after removing 
 
 2 pints of pus, left the wound unclosed. 
 There being no discharge afr.(?r 2 days, 
 I inserted a larainaria tent, having re- 
 opened the wound with a lancet. 
 
 A very free discharge went on for the 
 next fortnight. At first it was purulent, 
 but afterwards it consisted of clear fluid, 
 which was found to contain urea. The 
 urine became clear and free from pus. 
 Early in the morning of June 20 great 
 desire was felt to pass water. After much 
 difficulty and pain a calculus of uric acid 
 and urate of ammonia, as large as a broad 
 bean, and much of the same shape, was 
 passed, and was soon followed by a second 
 of .similar dimensions. Relief was im- 
 mediate. On July 1 there was still a 
 little discharge, perhaps 1 ounce in 24< 
 
O^ERATI^'E SURGERY OF THE KID^'EY 
 
 hours. Tlie abdomen was everywhere 
 clear on percussion ; but on deep pressure 
 a hard painless tumour, as large as an 
 orange, was to be felt in the right loin. 
 After a few weeks this could no longer 
 be felt. She died in 1880, after several 
 years of good health. 
 
 This case is in many respects very 
 instructive. The patient probably had a 
 tendency to deposit uric acid before her 
 last labour. The effects of that pro- 
 tracted labour led perhaps to the train of 
 symptoms which ended, for a time, in 
 the passage of numerous small calculi. 
 Then, in 18G3 or 1864, two renal calculi 
 began to form, and set up chronic pyelitis. 
 The fall in 1865 dislodged the calculi, 
 and they blocked up the ureter. The pus 
 and urine accumulated behind the calculi 
 and distended the pelvis of the kidney 
 into the cavity from which 1 removed the 
 large quantity of pus at the first tapping ; 
 and it was not till the calculi passed on 
 into the bladder and left the ureter free 
 that the formation of pus ceased and the 
 artificial opening closed. 
 
 Renal cijst tvith calculi; tcqyping. — 
 A single lady, 59 years of age, first con- 
 sulted me in June, 1865. She had then 
 a tumour which filled all the left side of 
 the abdomen and extended upwards under 
 the left false ribs. It had been observed 
 for nearly 2 years, but its increase had 
 only been rapid for about 6 months. 
 In August 1866 fluctuation was detected 
 in the upper part of the tumour, and 5 
 or G pints of yellowish pyoid fluid, with 
 mucous flakes floating in it, were re- 
 moved by tapping. A roll of intestine 
 adhered to the upper part of the tumour 
 on the right side. Relief followed the 
 tapping for a time ; but a second tapping 
 was necessar}'' in November, The true 
 nature of the tumour then became 
 apparent. The presence of intestine in 
 Iront of the tumour, and the limitation 
 of the tumour to the left side of the 
 abdomen, while the uterus was freely 
 movable, were the chief guides in diag- 
 nosis, as the urine was normal, and there 
 was nothing characteristic in the fluid 
 removed by tapping. In April 1867 the 
 patient fell Avhen out walking and rup- 
 tured the cyst. She died 28 hours after- 
 wards ; and Dr. Morton, of the Abbey 
 Road, found a large quantity of turbid 
 fluid in the peritoneal cavity, correspond- 
 ing with similar fluid found in a large 
 raptured cyst of the left kidney. The 
 
 renal tumour filled all the left half of the 
 abdominal cavity. Its lower end dipped 
 down into the pelvis, but was quite free. 
 Its upper end adhered to the spleen. The 
 ruptured cyst contained, besides the fluid, 
 a quantity of very thick viscid mucus, 
 and seven calculi of varied chemical 
 composition. The largest was Ig inch 
 in its long diameter; the smallest 
 was as large as a hazel-nut ; two Avere 
 smooth ; five were rough, and very 
 irregular in outline. One calculus Avas 
 loose in the cavity, as well as a quantity 
 of lithic acid gravel. The other calculi 
 were imbedded in the pelvis and dilated 
 calyces. The ureter was completely 
 occluded, and no communication could be 
 found Avith the bladder. The right kidney- 
 was slightly enlarged, . The uterus and 
 its appendages were healthy. The calculi 
 are in the Museum of the College of 
 Surgeons. 
 
 Eencd cyst; tapping. — In 1875, a 
 young lady, 22 years old, was brought to 
 me from Boston, U,S.. with a history and 
 description of her case as one of simple 
 ovarian cyst. She had suffered a good 
 deal Avith bladder irritation, Avithout much 
 injur}' to her health. I found a fluctuat- 
 ing tumour about the size of a cocoa-nut 
 on the right side, betAveen the pelvis and 
 umbilicus. Urine sp. gr. 1012, pale, 
 cloudy, acid and albuminous, Avith granu- 
 lar corpuscles, single and in groups, vary- 
 ing in size, some Avith single, others Avith 
 several smaller nuclei, and like pus cor- 
 puscles. 
 
 On Jul}' 3 I tapped and dreAv off 4 
 pints of slightly opalescent fluid, sp. gr. 
 1006, which, though it frothed Avhen 
 poured from one vessel to another, looked 
 like pure water. Reaction alkaline, and 
 heat caused no change. The chemical 
 tests Avere equivocal, and the microscope 
 showed nothing. On July 13 the urine 
 Avas found to be charged Avith pus, dis- 
 integrating red blood-corpuscles, and an 
 immense number of round and irregular 
 shaped epithelial cells, undergoing vacuo- 
 lation, and proliferating. These cells 
 Avere not bladder epithelium, and it re- 
 mained doubtful Avhether they Avere from 
 some neAV growth, or from the irritated 
 surface of the ureter. 
 
 Great temporary relief Avas afforded 
 by the tapping, and the patient Avent to 
 Edinburgh, Avhere she Avas again tapped 
 by Dr. Keith. I saw her in Edinburgh 
 in August 1875, and left her in Dr. 
 
 
 
194 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 Keith's charge. After about G weeks 
 several pints of pus escaped in the urine. 
 In October she returned to America. 
 Before long an abscess in the loin was 
 opened. A fistula remained, and at the 
 end of about G years she Avrote to Dr. 
 Keith, saying she Avas very well, Aveighing 
 140 pounds. Subsequently the fistula 
 not closing, it was injected with strong 
 carbolic acid. All sorts of troubles fol- 
 lowed, and I heard of her in the autumn 
 of 1883 as being quite bed-ridden. If 
 one had knoAvn 10 years ago all that we 
 BOW know of renal surgery, as soon as 
 tapping the cyst had proved to be merely 
 palliative, something more tnan injection 
 and drainage would certainly have been 
 suggested. 
 
 Tapping and draininf/ renal cyst. — 
 Towards the latter end of 1877, not long 
 before I changed my position of surgeon 
 to the Samaritan Hospital for that of 
 consulting siu-geon, I admitted a young 
 countrywoman with 2 tumours, both 
 deeply attached in the situation of the 
 kidneys. Fluctuation was quite distinct 
 in the right tumour, but could not be 
 made cut in the left, Avhich was small. 
 There Avas no tenderness in front, but it 
 was marked in the lumbar region on the 
 right side, Avhere there Avas also redness, 
 SAvelling, and fluctuation. The right thigh 
 had also SAVollen since the back had 
 become bad. She dated the first signs of 
 her ill-health to Avhat Avas said to be an 
 attack of inflammation of the kidney, 2 
 years after her confinement, Avhen she 
 Avas only 15. 
 
 On November 21 Itajiped the tumour 
 in the right loin, leaving a tube in the 
 cyst for drainage. An immense quantity of 
 fluid came aAvay into the bed, rendering 
 the cyst quite flaccid. The next day 
 there Avas nearly the same amount of dis- 
 charge. Then it became purulent, and 
 the tube was shortened, after which the 
 discharge resumed its serous character. 
 Urine Avas all the time abimclantly 
 secreted. During the month of December 
 the discharge gradually diminished, the 
 tube Avas AvithdraAvn, and on the 31st I 
 handed her over to INIr. Thornton Avith 
 not cA^en a stain on the gauze bandage. 
 She Avent home a]ipearing to be A'cry Avell 
 on Januai-y 9, 1878. 
 
 Subscffuently, hoAvevcr, the Avound 
 reopened, and gave exit to a quantity of 
 Avliite, glistening, fatty fluid, Avith great 
 relief to an attack of gout in both feet. 
 
 She soon recovered from this, but at 
 the end of 2 years reappeared Avith an 
 ovarian tumour (right side), which Mi'. 
 Thornton removed. During the operation 
 he A'crified the diagnosis of the cyst 
 tapped as being renal. In the course of 
 couA-alescence the renal cyst refilled, 
 burst, and healed. Then, at the end of 
 some Aveeks, the left side had to be dealt 
 Avith by tapping and draining. Again 
 she recovered, and again in 15 months' 
 time Avas discharging fluid, Avith choles- 
 terine, from the right side, and tliis lasted 
 for 14 months. Once more, in February 
 1883, she Avas reported to be in excellent 
 health in all respects. She has since mar- 
 ried again, and is now (1885) quite Avell. 
 
 INCISION AND EMPTYING HENAL CYST 
 
 The folloAving case of C//stic Degenera- 
 tion of the IjCJI Kidney, which was mis- 
 taken for a cyst of the left ovary, is not 
 less instructive : 
 
 On October 10, 1866, a married 
 woman, 43 years of age, called upon me 
 Avith a letter from Dr. M'Donnell, of 
 Stoke NeAvington, containing a very full 
 and accurate histoiy of her case. She 
 had been married 25 years, and had 
 9 children. Dr. McDonnell Avrote as 
 folloAvs : ' In April 1862 she sought my 
 advice for a hard swelling situated in the 
 hypogastric and left iliac regions, the size 
 of an infant's head. Examination ex- 
 ternally, and per vaginam, couAdnced me 
 it Avas an ovarian tumour. In 1854 and 
 1855 a swelling Avas complained of, and 
 had been the siihject of conversation be- 
 tween husband and Avife, but no advice 
 Avas asked for at the time. Aching pain 
 Avas felt, from time to time, in the tumour 
 without causing any alarm. It had in- 
 creased so much in the early part of 
 1863 as to suggest the question of preg- 
 nancy. In 1863 the tumour increased in 
 size, extended to the epigastrium, and 
 encroached so much on the chest as 
 greatly to impede the breathing, and even 
 prevent her moving about in bed. 
 Assisted by Mr. Forman, of Stoke NeAv- 
 ington, on August 4, 1866, I Avithdrew, 
 by tapping in the linea alba, 2 gallons 
 of dark discoloured fluid, of the consis- 
 tence of pea-soup. The opening Avas 
 made midway betAveen umbilicus and 
 pubcs. Ilcr strength and spirits liavo 
 much improved, though the cyst has re- 
 filled.' 
 
OPERATIVE SURGERY OF THE KIDNEY 
 
 lO: 
 
 It was rather more than 2 months 
 after this tapping when I first saw the 
 patient, and I then advised her to come 
 into hospital before she became as much 
 distressed as she had been before the 
 tapping. She was admitted on December 
 17, 18G6. The tumour then occupied 
 the position shown in the annexed dia- 
 
 gram. At the upper and central part 
 there was a patch of crepitus, giving the 
 feeling of adhering omentum ; and all 
 down the front of the tumour, about an 
 inch to the left of the umbilicus, was a 
 cordlike ridge, which Avas taken by some 
 Avho examined it for intestine, though it 
 felt very like a large, long, and thick 
 Fallopian tube. The measurements were : 
 Girth at the umbilical level, 3G inches ; 
 from umbilicus to ensiform cartilage, 9 
 inches ; to symphysis pubis, 7^ inches ; 
 to right ilium, 9 inches ; and to left ilium, 
 9^ inches. There was some mobility in 
 the tumour, both vertically and laterally. 
 Fluctuation was distinct across the whole 
 tumour, in all directions. The lefc loin 
 was dull on percussion, the right tym- 
 panitic. The uterus was high, the os 
 hard and fissured, admitting the tip of 
 the finger ; the cervix short. No part of 
 the tumour was below the brim of the 
 pelvis. The catamenia were expected in 
 a few days. They recurred regularly 
 every 3 weeks — lasting 5 days. Dr. 
 Jimker examined the urine and reported 
 — ' No albumen; deposits — urates, mucus, 
 and epithelium.' She was subject to 
 occasional nervous attacks, during which 
 she was partially unconscious. She said 
 they began by palpitation. She had four 
 while in hospital ; but they were regarded 
 as hysterical, and attracted little attention. 
 The catamenia came on, and ceased on 
 December 29 ; and on January 3, 1867, 
 chloroform having been administered by 
 Dr. Junker, I made an incision 5 inches 
 
 long, extending downwards alou"^ the 
 linea alba, from 1 inch below the umbili- 
 cus. On opening the peritoneum, I at 
 once found that the hard roll, or ridge, 
 observed running down the front of the 
 tumour was part of the transverse and 
 descending colon, adhering closely both 
 to the cyst and to the abdominal wall. I 
 separated some of these attachments, in 
 order to tap the cyst safely. On intro- 
 ducing the trocar, about 1.5 pints of fluid 
 escaped. It had the appearance of pea- 
 sonp. When tlie cyst was empty I made 
 some further separation of omentum and 
 intestine ; and wl:en passing my hand 
 round the right side of the cyst, what 
 appeared to be another cyst gave way, 
 and between 1 and 2 pints of clear fluid 
 escaped. I then found that the deep 
 attachments of the cyst were too close to 
 admit of separation ; and after tying 3 ves- 
 sels which were bleeding in the separated 
 omentum, and cutting off the ligatures 
 short, I closed the wound. 
 
 The patient rallied slowly from the 
 chloroform, and complained of pain, which 
 was relieved by an opiate. Two other 
 opiates were given at night — the total 
 quantity given amounting to 50 minims 
 of laudanum. Three hours after operation 
 a small quantity of clear urine was dra^vn 
 off" by the catheter. After this not a drop 
 of urine entered the bladder. At 10 p.m. 
 the temperature was 98'4°; pulse 116; 
 respiration 28. The next morning the 
 pulse was 120, and very feeble; skin dry ; 
 temperature 98° ; respiration 30. She 
 was comatose, but easily roused, and 
 answered questions sensibly. The coma 
 gradually became more profound, and 
 she died 30 hours after operation. 
 
 On examining the body 17 hours after 
 death there was no rigor mortis. The 
 wound had united well. There were 
 about 4 pints of blood-red serum, and 
 a small teacupful of blood-clot in the 
 peritoneal cavity. The right kidney was 
 enlarged, and very soft ; the cortical sub- 
 stance very friable, pale yellow in colour. 
 The calyces and pelvis Avere much dilated ; 
 and the thin sac formed by this dilatation 
 had given way longitudinally. A calculus, 
 weighing 40 grains, was in one of the 
 calyces, forming a perfect cast of tlie 
 calyx. The bladder was contracted and 
 empty. The uterus and ovaries were 
 healthy. The left kidney formed the 
 cystic tumour, which is described as 
 follows by Dr. Junker : 
 
 02 
 
19G 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 * The left kidney formed a cyst larger 
 than an adult head. It presented one 
 large cavity, composed of several wide 
 pouches, arranged vertically at one side 
 of the principal cavity. The stroma 
 which formed the external wall was of 
 varying thickness ; thicker and stronger 
 at the base of the pouches; thinner and 
 less dense around the main cyst. It had 
 a serous external coat ; at some places 
 hypertrophied, at others atrophied. Next 
 a fibrous structure (fibrous capsule of the 
 kidney). This was followed by Avhat 
 appears to have been the cortical substance 
 of the kidney, and from Avhich portions 
 could be traced into the septa (the former 
 columnte Bertini) which separated the 
 pouches (the expanded calyces). The 
 main cyst (the original pelvis) was formed 
 by the peritoneal and fibrous capsules. 
 The medullary portion could not be well 
 distinguished by the naked eye from the 
 thickened lining membrane. Thus the 
 tumour appears to be a good specimen of 
 genuine hydronephrosis, in which pelvis 
 and calyces expand into a large cavity, 
 and produce by pressure atrophy of the 
 original structures of the organ. 
 
 ' The peritoneal coat was rough with 
 shreds of the broken-down, extensive, and 
 intimate adhesions. Some of the neigh- 
 bouring organs, or portions of them, were 
 so intimately connected with the tumour 
 that their separation was impossible, and 
 portions had to be cut off in order to 
 remove the cyst.' 
 
 Incision, and opening renal cyst. — 
 Another case of great practical interest 
 is that of a girl in her 16th year, who was 
 sent to me by Dr. Wardell, of Tnnbridge 
 Wells, on account of an abdominal tumour. 
 She was a fat, ilorid girl, and apparently 
 in robust health ; but her abdomen began 
 to enlarge when she was about 12 years 
 old, and Avent on increasing, not attracting 
 any j^articular notice till May or June 
 1871, when she was seized with some 
 pain on the right side. This lasted only 
 a few hours, and was followed by swelling, 
 also on the right side, Avhich disappeared 
 after some days' rest, the general enlarge- 
 ment remaining. Dr. Wardell first wrote 
 to me about her in October IHJI. A 
 month later he wrote that the tumour was 
 enlarging, and she was admitted into the 
 Samaritan Hospital early in December. 
 On December 15 the girth at the umbi- 
 lical level Avas 35 inches, distance from 
 sternum to pubes 15 inches, and from one 
 
 ilium to the other, across the front of the 
 abdomen, 15^ inches. Fluctuation was 
 distinct all over the lower part of the ab- 
 domen, and the movement of a cyst was 
 distinctly visible between the umbilicus 
 and sternum — rising and sinking with the 
 respiratory movements — the upper border 
 of the cyst being about half way between 
 the sternum and the umbilicus. On both 
 sides of the abdomen the sound was dull 
 on percussion ; so it was from the pubes 
 to within 2 inches of the umbilicus. From 
 thence to the upper border of the cyst in 
 the centre it was resonant or tympanitic, 
 and on pressure with the fingers the pecu- 
 liar gurgling and contraction of intestine 
 could be felt. It was quite clear, there- 
 fore, that we had intestine adhering in 
 front to the upper part of the cyst. Both 
 loins and flanks were clear on percussion, 
 the right more distinctly so than the left. 
 The uterus was normal in size and situa- 
 tion. On the right side of the vagina a 
 soft fluctuating mass (the lower part of 
 the cyst) could be felt just above the brim 
 of the pelvis. The catamenia appeared 
 when she was 14, and continued regular 
 for 4 months, then ceased for 4 months, 
 and since then have been regular but ex- 
 cessive, lasting a week. There was some 
 irritability of bladder. Owing to a mis- 
 take, the urine was not examined. 
 
 The girl was kept in hospital, and on 
 January 23, 1872, the girth had increased 
 to 37 inches, and each of the other 
 measurements shoAved an increase of about 
 an inch. The presence of intestine in 
 front of the cy^t led to the suspicion of 
 hydronephrosis ; but the resonance of both 
 loins and the fact that the cyst could be 
 felt by the vagina on the right side, almost 
 negatived this suspicion, and it appeared 
 more probable that we had to deal Avith a 
 multilocular ovarian cyst, to which intes- 
 tine adhered in front. I made an explora- 
 tory incision on January 24, and at once 
 came upon the caecum, its appendix, and 
 the ascending colon, Avhich had been 
 pushed upAvards and across the median 
 line by the cyst, which Avas behind it. I 
 saw at once 1 had to deal with a hj'dro- 
 nephrosis ; so, pushing aside the intestine, 
 I tapped the cyst. Twelve pints of fluid 
 escaped through the canula, and I then 
 found that the uterus and both ovaries 
 Avere healthy. When the cyst Avas empty 
 I fixed the opening in its Avail to the ab- 
 dominal Avail by a harelip-pin, and then 
 closed the wounds by sutures. A small 
 
OPERATIVE SURGERY OF THE KIDNEY 
 
 107 
 
 cyst in each broad ligament I felt, but did 
 not disturb. 
 
 The fluid removed from the cyst was 
 clear, light yellow in colour, Avith a faint 
 lirinous odour, acid reaction, and specific 
 gravity of lOOG. On standing a few floc- 
 culent clouds formed and some red blood- 
 corpuscles were deposited. On careful 
 chemical examination, urea, urates, and 
 chlorides were found in about the normal 
 proportions of healthy urine. There were 
 traces of uric acid. A very small amount 
 of albumen and phosphates, but no traces 
 of sugar co\ild be detected. On micro- 
 scopic examination of the deposit large 
 numbers of red blood-corpuscles were 
 seen, a few pus cells, some squamous 
 epithelial cells and granular cells, but 
 neither tube-casts nor crystals. 
 
 The fever which followed the opera- 
 tion and caused her death on the 4th 
 day was so remarkable that I may refer 
 those interested in the subject to a lecture 
 on the case, v/hich was published in April 
 1<S72, in the * Medical Times and Gazette.' 
 
 KEPHROTOMY 
 
 Nephrotomy ; removal of sarcoma from 
 interior of i^enal cyst. — In May 1879 a 
 Greek lady came to me from Dr. White- 
 head, of Manchester, supposed to be suf- 
 fering from a solid movable tumour of 
 the right ovary, sufficiently large to call 
 for extirpation. Dr. Whitehead had seen 
 her several times between 18G8 and 1871 
 on account of dysmenorrhosa and several 
 early abortions. He did not see her be- 
 tween 1871 and 1877, when she went to 
 him on account of abdominal enlargement ; 
 but he could not detect any tumour. Her 
 next visit was in May 1879, and then he 
 found ' a large, solid substance, non-fluc- 
 tuant, on the right side, somewhat diffused, 
 extending towards the hepatic region. It 
 had not the iisuaily defined limits of an 
 ovarian tumour, yet, in the absence of the 
 great suffering commonly met with in 
 aggraA^ated kidney disease, and the urine 
 being normal, and as a perceptible im- 
 pingement of the tumour was felt against 
 the left hand on tilting the uterus up Avith 
 the right, I Avas led to sujipose its nature 
 to be ovarian.' 
 
 In 1881 and 1882 I saAV this lady oc- 
 casionally in consultation Avith Sir W. 
 Jenner. We both at first believed that the 
 tumour Avas one of the right kidney. But 
 as it became more fluctuant and increased 
 
 in size, and the urine proved to be normal 
 upon careful and repeated examination, 
 and the general health was beginning to 
 suffer, I made an exploratory incision in 
 1 882, assisted by Dr. Griffith, of Camber- 
 well, and Mr. Meredith, Dr. Day admini- 
 stering methylene. It Avas at once evi- 
 dent that the tumour Avas renal, but as it 
 appeared to be cystic I tapped it. No 
 fluid escaped, but some soft brainlike 
 substance. On enlarging the trocar open- 
 ing, several pounds of this substance, in 
 soft masses, came aAvay, and Avith it a good 
 deal of blood. By passing my hand into 
 a cystlike cavity I Avas able to press and 
 scrape aAvay a quantity of soft granular 
 substance, portions of a groAvth loosely 
 adherent to the inner surface of the cavity, 
 very much like the endogenous sprouts of 
 a proliferating cyst. The cavity was evi- 
 dently the dilated pelvis of the kidney, 
 the cyst its cortical layer, expanded and 
 covered by peritoneum, which it had 
 pushed forAvard. The cavity Avas only- 
 opened enough for me to pass in my hand, 
 and by carefully holding the edges of the 
 opening forAvard, none of the morbid 
 material or blood entered the peritoneal 
 cavity. There Avas such free bleeding from 
 the inner Avails of the cavity that I stuffed 
 it full of carbolised sponges, and had some 
 pressure kept upon these Avhile I was pass- 
 ing the sutures. These included the edges 
 of the opening in the renal cyst, as well as 
 the Avhole thickness of the abdominal wall. 
 I then gradually removed the sponges, 
 pressure being all the Avhile kept up. I 
 thought of tying the renal vessels and re- 
 moving the kidney. I also thought of 
 leaving a drainage-tube in the cyst, for 
 the oozing of blood was not quite stopped 
 Avhen I took out the last sponge. The 
 patient Avas so exhausted that I Avas sure 
 she could not survive nephrectomy. If I 
 had left a tube in I feared the bleeding 
 AYOuld go on ; so I closed the wound and 
 made firm pressure by pads and a bandage. 
 She remained in a state of profound col- 
 lapse for 5 or 6 hours, pulse almost, 
 sometimes quite, imperceptible ; she was 
 cold and sometimes quite unconscious. 
 Ether Avas injected subcutaneously, 
 brandy fi:eely given by the mouth, and 
 beef-tea and milk by the rectum. Dr. 
 Griffith stayed Avith her all night, and 
 to his assiduous care for several foUoAving 
 days I attribute her gradual and complete 
 recovery. There has never been any re- 
 appearance of the renal tumour since the 
 
UTERINE AND OTHER ABDOMINAL TmiOUES 
 
 operation, the xirine has been almost al- i 
 ■ways normal, and I saw her near the end 
 of I8<s4 in excellent health. The masses 
 removed "weighed more than 9 povmds, and 
 Mr. Meredith reported to me that, on mi- \ 
 croscopical examination of different speci- 
 mens of the material from the cyst, he i 
 found that ' the growth Avas undoubtedly a , 
 spindle- celled sarcoma, apparently under- i 
 going caseous changes. The spindle cells 
 were large and very distinctly nucleated.' 
 
 XEriiEECTOMY 
 
 Enlarrjed cancerous kidney ; excision. 
 On December 9, 1882, in consultation 
 with i\Ir. Hewer, of Highbury, I saw a 
 Grerman gentleman, aged 58, who was suf- 
 fering from the effects of repeated attacks 
 of hematuria, supposed to depend upon 
 an enlarged left kidney. The amount of 
 blood lost had seriously affected the general 
 health, and on different occasions it had 
 been with difficulty that the bladder had 
 been cleared from clots. There was no 
 evidence of any disease of the bladder nor 
 of the right kidney. The left kidney 
 appeared to be about 4 inches in breadth 
 and 6 inches from above downwards ; 
 extending from the iliac fossa upwards 
 imder the left false ribs, and centrally 
 nearly to the umbilicus. It was slightly 
 mobile, and could be pushed to the right a 
 little beyond the umbilicus. Feeling that 
 the surgical difficulties in removing the 
 kidney would not be great, and that the 
 patient was not likely to live long if it 
 were not removed, I advised early opera- 
 tion, and was supported by INIr. Hewer. 
 
 The patient took time to consider the 
 cjuestion, and consulted his old friend. 
 Dr. Herman Weber, who informed me 
 that in December 1880 he had observed 
 the movable tumour, which had first been 
 noticed by the patient himself a year 
 before this visit. 
 
 'In August, ISS], Mr. K was at 
 
 Margate, and one day the urine Avas 
 bloody. On the following day he came 
 up to me, when I fovind the urine quite 
 free from blood and albumen, jierfectly 
 clear, and normal. The first severe bleed- 
 ing occurred in May 1882, when I had 
 not .seeii him for 8 months. It ceased 
 completely under the administration, by 
 i\Ir. Hewer, of turpentine in ca2:)sules. In 
 July and August he went to Germany, 
 and was so well that he could climb 
 moderate mountains. By that time I had 
 
 attributed the tumour to the kidney, and 
 feared that probably it was malignant.' 
 
 Three days after my first visit ]\Ir. 
 Hewer wrote to me : ' December 12, 
 1882, the patient is losing more blood 
 and consents to the operation, which, I 
 think, should be done with as little delay 
 as possible.' Proposing to operate the 
 next afternoon, Mr. HeAver telegraphed 
 to me, ' Patient not so well, please make 
 operation, if possible, to-morrow morning.' 
 Accordingly, at 9 o'clock on the morning 
 of December 13 — Dr. Herman Weber and 
 Mr. Hewer being present — Dr. Day ad- 
 ministered methylene, and I was assisted 
 by Mr. Meredith and Mr. Hewer's son, 
 house-surgeon of St. Bartholomew's. 
 Phenol spray Avas used and the usual 
 antiseptic precautions were strictly ob- 
 served. I made an incision parallel with, 
 and about 2 inches to the left of the linea 
 alba, extending from about 3 inches above 
 to 3 or 4 inches beloAv the IcA-el of the 
 umbilicus. I meant to carry the incision 
 along the outer border of the left rectus, 
 but the muscle Avas spread out and some 
 of its fibres Avere divided or separated all 
 along the incision. SeA'^eral small arteries 
 were tied, and the peritoneal coat of the 
 anterior abdominal Avail Avas divided to 
 the extent of 6 inches. The intestines 
 Avere pushed aside, kept back by carboliscd 
 sponges, and the peritoneal covering of 
 the kidney Avas diAdded to the same extent 
 as the incision in the abdominal Avail. 
 Several large veins, Avhich Avere divided 
 Avith the peritoneal covering of the kidney, 
 Avere tied. The kidney Avas then separated 
 from its loose attachments and draAvn out. 
 The ureter AA-as first temporarily secured 
 by tAvo pressure-forceps and divided be- 
 tween them. I meant to have tied the 
 renal artery and vein before separating 
 the kidney, but I could not feel the artery. 
 I therefore compressed the connecting 
 tissue Avith forceps, cut aAvay the kidney, 
 then transfixed with a double silk ligature 
 behiiid the forceps, and tied in 2 parts. 
 Loose portions of tlie peritoneal covering 
 of the kidney Avere cut aAvay and several 
 ligatures Avere applied to small A'cssels. 
 The incision in the abdominal Avail Avas 
 united by silk sutures. 
 
 Not much l)lood Avas lost during the 
 operation, although it occupied nearly 1^ 
 hour from the commencement of inhala- 
 tion until the patient Avas in bed. Much 
 time was lost in tying small vessels in the 
 abdominal wall before opening the peri- 
 
OPEILVTIVE SURGEllY OF THE KIDNEY 
 
 199 
 
 toneum, and in securing A'cssels in tho 
 divided coverings of tiie kidney ; and, 
 during the closing ol' tlie wound, tliere 
 was unusual difficulty in keeping back 
 the intestines free from the sutures. 
 
 The kidney is now in the Museum of 
 the Koyal Coliege of Surgeons, and Mr. 
 Eve's report on the specimen is as follows: 
 
 'The kidney is G.V inches long and 4 
 wide. Its surface is laigely nodulated or 
 bossed, but the disease had not penetrated 
 the capsule. The section of the tumour 
 is white, soft, and marked by bands of 
 fibrous tissue, which give it a lobuluted 
 appearance. Portions of unaffected kidney 
 substance are situated at the upper and 
 back parts of the section. Neither the 
 ureter nor pelvis was compressed. Micro- 
 scopically the morbid growth was a soft 
 cancer, consisting of alveoli filled with 
 small spheroidal epithelium.' 
 
 For 3 days after the operation the 
 patient Avent on so Avell that I was hopeful 
 of I'ecovery. He suffered very little from 
 pain or sickness, but the urine never be- 
 came free from blood. On the 4th day 
 the temperature rose to 102°, and the 
 pulse became rapid and feeble. He was 
 much worse at night, and died on the 
 morning of the 5th day. The temperature 
 just before death was 103°, and the last 
 iirine passed contained blood. No post- 
 mortem examination of the body was per- 
 mitted. This I very much regret, as I 
 cannot explain the continuance of blood 
 in the urine in the absence of any proof 
 of disease of the right kidney or of the 
 bladder, nor can I offer any reason of the 
 precise cause of death. There Avas no 
 evidence of more than slight peritonitis, 
 nor of septicemia. The chances of suc- 
 cess would have been much greater if the 
 ojjeration had been done 6 months earlier. 
 If I should again be called upon to 
 excise a kidney, I shall be more careful 
 in bringing together not only the divided 
 peritoneum of the anterior abdominal 
 wall, but also the divided peritoneal 
 covering of the kidney. In this case I 
 was content Avith letting the tAVO edges 
 fall together; and it is probable that 
 blood or serum, exuding from the tissues 
 behind the peritoneum, passed into the 
 peritoneal cavity, or that some portion of 
 intestine became adherent there. Both 
 these evils would be prevented by a fcAv 
 sutures. I had not seen this detail in the 
 operative procedure described in cases of 
 nephrectomy previously recorded ; and I 
 
 have not no ticed any report of its having 
 been tried in more recent cases. In the 
 discussion Avhich folloAved the reading of 
 the above slightly abbreviated account of 
 the case at the Medico-Chirurgical Society, 
 it Avas argued that this Avould not be ad- 
 visable; that it Avould be better that 
 blood and serum should pass into the 
 peritoneal cavity, and be absorbed, than 
 retained behind the peritoneum in the 
 loin. Indeed it Avas suggested that a 
 counter opening should ahvays be made 
 in the loin Avhen nephrectomy Avas per- 
 formed by the abdominal incision, and 
 that one of the chief advantages of the 
 lumbar incision was the greater facility it 
 afforded for drainage. 
 
 In the papers and discussions at the 
 International Medical Congress in London, 
 in 1881, on nephrotomy and nephrectomy, 
 by Czerny, Langenbuch, Martin, Baker, 
 Lucas, and BarAvell, the situation of the 
 abdominal incision and the relative ad- 
 A-antages of the abdominal and lumbar 
 incision Avere ably entered into ; and quite 
 recently the discus.sion has been renewed 
 in the Royal Medico-Chirurgical Society, 
 Avhen Mr. Thornton's proposal to tie the 
 ureter, and to fix it in the abdominal 
 wound, Avas both supported and objected 
 to. My own feeling is that in most cases 
 of nephrotomy for renal calculus, or of 
 nephrectomy, Avhen the kidney to be 
 removed is not A^ery large, the lum- 
 bar incision should generally be pre- 
 ferred ; whereas the abdominal incision 
 is ratlier to be chosen whenever the 
 kidney is much more than double the 
 normal size. And, Avhenever the ab- 
 dominal incision is chosen, that of Lan- 
 genbuch has some advantages over an 
 incision in the middle line. It may be 
 made alono- the outer border of the right 
 or left rectus, according to Avhich kidney 
 it is intended to remove. I also think 
 Mr. Thornton has made out a fairly good 
 case in favour of his practice of fixing the 
 bladder end of the ureter outside the 
 abdominal incision. He ties it Avith 
 strong silk, and cuts it off so as to leaA'e 
 only just enough stump to pass a pin 
 through and keep it from slipping into 
 the Avound. He cleans this stump Avith 
 iodine, and packs it round Avith a little 
 cotton moistened Avith tincture of iodine, 
 until the peritoneum is Avell sealed. But 
 it is quite certain that Ave require a larger 
 number of cases, fully and accurately 
 reported, before these and other practical 
 
200 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 details in the operative surgery of the 
 kidney can be considered as settled. 
 
 Solid pei'i-7-enal tumours. — Since the 
 case of nephrectomy just recorded, I have 
 removed 2 very large solid tumours 
 formed, in the same patient, around the 
 right and the lelt kidney. One tumour 
 "weighed IGt? pounds, the other 14?y pounds, 
 and part of the lelt kidney was attached 
 to the tumour of that side. This portion 
 of kidney, with part of the tumour at- 
 tached to it, is preserved in the Museum 
 of the College of Surgeons. I removed 
 the tumours in November 1883, and the 
 following report upon them, by Mr. Eve, 
 Avas published in the ' British Medical 
 Journal,' April 19, 1884: 
 
 ' The portion of kidney on the tumour 
 comprises more than one-third oi; the 
 lower end of the organ. A calyx and 
 papilla may be seen upon the torn sur- 
 face ; they afford conclusive evidence that 
 the pelvis was opened. Within the calyx 
 is a small mass of fat. A section of the 
 kidney has a normal appearance. Sur- 
 rounding the surface of tlu; kidney is a 
 tolerably firm, greasy, pale yellowish 
 Avhite substance, evidently consisting, in 
 great part, of adipose and fibrous tissues. 
 It is in close contact with the capsule of 
 the kidney, but is only adherent to it 
 over a surface about ^ an inch in length. 
 The capsule can be easily separated from 
 the kidney at this point, leaving the sub- 
 jacent parenchyma perfectly smooth. 
 
 ' The portion of the tumour from the 
 opposite side was slightly more fibrous in 
 texture, but otherwise similar in its naked- 
 eye characters. 
 
 ' In minute structure, both tumours 
 consisted chiefly of adipose tissue. The 
 fat-cells were large, and closely approxi- 
 mated. There were also many large 
 tracts and bands of fibrillar connective 
 tissue, consisting of a close interlacement 
 of delicate fibrils, which give it somewhat 
 the appearance of mucous connective 
 tissue, but stellate cells Avere absent. The 
 blood-vessels were large and numerous, 
 and around them AVere masses of small, 
 round, so-called " indifferent" cells, Avhich 
 could be traced through transitions, by 
 elongation, to the formation of fibres. 
 
 ' 1'lie formation of fat Avas evidently 
 secondary to the growth of fibrous tissue, 
 tlie advance of the fiit-cells into it being 
 apparent ; Avliile the various stages in the 
 transformation of the fixed connective 
 tissue corpuscles into fat-cells were dis- 
 
 tinctly seen. Sections, cut through the 
 point Avhere the tumour was adherent to 
 the kidney, showed that numerous parallel 
 fasciculi of fibrous tissue intervened be- 
 tween the kidney-substance (which Avas 
 healthy) and the tumour. 
 
 ' The anatomical relations of the 
 tumours to the kindeys, and the micro- 
 scopic examination, support the view that 
 the tumours originated neither in the 
 pelvis nor capsule of the kidney, but in 
 the circumrenal connective tissue. 
 
 ' Histologically, they were fibro-lipo- 
 mata, and no grounds exist for believing 
 them to be in any part sarcomatous, since 
 the young cell-element exhibited a distinct 
 tendency to form mature tissues, either 
 fibrous or fatty. A complete immimity 
 from further disease may, therefore, be 
 anticipated, provided that the growths 
 Avere completely remoA'ed.' 
 
 The lady Avas 48 years of age ; Avas 
 married Avhen 21 ; had never been preg- 
 nant ; had begun to suffer from abdominal 
 trouble in 1874; and in 1878 Avas suffi- 
 ciently large for pregnancy to be sus- 
 pected. The enlargement had gradually 
 increased. Ever since 1881, owing to 
 prolapsus of the uterus, a ring-pessary had 
 been worn until the day of operation, and 
 numbness and stiffness of the right leg 
 had been troublesome. The catamenia 
 had been regular, and the urine Avas 
 always normal Avhen examined. 
 
 I had been very doubtful as to the 
 precise character and origin of the 
 tumours V)efore operation, simply saying 
 tliat there Avere 2 solid tumours, so moA^- 
 able that I did not think there could be 
 any unusual difficulty in their removal. 
 On making tlie incision usual in ovario- 
 tomy, a growth resembling an ordinary 
 fatty tumour Avas seen to be covered by 
 layers of loose serous membrane, just as 
 in tvmiours covered by the broad liga- 
 ments of the uterus. This membranous 
 capsule Avas divided, and the tumour easily 
 shelled out from a large deep cavity in 
 the left side of the pelvis and left loin. 
 Attached to the deepest part of the 
 tumour Avas a piece of dark red ti.ssue, 
 which I at first thought Avas a part of i\vi 
 spleen ; but Avhich afterwards j^roved to 
 be about a third of the left kidney. The 
 remaining portion of the kidney and the 
 ureter Avere then seen at the bottom of 
 the capsule. There was very little bleed- 
 ing. The capsular cavity was carefully 
 sponged, and the edges of the divided 
 
OPEKATIVE SURGERY OF THE KIDNEY 
 
 201 
 
 capsule Averc placed in apposition, but no 
 sutures were used. 
 
 Another large tumour was then found 
 similarly situated on the right side, and 
 was removed in the same way ; but the 
 right kidney was neither injured nor seen. 
 The only other difFerence in the proceed- 
 ing on the two sides was, that the ascending 
 colon led to no difficulty ; while, on the 
 left side, the descending colon was attached 
 to the tumour anteriorly, and was pushed 
 aside after dividing the serous capsule of 
 the tumour. There Avas not much Ijlood 
 lost, only a few small vessels requiring 
 ligature. 
 
 The patient recovered quite as well as 
 after an ordinary ovariotomy. In quantify 
 and appearance, the urine was quite nor- 
 mal. Dr. Hilder once or twice found 
 some small clots of blood in tlie deposit, 
 but, he said, ' none as large as a pin's 
 head.' She remained in good health ibr 
 several months, but towards the end of 
 1884 I heard from Dr. Ilabershon that 
 he was attending her on account of con- 
 siderable enlargement of the liver. 
 
 Addressing the Midland IMedical So- 
 ciety last November, 1 made the follow- 
 
 ing remarks upon the surgical IreatmeDt 
 of renal and peri-renal tumours : 
 
 ' Nephrotomy, nephrolithotomy, pyelo 
 lithotomy, and nephrectomy, terms hardly 
 entering into surgical literature twenty 
 years ago, define operations which are 
 now performed in increasing numbers, 
 and, especially to the physiologist, with a 
 wonderful success. My colleague, Know.s- 
 ley Thornton, can boast of 10 nephrec- 
 tomies, all by abdominal section, as well 
 as 4 nephrotomies and 3 nephrolitho- 
 tomies — the whole 17 cases successful. 
 These cases, and 7 successful cases of 
 pyelolithotomy out of 8, as lately re- 
 corded by Anderson, can only be the 
 efl'ect of rigidly abiding by the observance 
 of what we now know to be the rule and 
 criterion of good work. So also Avitli a 
 variety of solid and semi-solid abdominal 
 tumours, originating in the pelvic cellular 
 tissue, or in the peri-renal fat, or in the 
 mesentery, the appendices epiploicas, the 
 omentum, or the abdominal wall, extir- 
 pation is effected with a loss of life so 
 small as would have been almost in- 
 credible a few vears a2;o.' 
 
 ABSCESS AKD IIYDATIDS- 
 
 CHAPTER V 
 LIVER ANB GALL-BLABBER 
 
 —DISTENDED GALL-BLADDER GALL-STONES — CIIOLECYSTOTOMY 
 
 AND CHOLECYSTECTOMY 
 
 What has been said of peritoneal surgery 
 in relation to the spleen and the kidneys 
 may appear at first sight to require some 
 modification when we pass on to the liver 
 and gall-bladder. But it must be re- 
 membered that it used to be considered 
 essential to the success of any surgical 
 treatment of abscess or cysts of the liver, 
 of so-called dropsy of the gall-bladder, 
 and of the removal of gall-stones, that 
 the peritoneal cavity should be closed by 
 adhesions between the visceral and pari- 
 etal peritoneum, before any opening into 
 liver or gall-bladder Avas made. Opening 
 the peritoneum Avhen non- adherent, as 
 the first step of operative treatment, is 
 one of the most recent advances in ab- 
 dominal surgery. Thudichum and Hand- 
 field Jones had stimulated the ambition 
 of their surgical brethren ; but it Avas not 
 
 until the example of Marion Sims, and 
 the attention excited by the very remark- 
 able paper Avhich he published in the 
 ' British Medical Journal ' in June 1878, 
 that the present generation of siirgeons 
 entered upon the path which he opened 
 for us. It is true that Sims had been 
 preceded, in 1867, by another American 
 surgeon, Bobbs, Avho, after opening the 
 gall-bladder and removing some 50 stones, 
 closed the opening by stitches and did not 
 attach it to the abdominal Avail. The 
 patient, a woman 30 years old, recovered. 
 Sims does not seem to have read or heard 
 of a A'ery remarkable paper, oititled ' On 
 Tumours formed by Bile retained in the 
 Gail-Bladder,' Avritten 150 years ago (to 
 which attention Avas draAvn in 1879 by 
 Mr. Hulke), communicated by Petit to 
 the French Royal Academy of Surgery in 
 
20: 
 
 UTERINE AND OTHER ABD03IIXAL TUMOURS 
 
 1733, and published, in 1743, in the first 
 volume of the INIemoirs of the Academy. 
 In this paper Petit records 2 cases ob- 
 served 25 and 28 years before, where con- 
 siderable tumours in the region of the liver 
 were opened in the belief that one was a 
 cyst and the other an abscess, both proving 
 to be the distended gall-bladder, and death 
 following escape of bile into the peritoneal 
 cavity. He relates a third case where he 
 was about to open a similar tumour, when 
 it disappeared, and a large quantity of 
 bile soon afterwards passed Avith purging. 
 In a 4th case, a supposed abscess Avas 
 opened, and a biliary fistula was the 
 result, through which a gall-stone was 
 removed 7 or 8 months afterwards. In 
 another j^^tient a considerable tumour 
 disappeared after the vomiting of 3 pints 
 of very green bilious iluid. Petit wisely 
 says : ' In such difficult cases mistakes 
 are not faults when one has the courage 
 to publish them ; but they become crimes 
 when pride leads to concealment.' After 
 a careful description of the mode of dis- 
 tinguishing between cases of abscess of 
 the liver and distended gall-bladder, Petit 
 says that in some cases abscess, retention, 
 and gall-stones are all observed together. 
 He then traces the parallel between bile 
 retained in the gall-bladder with gall- 
 stones, and retention of urine with urinary 
 calculi — showing that, as the latter occa- 
 sionally pass by the urethra, the former 
 pass the duct into the intestine ; that 
 when retained in the gall-bladder they 
 may be numerous and of large size, and 
 in thin patients distinctly felt and heard ; 
 and when they occlude a duct may do 
 as much harm as a stone blocking a 
 ureter or the urethra. He then shows 
 that the danger of opening a distended 
 gall-bladder which is not adherent to the 
 abdominal wall, is not to be feared when 
 adhesions have formed, and that gall- 
 stones may be removed through a biliary 
 fistulous opening. Tie relates a case 
 where, 7 years after recovery f?-om severe 
 symptoms of distended gall-bladder, it 
 was foTuid that adhesions and communica- 
 tion with the colon had been completed 
 by nature ; and he says that when adhe- 
 sions have formed, not only may a gall- 
 bladder be opened and a fistula saiely 
 formed, but ' surgery may be enriched 
 by another operation ; I mean the extrac- 
 tion of stones from tlie gall-bladder. The 
 existence of the stone, and the adhesion 
 of the gall-bladder being ascertained, the 
 
 opeiation Avill be without danger.' He 
 describes the mode of sounding for gall- 
 stones, by first tapping with a trocar, 
 and then passing a long flexible probe 
 through the canula, which, when a stone 
 is found, serves as a guide to a bistoury. 
 An opening is made of sufficient size to 
 admit forceps and remove stones. In one 
 case he removed in this way a stone as 
 large as a pigeon's egg successfully ; and 
 he relates other cases where numerous 
 stones Avere found after death which 
 might have been safely removed, as 
 adhesions Avere firm. In one case, after a 
 spontaneous opening, a large number of 
 stones came aAvay during 2 months, when 
 the fistulous opening Avas enlarged after 
 sounding, and a stone successfully re- 
 moved. He says, also, that this has been 
 done by other surgeons after dilating 
 the opening by sponge tents. In one 
 case a stone, 3 inches in circumference 
 and 4 inches long, Avas broken into several 
 pieces by the forceps before extraction ; a 
 2nd stone Avas also removed, and perfect 
 recovery folloAved. 
 
 Godefroy Mliller's incision of a biliary 
 fistida, and extraction of a gall-stone after 
 breaking it up, might have been com- 
 pared Avith a combined lithotomy and 
 lithotrity. 
 
 In the chapter on Diagnosis, at page 
 2G, some record may be Ibund of cases 
 Avhere I have tapped and aspirated hydatid 
 cysts of the liver, and a few remarks iipou 
 injection of iodine and drainage. I have 
 never tapped the gall-bladder nor removed 
 a gall-stone myself; but I once assisted 
 Mr. Meredith in removing 3 gall-stones, 
 Avhich together Aveighed 1 ounce and 2G 
 grains. We had both carefully studied the 
 case of Sims's patient. She Avas 45 years of 
 age. Simsremovedfromherdistended gall- 
 bladder 24 ounces of fluid and GG stones. 
 He then cut away part of the gall-bladder 
 and sewed the other part to the abdominal 
 Avail, thus forming a biliary fistula. After 
 death on the iJth day, IG more stones Avere 
 found in the gall-bladder. In the same 
 year (187S) Kocher, of Berne, did the 
 first successful intentional cholecystotomy, 
 as Bobbs's operation Avas exploratory. 
 Kocher's patient Avas a Avoman 30 years 
 old. The gall-bladder Avas the size of a 
 man's head, and contained pus and 32 
 stones. A fistula Avas formed in this 
 case. As a result of experiments on dogs 
 and cats, proving that the gall-bladder in 
 these animals may be safely extirpated, 
 
LIVER AM) GALL-BLADDER 
 
 203 
 
 Langenbucli, in 1SS2, not only removed 2 
 gall-stones from the thickened and dis- 
 tended gsll-bladder, but he tied the cystic 
 duct with silk and dissected away the 
 gall-bladder. His patient, a man 43 years 
 old, recovered. Also in 1882, Wini- 
 warter cured a man, 34 years old, by 
 establishing a communication not only 
 from the dilated bladder through the 
 abdominal Avail, but also into the trans- 
 verse colon. Several other cases — some 
 of them very imperfectly recorded — may 
 be referred to in an able paper by Musser 
 and Keen in the ' American Journal of 
 the Medical Sciences,' of October, 1884. 
 These Aviiters justly give Thudichum the 
 credit of being the first to propose the 
 operation of cholecystotomy in his paper 
 on gall-stones in the ' British Medical 
 Journal ' in 1859 ; but they claim for 
 Bobbs and Sims the merit of having been 
 the first to carry the proposal into prac- 
 tice. What remains for us is to perfect 
 the different steps of the operation. In 
 Mr. Meredith's case, after exposing the 
 distended gall-bladder, he emptied it by a 
 fine trocar, drew the walls carefully for- 
 ward, opened the cystlike cavity, and ex- 
 tracted a gall-stone by forceps. It w^as 
 j^roposed to stitch the opening to that in 
 the abdominal wall ; but there would 
 have been so much ti'action that it was 
 thought safer to close the opening in the 
 gall-bladder by stttures and return it. We 
 thought of tying up the opening by a 
 circular loop of silk, like a purse ; but 
 found it difficult to accomplish. 
 
 After death it was found that the gall- 
 bladder contained about half a pint of 
 bile, the cystic and common ducts were 
 quite free, and there was bile in the duo- 
 denum. The opening in the coats of the 
 gall-bladder was so well closed tliat there 
 was no escape when the cavity was fully 
 distended by injecting water, and yet some 
 bile was found in the peritoneal cavity. 
 Whether this escaped unnoticed during 
 the operation, or oozed out during the 
 short time immediately afterwards, before 
 union was completed, must remain in 
 doubt. The coats Avere so thin, that 
 inversion and stitching of the serous coat 
 only, as suggested before operation, was 
 
 found to be very difficult or impossible. 
 In any future case, the question whether a 
 biliary fistula should be formed, or the 
 opening in the gall-bladder be closed by 
 sutures, or the gall-bladder cut away after 
 tying the cystic duct, must be determined 
 by the peculiarities of the case ; and the 
 possibility of establishing a fistulous com- 
 munication between the gall-bhidder and 
 the intestine, after Winiwarter, supported 
 as it is by the more recent experiments on 
 dogs by Dr. Gaston, of Atlanta, Georgia 
 — described in the ' British Medical 
 Journal,' February 14, 1885 — may also 
 be borne in mind. What we need is fur- 
 ther experience and accurate records of 
 all cases. The reports of some of the 
 more recent operations are so incomplete 
 that they are qtiite destitute of any scien- 
 tific or practical value. 
 
 CnOLECTSTECTOilT 
 
 or excision of the gall-bladder, has been 
 successfully performed by Langenbuch, in 
 a case where a thickened and adherent 
 gall-bladder, containing many gall-stones, 
 was first emptied by a syringe. The liver 
 was raised, the stomach and small intes- 
 tines protected by sponges, and the gall- 
 bladder was separated from the liver by a 
 few strokes of a scalpel. The cystic duct 
 was tied in two places with silk, and the 
 duct divided between the ligatures. Gross 
 has also removed the gall-bladder ; and 
 Thiriar, of Brussels, brought a 2nd 
 successful case of removal of gall-stones 
 and extirpation of the gall-bladder before 
 the Belgian Eoyal Academy of Medicine 
 in February 1885. The patient was 25 
 years of age, in the 4th month of preg- 
 nancy. The report of the full discussion 
 on these cases has not yet reached me, but 
 we have already sufficient proof that this 
 operation ought to be done rather than 
 cholecystotomy when the gall-bladder is 
 hypertrophied, or otherwise diseased. 
 Indeed, it appears not very improbable 
 that cholecystectomy may prove to be 
 better practice than either the formation 
 of a biliary fistula or suture of the open- 
 ing in the coats of the gall-bladder after 
 cystotomy. 
 
204 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 CHAPTER VI 
 
 MESEXTERIC, OMENTAL AND PANCREATIC CYST^ -UNDESCENDED 
 
 TESTICLE 
 
 MESENTERIC CYSTS 
 
 My last work on ovarian and uterine 
 tumours was published in May 1882. 
 Up to tliat date I had not met with a case 
 of a mesenteric cyst nor with a large 
 mesenteric tumour. But within a month 
 I had opened and drained a large 
 mesenteric cyst, and had removed a large 
 solid mesenteric tumour. Since that time 
 I have not seen another. 
 
 The cyst was in a lady, G3 years of 
 age, a patient of Dr. Duke, of St. Leonards. 
 The daughter, then 33 years old, told me 
 that her mother's illness was one of the 
 recollections of her early childhood, and 
 that the tumour began as a small lump on 
 the right side of the abdomen and gradually 
 increased. She had been under medical 
 care for many years, and saw me in 1871 
 and 1872, when, as there were no urgent 
 symptoms, I advised her to wait. She 
 went on for more than 10 years without 
 much increase in size, but latterly there 
 had been a rather rapid increase, and 
 her life had become that of an invalid. 
 Dr. Sedgwick afterwards told me that, 
 about the year 1858, he had suspected 
 mesenteric disease, that Baker Brown had 
 treated her for uterine disease, and Dr. 
 West for movable kidney. I operated at 
 St. Leonards, June 11, 1882, assisted 
 by Dr. Duke, Mr. Ticehurst administering 
 methylene. Alter a little peritoneal fluid 
 had escaped, I tapped and emptied a very 
 thin cyst, which contained about 6 pints 
 of reddish- brown turbid fluid, quite free 
 from odour, with l)roken-down blood clot 
 and a good deal of cholesterine. On ex- 
 amining the interior of this cyst when 
 emptied, I found that it had formed near 
 the root and between the two layers of the 
 mesentery, extending toward the ca;cum 
 and behind the ascending colon, its lower 
 end being so spread over the tipper part 
 of the pelvis that I could not make out 
 clearly either uterus or ovaries. The 
 liver and spleen were both somewhat en- 
 larged. Alter considering the question of 
 drainage, we decided against it, and were 
 content with carefully sponging out the 
 interior of the cyst ;ind closing the wound. 
 
 The patient went on remarkably well at 
 first. Dr. Duke wrote to me on the 19th 
 that he had removed the stitches and the 
 wound was healed, that the temperature 
 had never exceeded 100° nor her pulse 
 90. But soon afterwards she became 
 jaundiced, and, without there being any 
 signs of the reformation of fluid, got gra- 
 dually weaker and died on July 13. No 
 post-mortem examination having been 
 made, I regret that I cannot give a more 
 complete account of this unusual case. 
 
 A mesenteric cyst was removed in the 
 Beaujon Hospital, Paris, by M. Tillaux, 
 from a man 31 years of age. It was about 
 the size of the head of a foetus. It was a 
 cyst containing caseous matter springing 
 from the mesentery by a pedicle. This 
 was tied with catgut, the abdomen closed, 
 and jjerfect recovery ensued. — ' Lancet,' 
 August 18 SO. 
 
 Again, in the ' British Medical Journal' 
 for January 1883, Dr. C. H. Carter gives 
 an account of a case Avith all the indica- 
 tions of a unilocular ovarian cyst. During 
 the operation it was found that there were 
 no pelvic attachments. The cyst rose 
 from the left lumbar region, surrounded 
 by coils of adhering intestine. It could 
 not be removed, and treatment by drainage 
 Avas adopted. The Avoman died on the 
 6th day, of septiccemia. There Avas a 
 broad attachment to the side of the spine 
 and the left lumbar region, closely packed 
 in among the adhering bowels. On the 
 left side of the cyst the peritoneal coat 
 had been stripped ofl" by an extravasation 
 of blood from a large opened vein. 
 
 OMENTAL CYSTS 
 
 An interesting case of cyst of the 
 great omentum, by j\Ir. Doran, may be 
 found in the 23rd volume of the Obstetrical 
 Transactions. Mr. Thornton published 
 in the ' British INIedical Journal,' in 1882, 
 an account of a case of mesenteric tumour 
 for which he operated in 1877, adding 
 notes in the same paper of two cases 
 Avhere, in the course of ovariotomy, he 
 
MESENTERIC, OMENTAL, AND PANCREATIC CYSTS 
 
 205 
 
 removed cysts from tlie omentum. One 
 was as large as a cocoa-nut, with a thick, 
 fleshy wail, attached to the omentum by a 
 thick vascular pedicle, and was high up in 
 the abdomen under the right border of the 
 liver. The other was a very small multi- 
 locular cystic tumour, in a case of ruptured 
 papillomatous cysts of both ovaries. Tliis 
 tumour was attached by a small pedicle 
 to the lower border of the omentum and 
 probably had its origin in cell infection. 
 The tumour removed in 1877 was a large 
 thin cyst connected with the mesentery of 
 a portion of small intestine by a broad 
 vascular pedicle. The left ovary and 
 tube, being adherent to a fringe of solid 
 growth along the lower border of the 
 mesenteric cyst, were removed with it. The 
 solid parts weighed G pounds 4 ounces, 
 and there were 19 pints of fluid in the cyst. 
 The patient was in good health 5 years 
 afterwards. 
 
 Mr. Thornton alludes to other cases 
 which might have been mistaken for 
 omental tumours, but which resembled 
 several cases that I have recorded, where, 
 after twisting of the pedicle, ovarian 
 tumours were completely detached from 
 the uterus, and had derived their prin- 
 cipal blood-supply from adhering omen- 
 tum. 
 
 SOLID TUMOUR OF MESENTERY 
 
 Assisted by Mr. Jackson, Mr. Favell, 
 and Dr. Redpath, Mr. Shaw administer- 
 ing methylene, I removed at Sheffield, on 
 June 20, 1S82, a solid tumour from a 
 married lady, 40 years of age, a patient 
 of Mr. Arthur Jackson. She had been 
 married 18 years, but had no children, 
 though she had a premature labour some 
 months after marriage. Two or three early 
 abortions followed, and no further preg- 
 nancy. She was in good health until 
 about 4 years before, when pain in the 
 iliac regions and slight abdominal enlarge- 
 ment were noticed ; but no tumour was 
 discovered until early in 1881. After 
 that, increase was very manifest, with 
 some apparent diminution after each 
 menstrual period. Various opinions were 
 given as to the nature of the tumour — 
 some believing it to be ovarian, others 
 uterine. I frankly confessed my own 
 inability to give a positive opinion as 
 to its nature or connections ; but ex- 
 pressed a ■ confident belief that I could 
 remove it without any unusual difficulty 
 
 or danger. It was ([uite solid, central in 
 the abdomen, freely movable, about the 
 size of an adult head, and imparting 
 transmitted rather than associated move- 
 ments to a uterus somewhat enlarged. 
 Phenolised spray and all the usual anti- 
 septic precautions and dressings were 
 carefully employed. The tumour was 
 solid, and its origin was clearly in the 
 cellular tissue, at the root of the mesentery 
 proper, near the lumbar vertebra}. The 
 ascending colon was closely connected 
 with the tumour in front, and to the 
 right. All its blood-supply was derived 
 from the mesenteric vessels. Those which 
 were divided were secured with carbolised 
 silk, the ends of all the ligatures cut off 
 short, and returned. The uterus and 
 both ovaries were healthy. No drainage 
 was employed, and the wound was closed 
 exactly as after ovariotomy. There Avas 
 some sickness during the first 3 days ; but 
 recovery may be said to have followed 
 without fever. The highest temperature 
 was on the 3rd day, but was only 100°. 
 The patient left her bed on July 12, and 
 I saw her in London in the summer of 
 1884 in excellent health. 
 
 The tumoiir was sent to the Sheffield 
 Pathological Society for examination and 
 report. I have not yet received the 
 report, which I much regret, as the re- 
 moval of a solid mesenteric tumour may 
 still be regarded as a surgical curiosity. 
 
 In the chapter on Diagnosis, several 
 cases of abdominal tumours, both cystic 
 and solid, which had been mistaken for 
 ovarian cysts, have been recorded, such 
 as distended bladder, faecal accumulations, 
 pelvic cellulitis and abscess, hajmatocele, 
 hydatids, enchondroma or osseous tu- 
 mours, curvature of the lumbar vertebra?, 
 diseased lumbar glands, aneurism o£ the 
 aorta and extra-uterine foitation. Some 
 of these were surgical curiosities, and 
 illustrated the difficulties of diagnosis ; in 
 others the surgical treatment is related in 
 connection with the history of the case, and 
 will be found on referring to the chapter. 
 
 PANCREATIC CYSTS 
 
 Cases of hydatid cysts of the pancreas 
 are on record ; but the more frequent 
 cause is obstruction of the duct by cal- 
 culous concretion, or cancer — leading to 
 cystic dilatation behind — compared by Vir- 
 chiJw to salivary cysts, and named by him 
 ' Ranula pancreatica.' These cysts may 
 
206 
 
 UTERINE AND OTHER ABDOMINAL TUMOURS 
 
 ^ 
 
 contain only a few ounces, but Bozeman 
 has narrated a case where about 20 pints 
 of fluid were drawn off, and the tumour, 
 inchiding the fluid, weighed 20i pounds. 
 He operated, believing the cyst to be 
 ovarian; but found that it was pan- 
 creatic, with a pedicle nearly an inch 
 long. The pedicle was tied, the cyst cut 
 away, and the patient recovered. Eoki- 
 tansky also operated in a case which he 
 thought to be ovarian. He was prevented 
 by adhesions from completing the opera- 
 tion, and the patient died on the 10th 
 day. Other cases are on record where 
 pancreatic cysts have been simply tapped, 
 or tapped and drained, or opened after 
 stitching the cyst to the abdominal wall. 
 But pancreatic cysts must be very rare, 
 as I have never seen one. 
 
 A case is related by Gussenbauer, in 
 the 'Archiv. fiir Klin. Chir.' 1, xxiv. 
 p. 355, 1884, of a man who, with pain, 
 sickness, and emaciation, had a tumour in 
 the epigastric region, extending over a 
 space of 22 centimetres, and passing down 
 as low as the umbilicus. An incision was 
 made, and the wall of the cyst fixed in 
 the wound, peritoneum to peritoneum. A 
 portion of the fluid contents was taken 
 away by trocar ; then the opening in the 
 cyst was enlarged, and a quantity of dark- 
 coloured matter removed from the cyst 
 wall, which was thin and smooth, and, 
 when pressed back, allowed the finger to 
 feel the pancreiis and aorta. The man 
 recovered, the cyst contracted, and only a 
 thin colourless liquid was secreted, which 
 had all the characters of the pancreatic 
 juice. In about 3 months' time, only a 
 small fistula, not more than 3 centimetres 
 deep, remained. 
 
 UNDESCENDED TESTICLE 
 
 The only case which I have now to 
 add is almost unique; a large abdominal 
 tumour having been formed by the en- 
 largement and degenerative changes of an 
 undescended testicle. The patient was a 
 middle-aged German gentleman, father of 
 children, whom I saw early in 1878, in 
 consultation with Sir James Paget. All 
 the lower part of the abdomen was 
 occupied by a solid tumour. The left 
 testicle Avas normal, the right had never 
 descended, but had not begun to enlarge, 
 or at least to attract notice, until about a 
 year before I saw him. As he was in 
 fairly good health, and not suffering much 
 
 pain, at Sir James Paget's suggestion he 
 Avas put iipon liquor potassa^ in large 
 doses, and went to the .seaside. He 
 returned after a few weeks with the 
 tumour both larger and softer, suffering 
 more pain, and the general health mani- 
 festly giving away. It was accordingly 
 arranged in consultation that I should 
 remove the tumour, and I accordingly 
 did so on April 16, 1878. 
 
 Present : Sir J. Paget, Bart. ; Dr. 
 Oscar Liebreich, of Berlin ; Dr. Junker ; 
 Dr. Woodliam Webb ; and Mr. Thornton. 
 Dr. Day administered chloromethyl. Thy- 
 mol spray was used, and all the instru- 
 ments and sponges were bathed in warm 
 thymol solution — 1-1000. I made an 
 incision in the linea alba from 1 inch 
 above to 5 inches below the umbilicus. 
 On dividing the peritoneum a free tu- 
 mour was seen, very much like a large 
 uterus covered by a thin membranous 
 capsule, in which large veins ramified. 
 Passing my hand backwards, I found such 
 close attacliments behind, that removal of 
 the capsule (tunica vaginalis) would have 
 been impossible. I accordingly divided 
 the capsule in front, and began to separate 
 it from the enlarged testis. In doing 
 this, and pressing the whole tumour for- 
 Avard, a large cyst burst, and some 2 or 8 
 pints of fluid Avere expelled with great 
 force. I then broke away all the loose 
 portions of the tumour, and separated the 
 deeper part from the capsule by tearing, 
 and an occasional touch of the scissors. 
 Several blood-vessels Avere temporarily 
 secured by torsion forceps, and the vessels 
 afterwards tied. All the ligatures Avere 
 cut short, some portions of the capsule 
 Avere cut oflf, all clot sponged from the 
 cavity, and the Avound in the abdominal 
 wall closed Avith sutures, as in ovariotomy. 
 Ver}'- little blood was lost. The operation 
 lasted three-quarters of an hour. The 
 patient soon began to complain of pain, and 
 opiates Avere given by mouth and rectum. 
 Nine hours after operation, about a pint of 
 urine Avas draAvn ofl" by catheter. At night 
 he Avas comfortable ; had not been sick ; 
 pulse 100; skin moist; temperature nor- 
 mal. After this lever set in, and rapidly 
 increased. He died on the ord day 
 Avitli precisely the same symptoms of 
 peritonitis or septicaemia so often de- 
 scribed as septic peritonitis, and the most 
 frequent cause of death after the removal 
 of abdominal t^^mours of any kind. Esti- 
 mating the fluid Avhich escai^ed at _ or 
 
STOMACH 7VND INTESTINES 
 
 207 
 
 pints, the ■whole tumour weighed about 9 
 pounds. It was sent to the College o£ 
 Surgeons. No doubt was entertained as 
 to tlie malignant character of tlie growth, 
 but there was no evidence of disease 
 liaving extended beyond the capsule. If 
 it had not been for the septica}mia the 
 
 patient probably would have recovered, 
 and there would not have been greater 
 fear of the recurrence of the disease or of 
 its appearance in any other part of the 
 body than if the diseased testicle had 
 been removed from the scrotum. 
 
 CHAPTER VII 
 THE STOMA CII AND INTESTINES 
 
 gastrostomy; GASTROTOMY ; DILATATION OF CARDIAC AND PYLORIC ORIFICES; PYLO- 
 RECTOJIY ; OBSTRUCTED INTESTINE ; ENTEROTOMY AND COLOTOMY ; ARTIFICIAL 
 ANUS, RESECTION OF INTESTINE ; OPERATIVE TREATMENT OF PERITONITIS 
 
 All the operations incladed in the head- 
 ing of this chapter have received, and are 
 now receiving, a remarkable impulse from 
 the influence which the revival of ovario- 
 tomy has had upon modern surgery. It 
 is ti'ue that intestinal obstruction has been 
 treated by colotomy, in one or other loin, 
 since the days of Littre and Pillore, and 
 of Callisen and Amussat. Dupuytren's 
 treatment of artificial anus by his entero- 
 tome was in vogue more than 50 years ago. 
 Gastrostomy, from the time of the experi- 
 ments on Alexis St. Martin, though very 
 rarely, has been occasionally practised to 
 prolong life in cases where the oesophagus 
 has been closed by malignant disease, or 
 by the pressure of a tumour. But it is 
 only by the experience of ovariotomists 
 we have learned that, if intestine be 
 accidentally wounded, and the wound 
 be carefully and completely closed by 
 sutures properly applied, the recovery of 
 the patient is not hopeless ; that even 
 some portions o£ intestine may be removed 
 and the patient recover, if tlie continuity 
 of the canal is restored by suture. Although 
 in one case where I did this, after remov- 
 ing 3 inchesof intestine during ovariotomy, 
 the patient died, it was proved that union 
 of the intestine was complete, and that 
 the death was not due to this complication. 
 It was Koeberle's extraordinary case, re- 
 corded in the Memoirs of the Socicte de 
 Chirurgie, in 1881, where the patient 
 recovered after the removal of more than 
 G feet of small intestine, Avhich first effec- 
 tually aroused professional attention to the 
 possibility of excising portions of intestine, 
 and either restoring the continuity of the 
 canal immediately by suture, or secondarily, 
 
 after the temporary formation of an arti- 
 ficial anus. 
 
 GASTROSTOMY 
 
 I need not say more now of this operation 
 than I said in an address delivered at Bir- 
 mingham in Nov. 1884, that 'no one who 
 has watched the progress of these opera- 
 tions, has considered the causes of death in 
 fatal cases, and the details of the operative 
 proceedings in successful cases, can come 
 to any other conclusion than that one 
 important element in the attainment of 
 success is the scrupulous observance of 
 the principles laid down as necessary to 
 success in ovariotomy^ — not only as regards 
 the hygienic precaiitions never omitted in 
 modern surgery, but especially as to the 
 importance of a very accurate and exact 
 union, not only of the edges, but of the 
 surfaces of the peritoneal surface of the 
 viscera and of the abdominal wall. In 
 gastrostomy, for instance, it is found that 
 when the stomach is attached to the ab- 
 dominal Avail by a single ring of sutures, 
 the weak attachment may give wa}-, and 
 risk of extravasation into the peritoneal 
 cavity may be great. But Avlien, after 
 dividing the abdominal wall, the parietal 
 peritoneum is sewn to the skin all round 
 the opening, a broad surface of visceral 
 and parietal peritoneum may afterwards 
 be maintained in contact by a circle of 
 sutures, forming loops, passed through the 
 peritoneal coat of the protruding portion 
 of stomach, and through the whole thick- 
 ness of the abdominal wall, about half an 
 inch from the edge of the incision. Smaller 
 fine sutures beino: inserted between the 
 
208 
 
 L'TEPJXE AND OTHER ABDO:\JIXAL TUMOURS 
 
 laro-er ones, a very close and secure 
 attachment of the stomach to the peri- 
 toneal lined opening in the abdominal 
 wall, and complete occlusion of the peri- 
 toneal cavity, are guaranteed. This done, 
 we have an example of the carrying out 
 in its integrity of one of the fundamental 
 rules of practice in the operation of 
 ovariotomy as regards the peritoneum — 
 surface to surface, not edge to edge merely 
 
 and it is a fact not to be overlooked, 
 
 that in gastrostomy the result of the 
 operation seems to depend upon it _; the 
 rule being that the cases in which it has 
 been neglected fail, while those in which 
 it is observed end satisfactorily. Thus 
 the lessons learnt at an early stage of our 
 experience in one operation have been 
 the means of leading directly to the suc- 
 cessful performance of the other.' 
 
 In reference to the mode of operating, 
 I need only say that the incision should 
 be made about | of an inch below the free 
 margin of the cartilages of the 7th, 8th 
 and 9th ribs on the left side. The liver 
 is usually seen at the upper end of the 
 incision, and is a good guide to the 
 stomach, which is immediately beneath 
 it. The centre of the anterior surface of 
 the stomach is the part usually opened, 
 but in the absence of some very immediate 
 necessity for feeding by tlie stomach, it is 
 better not to open it until a firm union of 
 the peritoneal surfaces, kept together by 
 the sutures, has been obtained. There 
 can then be no fear of the escape of any 
 of the contents of the stomach into the 
 peritoneal cavity. When the opening is 
 made, it need not be larger than is required 
 for the passage of the teeding-tube. 
 
 GASTROTOMY 
 
 or incision of the stomach, for the 
 removal of a foreign body, has l)een 
 performed successfully by SchiJnborn, 
 and by iSIr. Thornton, in order to ex- 
 tract masses of hair. In Mr. Thornton's 
 case the mass weighed 2 pounds. It was 
 moulded into the shape of the stomach. 
 The incision across the greater curvature 
 was 5 inches long. Fifteen deep sutures 
 were passed through peritoneum, mus- 
 cular coat, and edge of the mucous mem- 
 brane. Fifteen superficial sutures were 
 passed through the peritoneum only, and 
 a very fine continuous suture over all 
 united the opening in the coats of the 
 stomach. The abdomen was closed as in 
 
 ovariotomy, and the patient perfectly re- 
 covered. 
 
 Professor Loreta, of Bologna, has 
 performed gastrotomy in order forcibly to 
 dilate the pyloric orifice, by inserting first 
 one index finger, then the other, and so 
 effecting foi'cible dilatation, just as is 
 done at the anus. In 1883 he published 
 a monograph containing two successful 
 cases. The opening in the coats of the 
 stomach was closed by silk sutures, not 
 more than 1 centimetre apart, including 
 all the tissues of the coats. Using a long 
 thread, armed at each end with a needle, 
 he made a zigzag, or sort of glover's suture, 
 each needle crossing alternately from left 
 to right. The operation was done on ac- 
 count of non-malignant stricture. Loreta 
 has since dilated the cardiac orilice of the 
 stomach, in a case where contraction 
 follovved the destructive action of a 
 caustic ; and oesophageal bougies or tubes 
 could not be passed. 
 
 EXCISION OF THE PYLORUS 
 
 A clear idea may be formed of pylorec- 
 tomy by a glance at the accompanying 
 woodcut, reduced from Wijlfler's report 
 of one of Billroth's cases. It shows very 
 
 clearly how the opening in the stomach, 
 left after excision of the diseased part, has 
 to be diminished, in order that it*may 
 correspond with the smaller opening of the 
 intestine after the pylorus has been cut 
 away. I have only twice seen a case where 
 I thought this operation could be seriously 
 advised. One patient was a captain of 
 one of the Cunard steamers. He said he 
 would submit to it after one more voyage 
 to New York, but he died there ; and I 
 heard afterwards that the disease was so 
 confined to the pylorus that the operation 
 would have been very easy. The other 
 
ENTERECTOMY 
 
 209 
 
 patient was a German tailor, who after- 
 wards died in the Cancer Hospital ; when 
 it was found that the disease of the pylorus 
 had just begun to involve the liver. Mr. 
 Jennings tried to prolong life by injecting 
 milk into a vein in his arm. Never having 
 done the operation, however, I think it 
 better to refer anyone proposing to do it 
 to the works of Wijlfler aud liydygier, and 
 to Southam's account of a typical pylorec- 
 tomy in the ' British Medical Journal' of 
 July 1882, than to offer any description of 
 my, own. But I do think it right to insist 
 that, belbre any siirgeon attempts to excise 
 the pylorus, or any portion of intestine or 
 the uterus, he should make himself fami- 
 liar with the details of the proceedings 
 by practice on the dead body. At post- 
 mortem examinations, whether in hospital 
 or private practice, or in our workhouse 
 infirmaries, opportunities may be obtained 
 without any great difficulty for the practice 
 of such operations. And I think it quite 
 inexcusable for anyone who has neglected 
 such opportunities to undertake, lor the. 
 first time, such an operation iipon any 
 living patient before he has had some 
 practice on the dead body. 
 
 INTESTINAL OBSTPaiCTION 
 
 Operations upon the intestines, entero- 
 tomy, colotomy, resection of intestine, 
 scarcely ever become subjects for con- 
 sultation imtil either acute or chronic 
 obstruction of intestine has produced 
 symptoms dangerous to life. In cases of 
 strangulated hernia, Avhere a portion of 
 intestine has become gangrenous, the 
 removal of the gangrenous intestine, 
 and the formation of an artificial anus, 
 has been the orthodox practice for 
 genei'ations. It is only since the modern 
 development of peritoneal surgery that 
 abdominal section has been proposed in 
 cases of intussusception, or as a mode of 
 ascertaining the seat of obstruction in 
 cases where it is doubted if the symptoms 
 are due to a hernia-like strangulation 
 through apertures, or by bands, or by 
 adhesion of coils of intestine to each 
 other, or by stricture, by compression of 
 the intestine by tumours, or by new 
 growths in the coats of intestines them- 
 selves, or by obstruction of the canal by 
 gall-stones, faecal masses or concretions, or 
 by a paralytic or spasmodic condition of the 
 bowel. The conflict between the surgery 
 of the past and the present still goes on. 
 
 "We have not yet sufficient experience to 
 enable us to lay down any such rules as 
 shall prevent, on the one hand, too great 
 haste in operating, and avoid, oa the 
 other, the dangers of delay too long con- 
 tinned. 
 
 I said in the address at Birmingham, 
 from which I have already quoted, that 
 in Mr. Treves's Jacksonian Prize JCssay 
 on Intestinal Obstruction, puVjlished last 
 year, 'you will see how firmly an 
 operator of to-day is taking his stand 
 on the true principles of abdominal sur- 
 gery Avhich we have watched emerging 
 from their obscurity. lie does not ignore 
 the teachings from experiments upon 
 animals. He supports himself by the 
 nine successful resections of lengths of 
 the intestines of animals made by Made- 
 lung. He traces the failures in many 
 operations of the same kind on the hu- 
 man subject to faults in the details, such 
 as want of perfect adaptation and insuffi- 
 ciency of sutures. And he lays down as 
 rules for his own action that he must 
 separate the peritoneum from the other 
 tissues — introduce abundance of sutures 
 after Lembert's method — bringing the 
 two serous surfaces together, and avoid- 
 ing the mucous membrane with the 
 needle. A recent paper by Eeichel in- 
 forms us that already 121 cases of resec- 
 tion of intestine have been collected, the 
 conclusion being that the two ends of the 
 bowel should not be united at the time of 
 the resection, but that an artificial anus 
 should be established. This can be 
 closed by a subsequent operation.' Mr. 
 Makins has had a successful case of 
 artificial anus treated in St. Thomas's 
 Hospital in 1884 by resection of more 
 than 3 inches of small intestine, and 
 suture of the upper and lower ends. 
 His paper in the loth volume of St. 
 Thomas's Hospital Eeports is a valuable 
 contribution to modern surgery. 
 
 Mr. Jessop, of Leeds, has also cured a 
 foBcal fistula by separating the injured in- 
 testine from the abdominal wall, and 
 uniting the upper and lower parts of the 
 gut by suture. What I said with regard 
 to practice on the dead body before oper- 
 ating on living women is equally applic- 
 able to the resection of intestine. But 
 here practice on the dead is not sufficient, 
 and if we are not allowed to experiment 
 on living animals in this country, we 
 must either go abroad or practise on men 
 and women. By my advice a young 
 
 p 
 
210 
 
 UTERINE AND OTIIEE ABDOMINAL TUMOURS 
 
 surgeon, Mr. Jennings, from whom 1 hope 
 and expect great things in the future, 
 and who is jilready one of the junior 
 surgeons of the Cancer Hospital, has re- 
 cently cut away portions of the intestines 
 of dogs, uniting the upper and lower 
 parts so as to maintain the continiiity of 
 the canal. Some of the preparations may 
 be seen in our College Museum, and they 
 strongly confirm the conclusion that suc- 
 cess depends upon complete union of the 
 apposed serous surfaces. In order to 
 prevent any blood or faecal matter es- 
 caping from the divided intestine into the 
 peritoneal cavity, clamps have been de- 
 vised by Mr. Treves and Mr. Bishop to 
 compress the upper and lower openings ; 
 and cylindrical plugs of dough or decalci- 
 fied bone have been introduced to facili- 
 tate the introduction of the sutures. At 
 my suggestion, Mr. Jennings, instead of 
 solid plugs, used hollow cylinders of 
 cocoanut butter and of gelatine. He had 
 them cast in eight sizes, conical at the 
 extremities. 
 
 Such cylinders afford a firm basis and 
 support for the intestine during the opera- 
 tion, and will not collapse (like an india- 
 rubber bag) if accidentally wounded by 
 the point of the needle. The cylinders 
 slowly melt during the first few hours 
 after these operations, thus allowing time 
 for adhesion of the peritoneal surfaces at 
 the line of union, but not too slowly to 
 form an obstacle to the passage of the 
 faeces. The gelatine have the advantage 
 of flexibility over the cocoa-butter cy- 
 linders. 
 
 So far as can be gathered from three 
 experiments upon dogs, it appears : 
 
 1. That, whenever possible, the por- 
 tion of intestine to be removed should be 
 isolated from the general peritoneal cavity 
 ])y passing it through a small aperture in 
 a sheet of transparent gutta-percha tissue. 
 
 2. That the section of the intestine 
 should be slightly oblique to lessen the 
 tension on the line of suture, and to pre- 
 vent the great diminution of the calibre 
 of the intestine at the seat of resection, 
 which obtains when the division is trans- 
 verse. 
 
 3. That a triangular portion of the 
 mesentery should be excised, the base 
 corresponding to the part of the intestine 
 which is removed. 
 
 4. That after the piece of intestine 
 has been removed, a cylinder slightly 
 larger than the calibre of the intestine 
 
 should be selected, in order to distend 
 the portions to be united. 
 
 5. That the gap in the mesentery 
 should be closed by a continuous suture ; 
 and that a double row of intestinal sutures 
 (each commencing where the mesentery 
 joins the intestine) should be employed 
 to maintain the peritoneal surfaces be- 
 tween the two rows in contact. The 
 inner row should unite the edges of the 
 pieces of the intestine : the outer row 
 should include only peritoneum or peri- 
 toneum and muscularis. By this means 
 sufficient peritoneal surfaces Avill be 
 maintained in contact : but if only one 
 row of sutures be employed, the edges of 
 the intestine Avill curl away from each 
 other, internal to that single line of 
 sutures. 
 
 6. Fewer sutures should be employed 
 for the inner than for the outer row, and 
 the stitches in the latter should not be 
 more than one-tenth of an inch apart. 
 
 7. A single continuous suture (for 
 each row) should not be used ; for if it 
 be, when the intestine contracts after the 
 operation, the ring of suture will not 
 adapt itself to the lessened calibre of the 
 intestine, and fteces will escape there- 
 from ; whereas, if interrupted sutures be 
 employed, when the intestine contracts, 
 the points of suture will fall still closer 
 together. 
 
 8. That Ilageborn's flat needles are 
 to be preferred, since they do not lacerate 
 the peritoneum so much as the ordinary 
 needles. 
 
 9. That silk, rendered antiseptic, 
 should be used for the intestinal sutures : 
 the braided, which will not kink, being 
 better than the ordinary twist. 
 
 OPERATIVE TREATMENT OF PERITONITIS 
 
 At pages 331-33 of my work on Dis- 
 eases of the Ovaries, which appeared in 
 18G5, 1 have recorded a case of tubercular 
 peritonitis, where recovery followed an 
 exploi-atory incision and removal of peri- 
 toneal fluid. That patient is still quite 
 well, 23 years after the operation, al- 
 though ' the whole of the peritoneum was 
 seen to be studded with myriads of 
 tubercles,' and the colon and omentum 
 with coils of small intestine were bound 
 down, and all ' nodulated by tubercle.' 
 I concluded by saying, ' The case would 
 .serve as a striking appendix to Marten's 
 curious paper on the operative treatment 
 
OPERATIVE TREATMENT OF PERITOMTIS 
 
 211 
 
 of peritonitis.' This paper may be found 
 in the 20tli volume of Vircliow's ' Archir.' 
 published in 18G]. Dr. Marten, of 
 Iliirde, there narrates two cases of Avhat 
 he calls ' empyema abdominis ' treated by 
 abdominal section. And he argues that 
 cases described as chronic peritonitis with 
 exudation, or Kup2:)urative peritonitis, or 
 of hajmorrhage into the peritoneal cavity, 
 of effusion in puerperal peritonitis, of 
 perforation of intestine, would be all 
 better treated by abdominal section along 
 the linea alba (he uses the word 'lapa- 
 rotomy') than by opium euthanasia. 
 Cases may be found at long intervals in 
 the medical journals bearing on these 
 questions; but the first really important 
 contribution is a paper by Marion Sims, 
 in the ' British MedicalJournal,' 1881-2, 
 on ' The Treatment of Gunshot Wounds of 
 the Abdomen, in Relation to modern Peri- 
 toneal Surgery.' In his usual strikingly 
 interesting manner, Sims argues that 
 ' ovariotomy is the parent of peritoneal 
 surgery,' that ' other wounds of the peri- 
 toneum follow the same course as those 
 made by the surgeon's knife in ovario- 
 tomy,' and that in all septicaemia is the 
 chief danger. The time will come, he 
 says, when ' gunshot and other wounds of 
 the abdomen, and perforations of the in- 
 testine, will be treated by opening the 
 peritoneal cavity, and washing out, or 
 draining off, the septic fluids that would 
 otherwise poison the blood.' In all cases 
 of wounds of stomach, intestines, or blad- 
 der — in all cases of haemorrhage into the 
 peritoneal cavity, or of foreign bodies 
 there, abdominal section should be the 
 rule of treatment, followed by any sutures 
 or ligatures that may be required, with 
 such -washing and drainage as the nature 
 of the injury demands. In uniting wounds 
 of the intestines Sims refers to the expe- 
 riments of Gross, published in 1843, in 
 favour of the continued suture of fine 
 silk, and to his conclusion in 1872, that 
 in all cases of wounded intestine, where 
 there is no protrusion, the surgeon should 
 ' enlarge the abdominal orifice, seek for 
 the wounded tube, and sew up the cut,' and 
 thoroughly cleanse the peritoneal cavity. 
 
 The next important paper on this sub- 
 ject is that of Mr. Treves, read at the 
 Medical and Chirurgical Society in March 
 1855, ' On the Treatment of Acute Peri- 
 tonitis by Abdominal Section.' Free in- 
 cision and drainage, argued Mr. Treves, 
 'has been already ajjplied for the relief of 
 inflammations of certain of the serous 
 membranes. It was at first adopted in 
 connection with the smaller serous cavi- 
 ties, as those of the joints. It has been 
 gradually and with increasing freedom 
 applied in the treatment of inflammatory 
 conditions involving the pleura. It has 
 finally become a recognised means of 
 treatment in certain forms of localised 
 and chronic peritonitis, especially when 
 purulent collections have formed. The 
 author would urge the adoption of this 
 principle in treatment in connection with 
 acute and diffused forms of peritonitis.' 
 
 After relating a very successful case 
 where acute diffused peritonitis was 
 treated by incision, washing, and drainage, 
 Mr. Treves advocates ' abdominal section 
 in the treatment of certain cases of a,cute 
 general peritonitis, such as that following 
 injury, gunshot wound, the bursting of 
 an abscess, and specified forms of per- 
 foration.' 
 
 All I need add to this is a caution 
 against putting off the operation until too 
 late — until the patient is dying of sep- 
 ticaemia. 
 
 CONCLUSION 
 
 It appearing that in a work on Abdo- 
 minal Tumours it would be rather out of 
 place to enter more fully upon the tempt- 
 ing theme of the operative treatment of 
 obstructed intestine, or to do luore than 
 allude to the important subject of excision 
 of the rectum, as this may be more or less 
 an extra-peritoneal operation — a consider- 
 ation which has also excluded an account 
 of the operation of shortening the round 
 ligaments in obstinate cases of uterine 
 prolapse and flexions — I can. only com- 
 mend the careful study of Peritoneal 
 Surgery to the Modern Student. 
 
INDEX 
 
 Abdomex, structure uf Av;ills of, <S1 
 
 Aljscess, pelvic, 33 
 
 Absence of ovaries, 1 
 
 Accidents during ovariotomy, 97 
 
 Acupressm-e, 9i 
 
 Adhesions, diagnosis of, 5 ; effect of on ovario- 
 tomy, 69 
 
 Adhesive straps, nse of to support abdomen after 
 operation, 96 
 
 Age, average, of ovariotomy patients, 71 ; mor- 
 tality at different ages, 71 
 
 America, ovariotomy in, 67 
 
 Amputation of uterus, 152 
 
 Antiseptics, .39 
 
 Aorta, compression of, 177 
 
 Arteries, spermatic, tying, 129, 172 
 
 Ascites, diagnosis between ovarian dropsy and, 
 12 
 
 Assistants, position of in ovariotomy, 80 
 
 Atlee, brings forward the case of Houston, 48 : 
 his book published in 1872, 67 
 
 Auscultation in diagnosis of ovarian tumours, 
 14 ; of uterine tumours, 139 
 
 Bandage and dressing, 96 
 
 Battey, his operation, 12.5; his opinions, 128 
 
 Belgium, ovariotomy in, 6-1 
 
 J'ell, John, influence of his lectures, 47 
 
 Billroth, results of his ovariotomj', remarks by, 
 
 66 
 Bluudell on extirpation of ovaries, 12.5; excision 
 
 of uterus, 177 
 Boddaert, operations by, 64 
 Boiaet, on contents of cysts, "> ; inj action of 
 
 iodine, 45 
 
 Canceb of peritoneum, 21 
 
 Carbolic acid, my early use of, -57 ; in spray, 60 ; 
 
 my experience of, 63 
 Castration of women, Fehling on, 129 
 Cautery clamp, 78 
 Cells in ovarian fluids, 19 
 Cellulitis, pelvic, 33 
 
 Chemical examination of fluids in diagnosis, 1-5 
 
 Children born after ovariotomy, 131 
 
 Cliloroform, objections to, 76 
 
 Cholecystectomy, 203 
 
 Cholecystotomy, 202 
 
 Chronic inflammation of peritoneum, 19, 211 
 
 Clamp, introduction of, .54; modifications of, .55; 
 
 use of, 88 
 Classification of ovarian tumours, 1 ; of uterine 
 
 tumours, 144 
 Clay's cautery clamp, 94 
 Colonies, ovariotomy in, 67 
 Complication of ovarian cysts with jJregnanc}', 
 
 115 ; of uterine tumours with pregnancy, 164 
 Conditions affecting the operation of ovariotom}-, 
 
 67 
 Conjugal condition as affecting ovariotomy, 71 
 Contra-indications, ovariotomy, 72 
 Cysts, ovarian, classification of, 1 ; diagnosis 
 
 of, 3 ; renal, diagnosis of, SO 
 
 Diagnosis of different kinds of ovarian tumours, 
 
 3 ; of adhesions, 5 ; of uterine tumours, 137 
 Differential diagnosis of ovarian tumours, 10 
 Distended bladder, diagnosis, 32 
 Doran on the ligatures of stumps, 93 
 Douglas's pouch, puncture of and drainage, 110 
 Dressing and bandage, 96 
 Dry dressing, 60 
 
 Eaelt history of ovariotom}-, 46 
 
 Ecraseur, 94 
 
 Emiliani, ovariotomy by, 66 
 
 Emptying and removal of cyst, 86 
 
 Enucleation of cysts, 92 ; of submucous uterine 
 
 growths, 163 
 Epithelioma of uterus, 172 
 Examination of ovaries, modes of, 1 
 Excision of uterus, 171 ; of pylorus, 208 
 Exploratory incisions, 121, 141 
 Extirpation of ovaries, Blundell on, 12-5 
 Extra-uterine foetation, diagnosis of, 28 
 
214 
 
 INDEX 
 
 F.iiCAL uccumulations, diagnosis of, 31 ; case of, 
 
 mistaken for ovarian tumour, 32; fistula after 
 
 ovariotomy, 113 
 Fainting after ovariotomy, 98 
 Fallopian tuLes, tumours of, 168 
 Fatty tumours of abdomen, 2-t 
 Fehling on castration of women, 129 
 Fibrine in abdominal fluids, 17 
 Fibroma-moUuseum, 2.3 
 Fibro-plastic tumoars of peritoneum, omentum, 
 
 &c. 24 
 Fistula, fa?eal, after ovariotomy, 113 
 Forceps, 79 ; left in abdomen, 99 ; description 
 
 of large, SO 
 France, ovariotomy in, 63 
 
 Gastrostomy, 207 
 Gastrotomy, 208 
 
 Germany, ovariotomy in, 64 ; results of myomo- 
 tomy in, 145 
 
 II.TJMATOCELE, diagnosis of, 34; after ovario- 
 tomy, treatment of, 109 
 
 Hegar on extirpation of ovaries, 125 
 
 History of patients recovered after ovariotomy, 
 130 
 
 Hofmeier, reports on myoniotoiny, 145 
 
 Houston, operation by, 48 
 
 Hunter, Dr. W., John, quotations from, 40 
 
 Hydatids, diagnosis, 25 
 
 Hjdrometra, diagnosis, treatment by tapping and 
 drainage, 29 
 
 Ice cap, 109 
 
 Incision, treatment of ovarian cysts by, 45 ; in 
 
 ovariotomy, 81 ; exploratory, 121, 141 
 Incomplete ovariotomy, 121 
 Injuries to viscera during ovariotomy, 98 
 Intestinal obstruction, 209 
 Intestines strangulated after ovariotomy, 1 1 1 
 Investigation and recording of cases, modes of, 
 
 35 
 Iodine, injection of, 45 
 Italy, ovariotomy in, 06 
 
 JuNKKR, apparatus for administering ana>stlielic.s, 
 58 
 
 Keith, ovariotomy by, 63 
 Kidney, operative surgery of, 190 
 Kivvisch, influence of liis book and tables ap- 
 pended by Clay of Birmingham, 53 
 Kceberle, drainage-tubes, 109; forceps, 79 
 
 Ligatures, material for, 50, 60 ; mode of apply- 
 ing, 91 ; experiments of Spiegelbcrg and 
 Waldeyer, 93 ; what becomes of them, 94 
 
 Lister, his antiseptic system introduced at 
 Samaritan Hospital, 68 ; my experience of 
 his spray and dressings, 63 
 
 Liver and gall-bladder, 201 
 
 Mkhu, conclusions from examination of ovarian 
 fluids, 17 
 
 Mesenteric cysts, 204 
 
 Methylene, its introduction, 77; my experience 
 of, 77 
 
 Microscope in diagnosis, 15 
 
 Mortality after ovariotomy, 59; increase of 
 caused by adhesions, 70 ; at diiferent ages, 
 71 ; after double ovariotomy, 101 ; from 
 tetanus, 114; after exploratory incisions, 122; 
 after oophorectomy, 129; after mj'omotomy, 
 145 ; after the Caesarean and Porro's opera- 
 tions, 181 
 
 Myomotomy, indications for, 144; early history 
 of, 144; results in Germany, Ilofmeier's re- 
 ports, 145 
 
 NjiLATOx, visit to England, his publication, in- 
 fluence in France, 63 
 
 Nephrectomy, 19S 
 
 Nephrolithotomy, 201 
 
 Nephroraphy, 190 
 
 Nephrotomy, 197 
 
 Nickel, on instruments, 60 
 
 Nicolajsen, operations by, 66 
 
 Note-book, description of, 35 ; mode of using, 
 36 
 
 Nurse, qualiflcations for, 74 ; duties of, 75 
 
 Nussbaum, operations by, 65 
 
 Ob-stkuction, intestinal, 209 
 
 Olshausen, operations by, 65 
 
 Omental cysts, 204 
 
 Oophorectomy, suggested by Blimdell, practised 
 by Battey, 125; Hegar's suggestions, 125; 
 cases of, 126 ; caution respecting, 128 ; for 
 hernia of ovaries, 129; statistics of, 129; 
 operations by Savage, 129; Fehling's reports 
 on, 130 ; at Samaritan Hospital, 130 
 
 Ovariotomy, early history of, 46 ; opinions of 
 the Hunters, 47 ; John Bell's lectures on, 
 McDowell's first operation, 47 ; operation by 
 Houston, 48 ; early operations in Great 
 Britain, 60; my first operations, 51; first 
 book on, 55 ; operations in Samaritan Hospi- 
 tal, 59; results, 59; influence of antiseptics, 
 60 ; by Keith, 03 ; in France, 63 ; in Belgium, 
 64; in Switzerland, 64; in Germany, 64; in 
 North of I'hiropo, 65; in Italy, 66; in 
 America antl Colonics, 67 ; preparation of a 
 patient for, 73 ; place for operation, 74 ; 
 qualifications of nurse, 74 ; tables for, 76 ; 
 instruments necessary for, 76 ; operation, 
 
INDEX 
 
 215 
 
 instructions for, 80 ; both ovaries removed at 
 one operation, 100; twice on the same patient, 
 102 ; treatment after, lOG ; fa?cal fistula afrcr, 
 113; aceiJents during the operation, 97 ; dur- 
 ing pi'ognancy, 115; incomplete ovariotomy, 
 121; results of. 130; history of patients re- 
 covered from, 130 
 Ovary, absence of, 1 ; examination of, 2 ; dis- 
 placements of, 2 ; diagnosis of different kinds 
 of tumours of, 3 ; solid tumours of, 4 ; 
 differential diagnosis of tumours of, 10; con- 
 tents of normal follicles of, 15 ; position when 
 tumefied, 29; palliative treatment of tumours 
 of, 37 ; removal of by natives of Australia 
 and Now Zealand, 46; cancer of, 72; examina- 
 tion of second ovary diiring ovariotomy, 95 ; 
 removal of both ovaries at same time, IOC ; 
 reasons for, danger of, 101 ; results of, 102; 
 return of disease in second ovary after re- 
 moval of one, 102; cysts of, drainage, 121- ; 
 removal of, for fibroid growths of uterus, 
 128, 167 
 
 Palliative treatment of ovarian cases, 37 ; 
 tapping through abdominal wall, 39 ; through 
 the vagina, 44 ; through the rectum, 45 ; 
 injection of iodine, 45; by incision, 45; of 
 uterine cases, 142; relief of symptoms, 143; 
 effect of Kreuznach and Woodhall spa waters, 
 143 
 
 Palpation, in diagnosis, 14, 138 
 
 Pancreatic cysts, 205 
 
 Pean, work on ovariotomy by, 64 ; work on uter- 
 ine tumours, 144; res\ilts of his practice, 145 
 
 Peaslee, repeated washings of peritoneum, 109 
 
 Pedicle, structure of, 7; rotation of, 8 ; absence 
 of, 10; compression of, 78; division of, 79; 
 large forceps for holding, 80 ; treatment of 
 by clamp, 88 ; by ligature, 91 ; ligatures for, 
 92 ; division of by ecraseur, 94 ; by cautery, 
 94 ; results of different modes of treating, 
 95 ; mode of dealing with in double ovario- 
 tomy, 102; adhesions of after ovariotomy, 111; 
 intra and extra peritoneal treatment of in 
 myomotomy, 163 
 
 Pelvic cellulitis and abscei-s, 33 
 
 Pelvis, gravitation of fluids or intestines into, 
 111 
 
 Percussion in diagnosis of ovarian tumours, 14 ; 
 in uterine tumours, 139 
 
 Peritoneum, cancer of, 21; chronic inflamma- 
 tion of, 19 ; closure of wounds of, 53; division 
 of in ovariotomy, 84; sponging of, 95; re- 
 peated washings of by Peaslee, 109; collection 
 of fluids in, 109; pouch of in pelvis, 112; 
 sewn over stump of uterine fibroids, 158 
 
 Peritonitis, early opinions about, 56 ; its rehition 
 to septicemia, 61 ; operative treatment of, 211 
 
 Physometra, diagnosis, 29 
 
 Porro, liis operation, 179; results, 181 
 Pregnancy, differential diagnosis of, 26 ; ovario- 
 tomy during, 115; table of cases, 121; exci- 
 sion of uterus during, 172; complication of 
 uterine tumours with, 164 
 Pylorus, excision of, 208 
 
 Removal of both ovaries at one operation, 101 
 
 Penal cysts, diagnosis, 30 
 
 Eesidts of different modes of treating pedicle, 
 95; of ovariotomy, 130; of exploratory inci- 
 sions, 122; of oophorectomy, 129 ; of myomo- 
 tomy, 145 ; of Porro's operation, 181 
 
 Peturn of disease after ovariotomy, 133 
 
 Round ligament, tumours of, 171 
 
 Russia, ovariotomy in, 66 
 
 Salicylic wool, 96 
 
 Samaritan Hospital, ovariotomies done in, 58 ; 
 
 Battey's operation, 130 
 Savage on removal of uterine append igcs, 129 
 Scherer on paralbumen, 16 
 Schroeder, operations by, 65 
 Schultze on displacements of ovaries, 2 
 Season as affecting ovariotomy, 71 
 Separation of cyst in ovariotomy, F,Q 
 Septicsemia, 67 
 
 Serous membranes, wounds of, 53 
 Silk for ligatures and sutures, 56, 60 
 Size of ovarian tumours, 69 
 Social condition as affecting^ovariotomy, 71 
 Spiegelberg, experiments on ligatures, 93 
 Spleen, extirpation of, 182 
 Sponges left in abdomen, necessity for counting 
 
 before and after operation, 99 
 Sponging of peritoneum, 95 
 Spray of carbolic acid, 60 
 Statistics of ovariotomy, 59 ; of myomotomy, 
 
 145 
 Structui'es in abdominal wall, 82 
 Sulphurous acid as a disinfectant, 00 
 Sutures, material of, 56, 60 ; node of applying 
 
 96 
 Switzerland, ovariotomy in, 64 
 
 Tappixg, 38 ; through abdominal wall, 39 : 
 
 through the rectum, 44 ; through the vagina, 
 
 44 ; of renal cysts, 192 
 Testicle, undescended, 206 
 Tetanus, 114 
 
 Thornton, case of gastrotomy, 208 
 Treatment after ovariotomy, 106 
 Trocar, 78, 86 
 Tumours, uterine, 134; of Fallopian tube, 168; 
 
 of round ligament, 171; of spleen, 182; of 
 
 mesentery and omentum, 204, 20o 
 Tympanites, 22 
 
210 
 
 INDEX 
 
 UxEEiXE tumours, 13i; forms of, 13o; size of, 
 135 ; life historj- of, 13G : early operations for, 
 137; examination for, 139; exploratory inci- 
 sions, 141; medical treatment, 142; surgical 
 treatment, 144; classification of uterine 
 tumours, 144 ; indications for myomotomy, 
 141; early history of myomotomy, 144: re- 
 sults in Germany, Hofmeier's reports, 145; 
 subperitoneal outgi'O'wths, 146 ; fibro-cj-stic 
 outgroAvths, 150; enucleation of, 160; sub- 
 
 mucous ingrowths, 1G3; complication of with 
 pregnancy, 164; removal of ovaries for, 167 
 Uterus, amputation of, 152; excision of, 171 
 
 YiECHow on fibroma-molluscum, 24 
 
 "Wards for ovariotomy, 74 
 
 Worms, pamphlet on ovariotomy, 63 
 
 Wound, closure of, 9a 
 
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CLASSIFIED INDEX, BY SUBJECTS, 
 
 OF BOOKS PUBLISHED BY 
 P. BLAKISTON, SON & CO., PHILADELPHIA. 
 
 AN/ESTHETICS 
 Sansom. Chloroform. - 
 Turnbull. 2d Ed. 
 
 Cocaine. 
 
 ANATOMY. 
 Braune. Topographical. 
 Heath. Practical. - 
 Holden. Dissections. 
 
 Landmarks. - 
 
 Handy. Te.\t-book. 
 Morris. On the Joints. - 
 Potter. Compend of 
 
 Visceral. 
 
 Wilson. 10th Ed. 
 
 ATLASES AND DIAGRAMS. 
 Bentley and Trimens. Medici- 
 
 PAGK 
 
 - 19 
 
 nal Plants 
 Braune. Of Anatomy. - 
 Flower. Of Nerves. 
 Fox. Of Skin Dis. - - 1 
 
 Godlee. Of Anatomy. - 
 Hutchinson. Surgery. - 
 Heath. Operative Surgery. 1 
 Jones. Membrana Tympani. 
 Marshall's Physiol. Platts. - 
 Schultze. Obstetrical Plates. 
 
 BRAIN AND INSANITY. 
 Bucknill and Tuke. Psycholog 
 
 cal Medicine. - . . 
 Mann's Psychological Med. : 
 Wood. Brain and Overwork : 
 
 CHEMISTRY. 
 Allen. Commercial Analysis. 
 Hartley. Medical. 
 Bernay. Notes. - - - i 
 Bloxam's Te.\t-Book. 
 
 Laboratory. 
 
 Bowman's Practical. 
 Krankland. How to Teach. i 
 Kollmyer. Key to. - . ] 
 Leffman's Compend. - - ; 
 Muter. Med'l and Pharm. - 
 
 Practical and Analy. 
 
 Richter's Inorganic. ■ - 1 
 
 Organic. - - - : 
 
 Stammer. Problems. - - : 
 Sutton. Volumetric Anal. - : 
 Thompson's Physics. - - ; 
 Tidy. Text-book. - - ; 
 
 Vacher's Primer of. - . ; 
 
 Valentin. Quant. Analy. - : 
 Ward's Compend of. - - ; 
 Watts. Phjsical and Inorg. - ; 
 
 CHILDREN. 
 Chavasse. Mental Culture of. 
 Day. Diseases of. - 
 Dillnberger. Women and. - 
 Ellis. Manual of Dis. of. - 1 
 
 Mother's book on. - : 
 
 Goodhart and Starr's New 
 
 Manual of Diseases of. - - ; 
 Hale. Care of. - - - ; 
 Hillier. Diseases of. - - : 
 Meig's and Pepper'sT realise. 
 Smith. Wasting Diseases of. 
 
 COM PEN DS 
 And The Quiz-Competids. 
 Brubaker's Physiology. 
 Genois. Pliarniacy. 
 Horwitz. Surgery. 
 Hughes. Practice. 2 Pts. - 
 
 13 
 
 19 
 
 PAGE 
 
 Landis. Obstetrics. - - i^ 
 
 Leffmann's Chemistry. - 14 
 
 Potter's Anatomy. - . 18 
 
 Visceral Anatomy - 18 
 
 Materia Medica. - - 18 
 
 Ward's Chemistry. - - 22 
 
 Mendenhall's Vade Mecum. 16 
 Roberts. Materia Medica and 
 
 Pharmacy. - - - - 19 
 DEFORMITIES. 
 
 Churchill. Face and Foot. 8 
 
 Coles. Of Mouth. - - - 9 
 
 Prince. Orthopaedics. - - 18 
 
 Reeves. " - - 18 
 
 DENTISTRY. 
 
 Barrett. Dental Surg. - - 6 
 
 Coles. Dental Note Book. - 9 
 
 Flagg. Plastics. - - - 10 
 
 Gorgas. Dental Medicine. - 11 
 
 Harris. 'Principles and Prac. 12 
 
 Dictionary of. - - 12 
 
 Heath. Dis. of Jaws. - - 12 
 Hunter. Mechanical Dent. 
 Leber and Rottenstein. 
 
 Caries. ----- 14 
 Richardson. Mech. Dent. - 18 
 Sewell. Dental Anat. - 
 Stocken. Materia Medica. - 
 Tomes. Dental Surgery. 
 
 Dental Anatomy. 
 
 Taft. Operative Dentistry. - 
 White. Mouth and Teeth. - 
 
 DICTIONARIES. 
 Cleveland's Pocket Medical. 
 Cooper's Surgical. - - - 
 Harris' Dental. ... 
 Longley's Pronouncing Med. 
 
 DIRECTORY. 
 Medical, of Philadelphia, 
 Pennsylvania, Del. and South- 
 ern N.J. - - . . 
 EAR. 
 Burnett. Hearing, etc. 
 Dalby. Diseases of. 
 Jones. Aural Surgery. - 
 
 Membrana Tympani. 
 
 Sight and Hearing. 
 
 ^Voakes. Deafness, etc. 
 Catarrh, etc. 
 
 ELECTRICITY. 
 Althaus. Medical Electricity. 
 Reynolds. Clinical Uses. 
 
 EYE. 
 Arlt. Diseases of. - 
 Carter. Eyesight. - 
 Daguenet. Ophthalmoscopy. 
 Fenner. Vision. 
 Gowers. Ophthalmoscopy. - 
 Harlan. Eyesight. 
 Higgins. Handbook, - 
 Jones. Sight and Hearing. - 
 Macnamara. Diseases of. - 
 Morton. Refraction. 
 Wolfe. Diseases of. 
 
 FEVERS. 
 Welch. Enteric Fever. - 
 
 HEADACHES. 
 Day. Their Treatment, etc. - 
 Wright. Causes and Cure. - 
 
 HEALTH AND DOMESTIC 
 MEDICINE. PAGE 
 
 Bulkley. The Skin. ■ - 
 
 7 
 
 Burnett. Hearing. 
 
 7 
 
 Cohen. Throat and Voice. - 
 
 8 
 
 Dulles. Emergencies. - 
 
 9 
 
 Harlan. Eyesight. 
 
 12 
 
 Hartshorne. Our Homes. - 
 
 12 
 
 Hufeland. Long Life. - 
 
 13 
 
 Lincoln. Hygiene. 
 
 14 
 
 Osgood. Winter. - 
 
 17 
 
 Packard. Sea Air and Sea 
 
 
 Bathing. . . . . 
 
 17 
 
 Richardson's Long Life. 
 
 18 
 
 Tanner. On Poisons. - 
 
 20 
 
 White. Mouth and Teeth. - 
 
 22 
 
 Wilson. Summer. 
 
 22 
 
 Wilson's Domestic Hygiene. 
 
 '3 
 
 Wood Brain Work. - 
 
 23 
 
 HEART. 
 
 
 Balfour. Diseases of. - 
 
 5 
 
 Fothergill. Diseases of. 
 
 10 
 
 Sansom. Phjf'l Diagnosis of. 
 
 '9 
 
 Diseases of. 
 
 19 
 
 HEALTH RESORTS. 
 
 Madden. Foreign. - - 15 
 
 Packard. Sea Air and Bath'g. 17 
 
 Solly. Colorado Springs. - 19 
 
 Wilson. The Ocean as a. - 23 
 
 HISTOLOGY. 
 
 See Microscope and Pathology . 
 
 HOSPITALS. 
 
 Burdett. Cottage Hospitals. 7 
 
 Pay Hospit;ds. - - 7 
 
 Domville. Hospital Nursing. 9 
 
 HYGIENE. 
 
 Bible Hygiene, - - - 7 
 
 Frankland. Water Analysis. 10 
 
 Fox. Water, Air, Food. - 10 
 
 Lincoln. School Hygiene. - 14 
 
 Parke's Hygiene (Price$3. 00). 17 
 
 Wilson's Handbook of. - - 23 
 
 • Domestic. - - - 23 
 
 Naval. - - - 22 
 
 Drainage. - - - 22 
 
 KIDNEY DISEASES. 
 Edwards. How to Live with 
 
 Briglii's Disease. - - - 10 
 
 Greenhow. Addison's Dis. - 12 
 
 Ralfe. Dis. of Kidney, etc. 18 
 
 Tyson. Brighl's l>iscase. - 21 
 
 LIVER. 
 
 Harley. Diseases of. - - 12 
 
 LUNGS AND CHEST. 
 
 jfitjf* See Physical Diagnosis 
 
 and Throat. 
 
 MARRIAGE. 
 
 Ryan. Philosophy of. - - 19 
 
 Walker. For Beauty, Health, 22 
 
 MATERIA MEDICA. 
 
 Biddle. 9th F.d. - - . 7 
 
 Charteris. jM.<iuial of. - - 8 
 
 Gorgas. Denial. - - - 11 
 
 Merrill's Digest. - - - 16 
 
 Potter's Coinpcnd of. - - 18 
 
 Roberts' Compend of. - - 19 
 
 Stocken's Dental. - - 20 
 
CLASSIFIED LIST OF P. B LA K IS TON, SON &- CO.'S PUBLICATIONS. 
 
 MEDICAL JURISPRUDENCE. 
 
 PAGE 
 
 Abercrombie's Handbook of, 5 
 Reese's Text-book of - 18 
 Woodman and Tidy's Treat- 
 ise, iiicliRliii)^ Toxicology. 23 
 
 MICROSCOPE. 
 
 Beale. How to Work with. - 6 
 
 In Medicine. - - 6 
 
 Carpenter. The Microscope. 8 
 
 Lee. V'adc Meciim of. - - 14 
 MacDonald. Examination of 
 
 W.ilcrby. - - - - 15 
 
 Martin. Mounting. - - 15 
 
 ■Wythe. The Microscopist. - 23 
 
 MISCELLANEOUS. 
 
 Allen. The Soft Palate. - 6 
 
 Beale. Life Theories, etc. - 6 
 
 Slight Ailments. - 6 
 
 Black. Micro-Organisms. - 7 
 
 Cobbold. Parasites, etc. - 8 
 
 Edwards. Malaiia. - - 10 
 
 Vaccination. - - 10 
 
 Constipation. - - 10 
 
 Gross, Life of Hunter. - 11 
 
 Hardwicke. Med. Educat'n. 12 
 
 Hodge. Foeticide. - - 13 
 
 Holden. The Sphygmograph. 13 
 
 Hunter (John). Portrait of. 13 
 
 Kane. Opiiun Habit. - - 14 
 
 MacMunn. The Spectroscope 15 
 
 Mathias. Legislative Manual. 16 
 
 Smith. Ringworm - - '9 
 
 Sieveking. Life Insurance. - 19 
 
 Smythe. Med'! Heresies. - 20 
 
 Wickes. Sepulture. - - 22 
 
 NERVOUS DISEASES. 
 Buzzard. Ner. Affections. - 8 
 Flowers. Atlas of Nerves. 
 Gowers. Dis. of Spinal Cord. 
 
 Epilepsy. - - - 
 
 Granville. Nerve Vibration. 
 Page. Injuries of Spine. 
 Radcliffe. Epilepsy, Pain, etc. 
 Tuke. Hypnotism, etc. 
 Wilkes. Nervous Diseases. 
 
 NURSING. 
 Cullingworth. Manual of. - 
 
 — • Monthly Nursing. 
 
 Domville's Manual. 
 Record for the Sick Room. 
 Temperature Charts. - 
 
 OBSTETRICS. 
 Cazeaux and Tarnier. New 
 
 Ed. Colored Plates. - 
 Gallabin's Manual of. - 
 Glisan's Text-book. 
 Larjdis. Compend. 
 Rigby and Meadow's. 
 Savage. Female Pelvic Org. 
 Schultze. Diagrams. 
 Swayne's Aphorisms 
 
 OSTEOLOGY. 
 Holden's Text-book, i Vol. 
 Wagstaffe. Manual of. 
 
 PATHOLOGY & HISTOLOGY 
 
 Gibbes. Practical - - - n 
 
 Gilliam. Essentials of. - - 11 
 
 Jones and Sieveking. - - 14 
 
 Paget's Surgical Path. - - 17 
 
 Piersol. Histology, 40 Plates. 17 
 
 Rindfleisch. Jeneral. - ig 
 
 Virchow. Post-mortems. ■ - 21 
 
 Wilkes and Moxon. - - 22 
 
 PHARMACY. 
 
 Beasley's Druggists' Receipts. 6 
 
 I ormidary. - - - 6 
 
 Fliickiger. Cinchona Barks. 10 
 
 Genois. Compend of. - - 11 
 
 Mackenzie. Phar. of Throat, 15 
 
 Merrill's Di,gest. - - - 16 
 
 Oldberg. Unofficial Pharm. 17 
 
 Piesse. Perfumery. - - 17 
 
 Proctor. Practical Pharm. - 18 
 
 13 
 
 PAGE 
 
 Roberts. Compend of. - 19 
 
 Sweringen's Pharm. Lex. - 20 
 
 Tuson. Veterinary Pharm. - 21 
 
 Kirby. I'harm. of Remedies. 14 
 
 POISONS. 
 
 Black. Formation of. - - 7 
 
 Tanner. Memoranda of. - 20 
 
 Reese. Toxicology. - - 18 
 
 PHYSICAL DIAGNOSIS 
 
 Barth and Roger. - - 6 
 
 Bruen's Handbook. 2d Ed. 7 
 
 Sansom. Of Heart. - - 19 
 
 West. Exam, of Chest. - 22 
 
 PRACTICE. 
 
 Aitken. 2 Vols, New Ed. - 5 
 
 Beale. Slight Ailments. - 6 
 
 Charteris. Handbook of. - 8 
 
 Cormack. Clinical Lectures. y 
 
 Fenwick's Outlines of. - - 10 
 
 Hughes. Compend of. - - 14 
 
 Roberts. I'ext-book. 5th Ed. 19 
 
 Tanner's Index of Diseases. - 20 
 
 Warner's Case Taking. - 22 
 
 PHYSIOLOGY. 
 
 Beale's Bioplasm. - - - 6 
 
 Protoplasm. - - - 6 
 
 Brubaker's Compend. - - 7 
 
 Chapman. Blood. - - 8 
 
 Fulton's Text-book. - - 10 
 
 Kirke's nth Ed. - - - 14 
 
 Landois. Text-book. - - 14 
 
 Sanderson's Laboratory B'k. 19 
 
 Tyson's Cell Doctrine. - - 21 
 
 Yeo's Student's Manual - - 23 
 
 PRESCRIPTION BOOKS. 
 Beasley's 3000 Prescriptions. 6 
 Receipt Book. - - 6 
 
 Formulary. - - - 6 
 
 Oldberg's New Prescriptions. 17 
 
 Pereira's Pocket-book. - 17 
 ■Wythe's Dose and Symptom 
 
 Book. - - - - - 17 
 
 RECTUM AND ANUS. 
 
 Allingham. Diseases of. - 5 
 
 Cripps. Diseases of. - - 9 
 
 SKIN AND HAIR. 
 
 Bulkley. The Skin. - - 7 
 
 Cobbold. Parasites. ; - 8 
 
 Fox. Atlas of Skin Dis.' - 10 
 Van Harlingen. Diagnosis 
 
 and Treatment of Skin Dis. 22 
 
 Wilson. Skin and Hair. - 23 
 
 STIMULANTS & NARCOTICS. 
 
 Anstie. On, - - - - 5 
 
 Kane. Opium Habit, etc. - 14 
 
 Lizars. On Tobacco. - - 15 
 
 Miller. On Alcohol - - 16 
 
 Parrish. Inebriety. - - 17 
 
 STOMACH & INDIGESTION. 
 
 Allbutt. Visceral Neuroses. 15 
 
 Edwards. Constipation - 10 
 
 Fenwick. Atrophy of. - - 10 
 
 Gill. Indigestion. - - - 11 
 
 SURGERY. 
 
 Cooper's Dictionary of. - - 8 
 
 Druitt's Handbook of. - - 9 
 Gamgee. Wounds and Frac- 
 
 tiues. II 
 
 Heath's Operative. - - 12 
 Minor, - - - - 12 
 
 Surgical Diagnosis. - 12 
 
 Diseases of Jaws. - 12 
 
 Horwitz. Compend. 2d Ed. 13 
 
 Hutchinson's Clinical - - 13 
 
 Mears. Practical. - - 16 
 
 Pye, Surgical Handicraft. - 18 
 
 Roberts. Surgical Delusions. 19 
 
 ■Watson's Amputations. - 22 
 
 'TECHNOLOGICAL BOOKS. 
 
 Sci' (ilso Clieinistry. 
 
 Gardner. Brewing, etc. - 11 
 
 Bleaching and Dyeing, n 
 
 Gardner. Acetic Acid, etc. - 
 Overman. Mineralogy. 
 Piggott. On Copper. 
 Thompson. Physics. - 
 Piesse. Perfumery, etc. 
 
 THROAT AND VOICE. 
 Cohen. 'Throat and Voice. - 
 
 Inhalations. 
 
 Dobell. Winter Cough, etc. - 
 Greenhow. Bronchitis. 
 Holmes. Laryngoscope. 
 James. Sore Throat 
 
 Mackenzie. 'Throat and Nose. 15 
 
 Larynx. - - - 15 
 
 Hay Fever. - - 15 
 
 Pharmacopoeia. - - 15 
 
 Potter. Defects of Speech. - 18 
 
 Thorowgood. ."Vsthma. - 21 
 
 THERAPEUTICS. 
 
 Cohen. Inhalations. - - 3 
 
 Headland. Action of Med. - 12 
 
 Kirby. Phosphorus. - - 14 
 
 Selected Remedies. - 14 
 
 Mays. 'Therap. Forces, - 16 
 
 Ott. Action of Medicines. - 16 
 
 Potter's Compend. - - 18 
 
 Waring's Practical. - - 22 
 
 TRANSACTIONS AND 
 REPORTS. 
 
 Penna. Hospital Reports. - 37 
 Power and Holmes' Reports. 18 
 Trans. College of Physicians. 21 
 Amer. Surg. Assoc. - 21 
 
 TUMORS AND CANCER. 
 Hodge. Note-book for. - 13 
 Purcell. Cancer. - - - 18 
 Thompson. Of the Bladder. 20 
 Wells. Ovarian and Uterine. 22 
 Abdominal - - - 22 
 
 URINE & URINARY ORGANS. 
 
 Acton. Repro. Organs. - 3 
 
 Beale. Urin and Renal Dis. 6 
 
 Urinary Deposits. - 6 
 
 Curling. t)n the Testes. - 9 
 
 Legg. On Urine. - - - 14 
 
 Marshall and Smith. Urine. 15 
 
 Thompson. Urinary Organs. 20 
 
 Surg, of Urin, Organs, 20 
 
 Calculou.s Dis. - - 20 
 
 Lithotomy. - - - 20 
 
 Prostate. - - - 20 
 
 'Tumors of Bladder. - 20 
 
 Stricture. - - - 20 
 
 Tyson. Exam, of L^rine. - 21 
 
 VENEREAL DISEASES. 
 
 Cooper. Syphilis, - - . ^ 
 
 Durkee. Gonorrhoea, - - ,j 
 
 Lewen. Syphilis, - - - 14 
 
 VISITING LISTS AND AC- 
 COUNT BOOKS. 
 Lindsay and Blakiston's 
 
 Regular Edition. - - - 17 
 
 Perpetual Edition. - 17 
 
 Watson's Led. and Cash Bk. 22 
 
 VETERINARY PRACTICE. 
 
 Armatage's Pocket-book of. - 5 
 
 Tuson's Vet. Pharmacopoeia. 21 
 
 WATER. 
 
 Fox. Water, Air, Food. - lo 
 
 Frankland. Analysis of. - lo 
 
 MacDonald. " " - 15 
 
 WOMEN, DISEASES OF. 
 
 Byford's Text-book. - - 8 
 
 Uterus. - - - . 8 
 
 Courty. Uterus, Ovaries, etc. 9 
 
 Dillnberger. Children and. 9 
 
 Duncan. Sterility. - - 9 
 
 Gallabin. Diseases of. - - 11 
 
 Savage. Surgery of. - - 19 
 
 Tilt. Change of Life. - - 20 
 
THE LATEST AND 
 
 Most Important Books, 
 
 GOODHART AND STARR. A MANUAL OF THE DIS- 
 EASES OF CHILDREN. By J. F. Goodhart, m.d., Physician 
 to the Evelina Hospital for Children ; Assistant Physician to Guy's 
 Hospital, London. American Edition, revised and edited by Louis 
 Starr, m d., Clinical Professor of Diseases of Children in the Hospital 
 of the University of Pennsylvania; Physician to the Children's Hospital, 
 Philadelphia. With Formulae. Cloth, $3.00; Leather, $4.00 
 
 The New York Medical Record, for May, 1885, says: — 
 
 " As it is said of some men, so it might be said of some books, that they are ' born to greatness ' This new 
 volume has, we believe, a mission, particularly in the hands of the younger members of the profession. In these 
 days of prolixity in medical literature, it is refreshing to meet with an author who knows both what to say and 
 when he has said it. The work of Dr. Goodhart (admirably conformed, by Dr. Starr, to meet American re- 
 quirements) is the nearest approach to clinical teaching without the actual presence of clinical material that wc 
 have yet seen. It does not discuss mooted questions of Pathology, b\it is a terse, straightforward account of 
 the author's e.xperience at the bedside of ailing children. Domestic hygiene is awarded its important place in 
 the therapeutics of pediatrics. The details of management so gratefully read by the young practitioner are fully 
 elucidated. Altogether, the book is one of as great practical working value as we have seen for many months." 
 
 BEALE. URINARY AND RENAL DISEASES and Calculous 
 Disorders. By Lionel S. Beale, m.d., f.r.c.p.. Professor of the Princi- 
 ples and Practice of Medicine in King's College, London. Demi-octavo. 
 360 pages. Cloth. Just Ready. 
 
 WATSON. ON AMPUTATIONS OF THE EXTREMITIES 
 AND THEIR COMPLICATIONS. By B. A. Watson, a.m., 
 M.D., Surgeon to the Jersey City Charity Hospital, to St. Francis and to 
 Christ's Hospital, Jersey City, N. J.; Member of the American Surgical 
 Association and of the N. Y. Pathological and Neurological Societies. 
 With over 250 wood engravings and two full-page colored plates. Octavo. 
 762-l-xx pages. Cloth, $5.50 
 
 VON ARLT. DISEASES OF THE EYE. Including those of the 
 Conjunctiva, Cornea, Sclerotic, and the Iris and Ciliary Body. By Dr. 
 Ferdinand Ritter von Arlt, Professor of Ophthalmology in Vienna. 
 Translated by Lyman Ware, m.d.. Surgeon to the Illinois Charitable Eye 
 and Ear Infirmary ; Ophthalmic Surgeon to the Presbyterian Hospital, 
 Chicago. Illustrated. 8vo. 300 pages. . Cloth, 1^2.50 
 
 HORWITZ. A COMPEND OF SURGERY for Students and Phy- 
 sicians. By Orville Horwitz, m.d.. Resident Physician at the Pennsyl- 
 vania Hospital, late Resident at the Jefferson College Hospital, Philadel- 
 phia. 2d Edition, Revised and Enlarged. With 62 Illustrations. i2mo. 
 15C pages. Cloth, $1.00; Interleaved for the addition of Notes, ^1.25 
 
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 ]\/[edical and |§cientific publications, 
 
 No. IOI2 Walnut St., Philadelphia. 
 
 ABERCROMBIE. Medical Jurisprudence, for Medical and Legal Students and 
 Practitioners. By John Abercrombie, m.d. In Press. 
 
 ACTON. The Functions and Disorders of the Reproductive Organs in Child- 
 hood, Youth, Adult Age and Advanced Life, considered in their Physiological, 
 Social and Moral Relations. By William Acton, m.d., m.r.c.s. Sixth Edition. 
 8vo. Cloth, $2.00 
 
 AITKEN. Science and Practice of Medicine. By William Aitken, m.d., f.r.s., 
 Professor of Pathology in the Army Medical School, London. Seventh Edition. 
 Revised throughout. 196 Engravings on Wood, and a Map. 2 vols. 8vo. 
 
 Cloth, $12.00 ; Leather, ^14.00 
 
 ALLBUTT. Visceral Neuroses. On Neuralgia of the gtomach, and Allied Dis- 
 orders. By T. Clifford Allbutt, m.u., f.r.s., Consulting Physician to the 
 Leeds General Infirmary. 8vo. Cloth, $1.50 
 
 ALLEN. Commercial Organic Analysis. A Treatise on the Modes of Assaying 
 the Various Organic Chemicals and Products employed in the Arts, Manufactures, 
 Medicine, etc., with Concise Methods for the Detection of Impurities, Adultera- 
 tions, etc. Second Edition. Revised and Enlarged. By Alfred Allen, f.c.S. 
 Vol. I. Alcohols, Ethers, Vegetable Acids, Starch and its Isomers, etc. 
 
 Nearly Ready. 
 
 Vol. II. Fixed Oils and Fats, Hydrocarbons and Mineral Oils, Phenols and 
 
 their Derivatives, Coloring Matters, etc. In Press. 
 
 Vol. III. Cyanogen Compounds, Alkaloids, Animal Products, etc. In Press. 
 
 ALLEN'S New Method of Recording the Motions of the Soft Palate. By Harrison 
 Allen, m.d.. Professor of Physiology University of Pennsylvania. Cloth, .50 
 
 ALLIN6HAM. Diseases of the Rectum. Fistula, Haemorrhoids, Painful Ulcer, 
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 Treatment. By William Allingham, f.r.c.s. Fourth Edition, Enlarged. 
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 London Edition, thick paper and larger type, $3.00 
 
 ALTHATJS. Medical Electricity. Theoretical and Practical. Its Use in the Treat- 
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 ANSTIE. Stimulants and Narcotics. With special researches on the Action of 
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 ARLT. Diseases of the Eye. ClinicalStudiesonDiseasesof the Eye. Including the 
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 Protoplasm ; or Matter and Life. Sixteen Colored Plates. Part I. Dissen- 
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 the memory." — Neiu Orleans Med. and Surg. Jl. 
 
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 not an involved sentence, or one capable of being misunderstood, in any of his writings. * * * '|'he new edi- 
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 cal Medicine, at University College; Physician to University College Hospital 
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 of the Physicians to the Pennsylvania Hospital; Consulting Physician to the 
 Children's Hospital, etc., and William Pepper, m.d., Professor of the Practice 
 of Medicine, University of Pennsylvania, and Provost and ex-officio President 
 of the Faculty; Physician to the Philadelphia Hospital. The Seventh Revised 
 and Improved Edition. 8vo. Cloth, s;6.oo; Leather, $7.00 
 
 " But as a scientific guide in the diagnosis and treatment of the diseases of children, we do not hesitate to say 
 that we have »cld<.m met with a tcxt-bf.ok so comnlctc, so just, and so readable, as the one before us. which in its 
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 and agreeable diction are appreciated,"— ./^wirr/VaM Journal of Obstetrics. 
 
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