X. CASE OF THE REMOVAL OF A DISEASED OVARIUM, TERMINATING FATALLY ON THE SEVENTH DAY AFTER THE OPERATION. By T. M. Greenhow, Esq.

Mary Nicholson, æt. 29, had enjoyed good health till her marriage two years ago, except that, for about two years previously, she had frequent uterine discharge of blood. Shortly after marriage the discharge returned, and about six months afterwards she first felt a swelling in the pubic region, which extended to the right side, and in a short time a moveable tumour, about the size of an orange, could be distinguished. The swelling from this time rapidly enlarged, and was attended with almost constant uterine discharge, under which her strength gave way. She had once been tapped, but little else than blood in moderate quantity was removed, and, since the operation, no uterine discharge has taken place. At present her strength is much increased, and she has no symptoms of constitutional disorder. "The abdomen is about as large as at the full period of uterogestation; fluctuation in one or two situations; but generally the tumour is firm, and feels as if divided into two separate masses. She has no pain or tenderness in any part of abdomen, except at one point towards the right iliac region, were the original moveable swelling was first felt. No alteration in the os, or cervix uteri, can be discovered, and, as far as can be ascertained by examination per vaginam, the organ is in a natural condition."

The operation was performed on September 3d, at 11, a. M. The temperature of the room having been raised to 76°.

"The incision reached from a little below the ensiform cartilage to near the pubis. The peritoneum was opened a little below the umbilicus, near the scar left by the trocar when she was tapped, in the expectation that at this part some adhesions would probably exist. This was the case, but they were easily separated. The incision was completed upwards and downwards with a bent bistoury through the peritoneum, directed by two fingers. Several adhesions existed in different parts of the tumour, which now became fully exposed. The prin cipal one however was to the omentum, which was spread over the upper part of the right side of the tumour, and was closely united to it. This adhesion was divided with the bistoury, and then the tumour, with some effort from its great size and weight, was raised from its situation. Being carefully supported by Mr. Frost, while Mr. Heath closed the wound as it passed out, and retained the intestines in their place, I was enabled to pass double ligatures through the pedicle, and having firmly tied them, divided it close to the tumour, which was thus liberated from its attachments, and removed. Two arteries bled freely, one in the divided omentum and the other in the pedicle; these being carefully secured, the wound was brought together by sutures and adhesive plaister, compresses of lint and linen were placed over the abdomen, and a many-tailed bandage, which had been placed under the patient in readiness, secured the whole. The operation was well borne by the patient, though she vomited towards the end several times. This however she attributed to some spirits of ammonia, and brandy-and-water, occasionally given to obviate faintness, which she says always made her vomit. The pulse remained firm, and within half an hour from being placed on the table she was again laid in bed. The quantity of blood lost did not exceed 3vj. After being put to bed she complained much of pain and smarting of the abdomen. Mur. morph. gr. ss in camphor mixture was given, which induced a tendency to sleep. The pulse varied from 72 to 90. After half an

hour, the pain continuing severe, the opiate was repeated. The strictest injunctions as to quietude and diet were given, the latter being confined to barley and toast water." 92.

We have not space for the minute account of the subsequent progress of the case given by Mr. Greenhow. Symptoms of inflammation in the abdomen arose. She gradually got worse, and died at 2, A. M., on the 9th, the sixth day after the operation. On examination of the body, the wound was found nearly healed throughout. On laying open the abdomen, the omentum presented itself adhering to the intestines, and its folds matted together. General, but not very strong, adhesions existed between the folds of intestine as well as to the walls of the abdomen. In addition to these, and other marks of peritonitis, the pylorus exhibited a distinct inflammatory blush, which extended two or three inches into the duodenum, gradually diminishing in intensity. In this situation, the mucous membrane was softened, and exhibited numerous points of ulceration. Two or three patches of similar vascularity and softening showed themselves at long intervals in the course of the small intestines, but without any ulceration. The peduncle to which the tumour had been attached, proved to be the left broad ligament of the uterus, and it appeared that the diseased ovarium after attaining a certain size, had passed over to the opposite iliac region, the uterus at the same time making a semi-turn on its own axis, so as to place its dorsum in the anterior position. A small portion of coagulated blood was found in the pubic region. The right ovarium and the uterus were healthy, but the cavity of the latter was lined with a fine vascular membrane resembling the decidua. The tumour, with the exception of one or two small cysts containing a few ounces of yellow fluid, was firm and solid, and the size of the uterus before delivery. It weighed 12lbs. 7 oz. avoirdupois.

"The general structure is cellular, but in many parts it is very dense; a number of small cells or cysts, however, pervade its substance, besides the larger ones already mentioned. One of these cells, about the size of a walnut, near the centre, contained a brownish pulpy substance, resembling thickened pus. The centre of the mass, for the space of several inches, was of a bright red colour, as if an active circulation had been carried on in the interior. The largest cyst, at the upper part of the tumour, was white and glistening in its interior, resembling the ordinary character of ovarian cysts; but the dense solidity of the general mass, and vascularity of the interior, distinguish this tumour from the other instances of ovarian disease which have come under my notice." 100.

Owing to the reduced condition of the patient from discharges of blood, this case was not so favourable for an operation as the preceding one. Mr. Greenhow believes that her convalescence after the inflammatory attack was very nearly established, and that, but for the diseased condition of the pyloric extremity of the stomach, her recovery would have been effected. At so early a period as on the sixth day after the operation, and with unabsorbed lymph and coagula of blood in the abdomen, convalescence cannot be said to be established, and we must regard the morbid state of the pylorus as one of the results of the operation, probably induced by, and

* In the heading of the case, the day of death is erroneously stated to be the

seventh.

not the cause of, the severe vomiting from which the patient suffered. Mr. Cooper and Mr. Greenhow are entitled to the thanks of the profession for fairly and faithfully recording the particulars of these unsuccessful cases. It is right to add, that, in both instances, the operation appears to have been performed with every care and precaution.

The following paper, though the last in the volume, may be advantageously considered after these two cases.

XI. OBSERVATIONS ON THE RECORDED CASES OF OPERATIONS FOR THE EXTRACTION OF OVARIAN TUMOURS. By Benjamin Phillips, F.R.S.

In this paper, the author has brought before the Society all the information which he has been able to collect on the subject of the extraction of ovarian tumours, in order to afford some aid in coming to a right judgment, whether this operation shall be classed amongst the benefits conferred by science upon man. It is remarked, that the opinion of any man, however eminent, pronounced without a careful estimate of the materials which have now become available to us, cannot and ought not to determine the question. He observes, that it has been the fate of some grave and dangerous operations, to be received into favour and admitted into practice from the moment they were proposed; and of others less grave and dangerous, to be assailed by great prejudice; whilst those who have desired to afford them a fair trial, have been exposed to censure and contumely; in either case the results of the operation being disregarded.

"In 1818, Mott placed a ligature around the arteria innominata, and the operation was unsuccessful; and yet, formidable as is the operation, and unvaried the failures in every instance, though performed by the ablest surgeons, it has been repeated twelve times, and still I have no doubt that men of the greatest eminence and most unquestionable skill would nevertheless resort to an operation the almost certain result of which would be death. The extraction of an ovarian tumour is much more simple, much less grave, than the ligature of the innominata, and yet by a large portion of the profession, and by some of the most celebrated of its members, it has been denounced as rash and imprudent. With a few exceptions it has not been performed by the more experienced and able surgeons either in this country or on the Continent; it has fallen into the hands of men less accustomed to perform great operations, and it may be not unreasonably assumed, less conversant with the after-treatment which may be needful. Although performed many times in London, I believe it has been introduced into no other Hospital than Guy's, and even were its performance more frequently called for, and its success more decided, it would hardly be classed amongst the recognised operations of surgery until warranted by the experience of Hospital practice." 471.

The operation of tying the arteria innominata for the cure of aneurism cannot be fairly compared with the operation for the removal of an ovarian tumour. In the first case the disease is so dangerous, that death is almost certain within a brief period, and the surgeon knowing from his experience of the efficacy of ligatures on arteries in cases of aneurism generally, that the operation affords the only chance of saving life, offers it as a dernier ressort to his patient. The next case may be a successful one, and if, in one case in thirteen, or even one in twenty, life is preserved, the operation is warranted; and it is so upon precisely the same principle, that in the case of two limbs irretrievably damaged by violence, we should am

putate if necessary both thighs or both arms as the only chance of rescuing the sufferer from death-poor as that chance may be. But how different are the circumstances of a person with an ovarian tumour! The danger is distant-the patient will probably live at least four years, and she may survive twenty or even longer; whereas, if an operation be performed, the chances are nearly even that she dies in a week. We have a patient who has a large abdominal tumour which has existed for years, and been stationary for the last two. She passes her days in comparative ease, is able to perform the common offices of life, to enjoy society, and even to tend a sick husband. Until this can be said of a patient with a subclavian aneurism, no fair comparison can be drawn between the circumstances of these two cases.

Mr. Phillips gives a Table of eighty-one cases, in which are exhibited, the names of the operators, the ages of the patients, the nature of the operations, the state of the tumours, the results, and remarks on the cases. The Table includes cases operated on in this country as well as on the Continent. It would have been more complete and useful, if the authorities had been quoted. In sixty-one cases, the tumour was extracted: in fifteen cases, adhesions, or other circumstances, prevented its removal; in five instances no tumour was found. Of the cases in which the operation was completed, the tumour being extracted, thirty-five terminated favourably; the patient recovered in twenty-six instances the termination was unfavourable; the patient died. Of the five cases in which no tumour was discovered, all recovered. Of the fifteen cases in which adhesions, or other circumstances, prevented the extraction of the tumour, nine recovered, six died. Mr. Phillips very justly observes, the proper way" of looking at this plan of treatment, is to observe the number of cases submitted to operation, and the number of recoveries after the removal of the tumour. I conceive this to be the fair way, because, what has happened already is, in my judgment, likely to happen again. Adhesions may be too strong and extensive to make removal prudent; the tumour may be other than ovarian, or it may be that no tumour can be found. Regarded in this light, it appears that the operation has been performed eighty-one times, and that in thirty-five instances the patient has recovered after the extirpation of the tumour. It is true, that forty-nine patients survived gastrotomy; but many of them were subjected to such a painful and dangerous operation, on the one hand without necessity, and on the other without being disembarrassed of the disease."

In order to estimate the relative advantages and dangers of the major and minor operations, Mr. Phillips has made two Tables, one including the cases in which the tumour was removed entire, the incision having an extent of six inches or upwards: the other, including those cases in which part or the whole of the fluid was evacuated before the extraction was attempted, the length of the incision having been under six inches. Of the former, there are fifty-five cases, twenty-three of which were successful of the latter, there are twenty-seven instances, of which thirteen were successful.

In the consideration of these cases, the following points arise: "First.-Can we determine, with certainty, whether a tumour be ovarian or > not? If not, have the failures been so frequent as to constitute a reason why the operation should not be attempted?

"Second. Supposing a tumour to exist, and to be ovarian, can we ascertain the nature of its contents, as well as its connections? If not, have the failures been so many as to be an objection to the adoption of the operation at all?

"Third.-Are the results of this plan of treatment sufficiently favourable to justify us in preferring extirpation to any other mode of treating ovarian tumours? And if so, what plan of operation promises most success?" 481.

In proof of the uncertainty of the signs of ovarian tumour is adduced the fact, that out of the eighty-one instances in which the operation for extirpation was attempted, five times, at least, the abdomen has been laid open, and no tumour discovered-and in six others the tumour was not ovarian. The patients recovered in all the instances in which no tumour was found, and hysterical or other tympanitis, or tumours of the omentum were the sources of error in the cases referred to. Though it must be acknowledged that in many instances the diagnosis of abdominal tumours is extremely difficult, yet many cases occur in which the surgeon can positively predicate the existence of ovarian disease, and we need scarcely say, that it is only in such cases where the nature of the tumour is plain and indisputable that an operation should be thought of.

With regard to the second point for inquiry, Mr. Phillips says "we have no certain means of ascertaining the contents and connections of tumours presumed to be ovarian. In six instances, the abdomen has been laid open, and the tumour has been found to be either diseased omentum, or diseased or gravid uterus. Many times a presumed ovarian cyst has been punctured, and no fluid has escaped; the operation has been a dry tapping.' I have been present when an operation has been performed for the extraction of the cyst, where, although the examination was made by men of tried ability, who had no doubt of the contents being fluid, yet not a drop of fluid was contained in it-it was a stiff jelly.

"With reference to connections or adhesions, the difficulties met with. are still more formidable. In fifteen cases where the operation for extraction was commenced, it was found necessary to discontinue it, in consequence of the extent of the adhesions. In twenty-five other instances adhesions existed. Of the fifteen cases in which they caused the abandon-ment of the operation, six terminated fatally."

A Table is given of these fifteen cases of " no extraction." Upon the subject of adhesions we find the following just remarks:

"This seems to me to be the pinching point of the case. I would admit, that a very careful and competent observer would not be likely to fail often, in his conclusions as to the existence or non-existence of a tumour, and as to its being ovarian or not; I would admit that he would not often fail in the determination of the contents, but I know no sure means of ascertaining whether there be extensive adhesions or not: in most cases, there are no physical signs by which we can determine this. Is it not certain that we can, in ordinary cases, cause the abdominal parietes to glide over the surface of the tumour; in many cases, persons are deceived by the gliding of the superficial upon the deeper-seated layer of the abdominal walls, and if we could, it would only avail for its anterior surface. The crepitating sign pointed out by Dr. Bright is only present when the adhesions are recent; and as to the motion of the tumour with the diaphragm, considerable adhesions may exist without much interfering with it. An examination per vaginam would not set the question at rest. Our main reliance is therefore upon the signs of peritonitis-if the evidence be clear that peritoneal inflammation has existed, it is probable that adhesions are present; but we may find adhesions where there has been no reason to suspect peritonitis. Still, extensive adhesions