A YEAR’S WORK

IN

ABDOMINAL SURGERY.

BY

WILLIAM GARDNER, M.D.,Professor of Gynaecology, McGill University; Gynaecologist to the

Montreal General Hospital; One of the Vice-Presidents of the

British Gynaecological Society.

Reprinted from the Canada Medical ds Surgical Journal, October, 1887-

—MONTREAL: iGAZETTE PRINTING COMPANY.

iSSy-

A YEAR’S WORK IN ABDOMINAL SURGERY."William Gardner, M.D.,

Professor of Gynaecology, McGill University; Gynaecologist to the Montreal GeneralHospital; one of the Vice-Presidents of theBritish Gynaecological Society.

Mr. President and Grentlemen—During the last workingyear I have opened the peritoneal cavity 38 times. Of these35 were abdominal sections, the others were total vaginal extir-pations of the uterus, and I have included them in the listbecause the important element of peritoneal section obtainsequally in them with the abdominal cases proper. The list Isubmit includes an unusual variety of cases and conditions, and Iventure to think that its recital may he of some interest andfurnish material for a useful discussion. Every operation wasdone in a private hospital, with the most scrupulous attention tocleanliness of the hands of operator, assistants and nurses ; andof instruments, sponges and ligatures, but without the use ofany antiseptic whatever except to the field of operation—abdomi-nal wall or cavity of the vagina,—where a 1-1000 sublimatesolution was always freely used after thorough scrubbing of thepart with soap and water. The after-treatment was entirelyunder my own watching and control, a circumstance to which Iattribute great importance in determining the results obtained.The following is a brief classification of the cases with results:

Recoveries. Deaths.Ovariotomies.. 16 16Hysterectomies 2 2Removals of Uterine Appendages 11 10 1Abdominal section for opening

Pelvic Abscess 2 2Puerperal Peritonitis 2 2

Abdominal section forRetro-Peritoneal Cyst 1 1Exploratory Operations 3 2 1Total Vaginal Extirpation of

Uterus 3 3Of the ovariotomies several were of exceptional interest. In

* Bead in abstractbefore the annual meeting of the CanadianMedical Association,at Hamilton, Sept. Ist, 1887.

4

two there was twisting of the pedicle, giving rise in both toviolent pain, and in one of them to severe peritonitis. In thelatter case, a patient of my friend Dr. Molson, the pedicle wastwisted three times ; the walls of the cyst, a dermoid, werealmost black ; adhesions were universal; the second ovary beingenlarged and cystic, was also removed; the cavity was washedout and a drainage-tube employed for five days. The uteruswas found to be somewhat enlarged, soft and vascular. A sus-picion of possible pregnancy flashed across my mind, but theidea was not seriously entertained at the time of the operation.The patient recovered without a bad symptom. Three monthsafterwards I had an opportunity of examining her, and foundher undoubtedly pregnant to about five months, gestation per-sisting in spite of the rotation of the tumor, with strangulationand consequent severe peritonitis, a double ovariotomy withwashing out and drainage, the glass drainage-tube lying behindthe uterus and in contact with its posterior wall for five days.This is my second ovariotomy during pregnancy; the first alsorecovered without a symptom worthy of note. The patient wasdelivered at full term just six months after the operation. Bothmother and child are alive and well to-day.*

The other twisted pedicle case was sent to me by Dr. Yauxof Brockville, and was that of an unmarried woman of 25. Shehad for several weeks suffered severe pain, unrelieved by morphiain full doses. The twisted pedicle was enormously thickenedfrom oedema the result of obstructed circulation, and the cyst wallmuch discolored ; there were papillomatous growths from itsinterior, and hemorrhage into its cavity. Recovery was rapidand complete.

In both cases the tumors were small, as is usual in axial rota-tion, and they are good examples of the many untoward acci-dents to which all ovarian tumors are liable, and furnish strongarguments in favor of the plea for early ovariotomy.

Another of the series was in a hale old lady of 68, whoserecovery from the conditions incidental to the operation wasabsolutely without any event worthy of note, except slight cys-

* See CanadaLancet, February, 1887.

5

titis, but who on the second day developed pleurisy, which soonbecame double, with most alarming symptoms. The pulse roseto 180, and was irregular and unequal. She ultimately madea perfect recovery.

In two of the cases the tumors were sarcoma, one being sar-comatous degeneration of a dermoid cyst. In both there wereadhesions to intestine and every other structure within reach.In both, washing out and drainage were resorted to. Theywere desperately severe operations, but both recovered. Inone the curious symptom of polyuria developed in the thirdweek, and for several days six to seven pints of urine weresecreted. There was great thirst and enormous appetite. Thesesymptoms had completly disappeared before the patient was dis-charged.

In one case—an enormous tumor—the patient had a success-ful pregnancy and uneventful delivery at full term, after thetumor had attainedjmnsiderable size, and she had been tappedfour times, once at the interval of a fortnight before her con-finement.

In nine of the sixteen cases the condition of the second ovarywas such as in my opinion to demand its removal. Such con-ditions were marked enlargement and cystic disease. Thequestion of the necessity of removing the second ovary underthese circumstances has given me some anxiety in young sub-jects, as it seems to me it must to every conscientious surgeon.So far as I know there is no known method by which to diagnoseon the operating-table a condition comparatively harmless, andwhich may not prevent successful ovulation and conceptionfrom one which is the commencement of a disease that mustultimately demand operation. It is quite certain that all slightlyenlarged and cystic ovaries are not commencing ovarian tumors.In a woman who has already attained or is nearing the meno-pause, the second ovary when in such a condition, or, accordingto some surgeons, even when apparently perfectly healthy, mustalways be removed, knowing as we do its proneness to thedisease which has required operation for the first. But it is farotherwise in the young woman, married or not, from whom by adouble ovariotomy, it may be, needless, all possibility of realiza-

6

tion of the much cherished hope of maternity is for ever re-moved. I confess that for myself the question is as yet unsolved.All recently published experience is quite in accord with myown that the double operation does not in the least add to thedangers. It may be remembered that Sir Spencer Wells’ sta-tistics seemed to indicate an opposite conclusion.

The operation of removal of the appendages is one, now-a-days,of even more interest than ovariotomy, because more recent andinasmuch as it involves certain questions not yet quite solved tothe satisfaction of everybody, f can honestly say that some ofmy cases have given me more satisfaction than anything else inmy work during this last, as in former years of my work. Thelist comprises examples of almost all the conditions for whichthe operation is ever necessary. Such were pyosalpinx, haemato-salpinx, pelvic haematocele, enlarged and cystic ovaries, andcirrhotic very small ovaries, with and without adhesions fromprevious pelvic peritonitis. Some have been restored in a fewweeks from a life of more or less complete invalidism to health,activity and usefulness. Others have been slow in recoveringfrom the operation, because of secondary inflammation about thepedicle. In others still, nothing could have been more favorablethan the after course quoad the operation, but the morbid con-dition of nerve centres which is in some the result of long-con-tinued suffering and habits of invalidism continued for severalmonths to manifest itself in the persistence of pain in theregions whence the diseased appendages were removed, or insome distant reflex symptom, most commonly headache. Thesingle death of the series was from hemorrhage, and it is theonly death in the list of which I have any reason to be ashamed,as it might have been prevented if I had been called to thepatient in time. As it was, I reached her bedside nine hoursafter the operation, when she was moribund. The peritoneumwas found full of blood, but the ligatures held fast. The exactsource of the blood flow was not found, but it was doubtlesseither a rent of some part of the broad ligaments or one of thesuture needle punctures. The operation was a perfectly simpleone for cystic ovaries without any adhesions whatever. Someof the operations were the most difficult I have ever had to

7

encounter, by far more difficult than any but the most difficultovariotomies, and I think that without washing out and thedrainage-tube some of them had scarcely a chance of recovery.It is in such cases, perhaps, more than in any other in the wholerange of abdominal surgery that the value of experience becomesapparent in the separation of adhesions and recognition by touchof the educated finger of the parts which must be removed.This all important part of the operation must be done solely bythe sense of touch, and in some of my cases the whole operationwas done through an inch-and-a-half incision.

Of the miscellaneous cases, the following one of exploratoryincision is of exceptional interest: A tumor-like mass of doubt-ful nature remained after the symptoms of a severe attack ofperitonitis in a delicate girl of 30, had subsided. The patientcontinued to vomit and suffer from great pain and difficulty indefecation She was much emaciated. On opening the abdomenthe peritoneum was found studded in numerous places withtubercle. This was verified by microscopic examination of aportion removed. The mass described was found to consist ofthe small intestine densely matted together in its own coils andadherent to everything around. The mass was somewhat sepa-rated from its surroundings, returned, and the abdominal open-ing closed, with a drainage-tube in the pelvis. She recoveredeasily and rapidly from the operation, and for a time was muchrelieved of her symptoms. For a few weeks she was able todispense with morphia, which she had taken daily up to thetime of operation, and the bowels acted spontaneously andwithout pain. She survived the operation six weeks, dying ofexhaustion. This is my second case of tubercular peritonitissimulating ovarian tumor. The other case will be found recordedin the Canada Medicaland Surgical Journal for June 1885.

In the two puerperal cases the patients were almost in extremisand the operations were done as a last resort, but without availin influencing the symptoms. In both the abdominal cavity wasopened, washed out, and a drainage-tube inserted. The con-ditions found were those of intense general peritonitis, withcopious exudations of lymph and pus, and infiltration of ovaries,

8

tubes and cellular tissue with inflammatory exudation. Inneither was there any encysted collection of the products ofinflammatory action or evidence of disease in or about the appen-dages from which the general peritonitis might have started.In one of the cases there had been persistent right iliac painduring the pregnancy, and the symptoms of the fatal illnessbegan by an aggravation of this pain. These facts justifiedDr. George Ross and myself in opening the peritoneum in thehope that some condition within the power of surgery to relievemight be found. Puerperal fever was, however, prevailing, andthe result of the exploration confirmed the idea that these caseswere of septic character. Both patients died within twelve hoursof the time of operation, but in neither was death in the leasthastened by the operation, so far as an opinion could be formedfrom the symptoms present when the operation was undertaken,and in one the agonizing pain was at once relieved, an effectwhich morphia had failed to produce.

The results of exploratory abdominal section for peritonitis, avery recent development, have already proved beyond doubtthat many lives may be saved by an operation which in compe-tent hands does not in the least lessen the patient’s chances.That peritonitis in the lying-in woman not rarely is of a characterand has such an origin that we can occasionally thus save a lifehas already been amply demonstrated by the experience of Law-son Tait and John W. Taylor of Birmingham, and others. Oneof Mr. Tait’s successful cases I had the good fortune to see andassist at during my stay with him last summer. The kind ofcase in which we have the best reasons to anticipate success arethose of previously existing, perhaps latent disease of ovaries ortubes, such as abscess of the ovary or pyosalpingitis, roused toactivity by the process of parturition, and leading, it may be,to general peritonitis. That such conditions not rarely exist wasshown by Dr. Grigg, of the Queen Charlotte Lying-in Hospital,in a paper read before the British Gynecological Society, basedon the conditions found in certain autopsies. Other conditions inwhich the operation is indicated are encysted collections of the pro-ducts of inflammation in the peritoneum or pelvic cellular tissue, I

9

believe the time has come when it may with perfect justice besaid that in a suitable case of puerperal, pelvic or peritonealinflammation in which life is threatened, the practitioner is boundto do the operation or have it done for him, and so will save thevaluable life of many a wife and mother.

The two hysterectomies recovered, both without any badsymptom. In both I adopted, as in all my previous hysterec-tomies, the extra-peritoneal method of dealing with the pedicle,clamping it with Koeberle’s serre-noeud. It is possible, andmuch to be desired, that “ a more excellent way” (as Keith hasit) may yet be devised, but that it has not yet been attained isamply proved by a comparison of the experience of Keith,Bantock and Tait by the extra-peritoneal method, with the pub-lished results of Schroeder and Martin in Germany by the intra-peritoneal method. If ever induced to try the latter method,I shall certainly combine it with drainage of the Douglas’ pouchthrough the vagina after Martin’s method.

In 19 of the 35 abdominal sections the drainage-tube wasused. It was employed in all cases where adhesions were exten-sive and oozing surfaces remained, and when washing out wasresorted to. In the latter case much sponging to remove thewater used was thereby saved, as it was sucked out through thedrainage-tube. Of all improvements in the technique of abdomi-nal surgery next to the intra-peritoneal ligature, none has somuch conduced to success as the use of the drainage-tube. Byits employment operations may often be much shortened and theperitoneum saved much labor in the absorption of effused blood,and the patient’s chances of recovery correspondingly increased.

Experience in the use of the drainage-tube is an importantfactor in the amount of good to be gained by it. In the experi-ence of other surgeons I had learnt much as to the kind of casein which to use a drainage-tube, but not much as to the lengthof time it must be allowed to remain in the wound. I had neverseen any definite rules on this point laid down till I read theremarks of my friend Dr. Bantock in his paper on “ A HundredCases of Abdominal Section ” published in the London Lancet afew months ago. It is possible to remove the drainage-tubemuch too soon, and I am sure I have seen ill results in my own

10

practice from this. Since reading Dr. Bantock’s paper I havefollowed his instructions on this point, and with, I believe, signaladvantage. These are, in the main, to the effect that the drain-age-tube ought not to be removed till the whole amount of secre-tion that can be removed from it in twenty-four hours does notexceed one drachm of amber-colored serum.

Next to improvements in the technique of abdominal surgerythe after-treatment of cases is of prime importance as affectingthe patient’s prospects. When in Europe last year I found thatMr. Lawson Tait and Dr. Bantock held very strong opinions oncertain questions connected with the management of such casesafter operation. One of the principal points on which they agreedis the advantage of the avoidance of opium entirely. Duringthe last twelve months I have uniformly followed this examplewith the exception of one or two instances, and a comparisonwith my previous experience has thoroughly convinced me thatthey are right. As a rule, the pain after an abdominal sectionis mainly at the needle punctures of the abdominal wall, andalmost invariably ceases in twelve hours. A dose of opium ormorphia will, it is true, relieve the pain, but it dries the secre-tions, makes the patient clamorous for drink which it is so im-portant that she should avoid for thirty-six hours, it quiets thebowels and so favors accumulation of flatus, and distension,whereas it is all-important that the peristaltic action of the in-testines should be kept up, not only to carry off flatus, but toprevent adhesion of coils of intestine to the pedicle, to rawsurfaces whence adhesions have been separated, or to the inneraspect of the abdominal wound, which may lead to obstruction. Itis more than probable that most of the deaths after abdominalsection attributed to peritonitis in recent years have been dueto obstruction.

In my work during the year I have given no opium, and in-variably, immediately on the appearance of distension, pain orvomiting, I have given enemas and purgatives with the mostsignal advantage. lam convinced that in my own experienceI have thus seen lives saved, besides a vast diminution of thetrouble and difficulty in managing the cases afterwards.

I append the following table of the ovariotomies included inthe series:—

11

OVARIOTOMIES.Name,&c.

Ordinary Attendant.Historyand

Symptoms.LocalConditions.Operation.

Recovered orDied.

Subsequent History-

E.T.,

aged31,

unmarried.Dr.

Bingham, Williston,Vt.,

U.S.A.

Mensesbeganat14;

always

regular.General

health

good.First

noticeden-

largement3|

yearsbefore

operation.

Generalabdominal

en-

largement;wavefluc-

tuation,bulgingin

flanks,flatin

front;

bowelnotenot

distinctinflanks;girth3bin.;

uterusretroverted,

prolapsed,andslightly

mobile.

Twoand

a-halfinchin-

cision;

noadhesions;

parovariancyst

right

side,limpidfluid,favor-

ablepedicle;

ovaryand

tubespreadoutoyer

cystwall;

operationcompletein25minutes.

Recovered.Perfect

health

M.B.,

aged69,

married.Dr.Hill,Ottawa-

Motherofseveralchildren.

Menopausemany

yearsago.

Generalhealth

perfect.No

symptoms,but

tumorfirst

noticedli

yearsago.

Fluctuationinareas;

greatenlargement;

notenderness;uterus

pushedforward,lying

behindpubes.

Multilocularovariancys-

toma;fewslight

anterioradhesions;

tumorisof

rightside.Severe

attack

ofdouble

pleurisywith

rapidpulse,

reaching180,

rapidlyreducedbydigi-

talis;

rapidrecovery.

Recovered.Slight

cystitisfora

fewweeks;two

monthsafter

oper-

ation,a

smooth,tenderswellingin

'regionof

pedicleslowlydisappear’d.Otherwise

well.

M.0.,aged51,

married.ReferredbyDr.

R.P.Howard,Montreal.

Mensesbeganat17;

married30

years;

onechild25

years

ago;mensesceasedeight

monthsago.

Paininleft

lumbarregionandfirst

signsoftumor

oneyearago,

rapidgrowth:threemonths

beforeoperationmeasured

42inches.Wastapped,2J

gallonsremoved,in

Bur-

lington,Yt.

Fluctuating _tumor;

clearnoteinflanks;

nofirmareas;35iin.;

uterusretroverted;

moveable3finchesby

sound.

Unilocularcystofleft

ovary;

noadhesions;

verybroadpedicle;

liga-

turedin

sections;a

smalldermoidcystat-

tachedto

baseoflarge

tumor.

Recovered.Perfectlywell.

12

OVARIOTOMIES—{Continued.)

Name,&c.

Ordinary Attendant.History

andSymptoms.

LocalConditions.Operation.

Recovered orDied.

SubsequentHistory.

C.M.,aged53,

unmarried.Dr.

JamesBell,Montreal.Mensesbeganat12;

ceased

fouryearsago.

Neverpreg-

nant-Ismuchemaciated

andsallow;

severeabdomi-nalpain,rectal

tenesmusandpain.Sixmonthsago

firstnoticedlumpinleft

iliacregion.Steadyin-

creaseofsize,withpain.

Fulldosesof

morphiafor

sixweeks.

Nodulated,firmtumor

springingfromleft

side,extendingfrom

pubesto

within2in.

oflower

ribs;

inparts

elasticfeel;

uterusmoveable:markedin-

durationin

posteriorcul-de-sacandrecto-

vaginalseptum:

girth

ofabdomen34inches-

Noadhesions:favorable

pedicle;multilocular

cystofleft

ovary,jelly-

likecontents.In

Doug-

las’pouchtheinduration

felt,evidentlymalignant

diseaseofthe

rectum.Recovered.

Recoveryfrom

ope-

rationrapidand

perfect;greatre-

lieffrompain;no

morphianeeded

forsome

weeks.Diedthreemonths

afterfromcancer

ofrectum.

M.B.,aged29,

married.

Dr.M.C.

MoGannon,Brockville,Ont.

Mensesbeganat11;

always

regular,profuse.Married

threeyears;one

child22

monthsago.

Firstnoticed

tumorinleftiliac

region

12monthsago,

steadilyin-

creasing;

dysurialast18

months.

Abdomenenlarged,32i

inches;unevenfluc-

tuatingareas;uterus

retroverted,prolapsed

andmoveable.

Multilocularcystomaof

leftovary;omental

ad-

hesions,grumouscon-

tents;

favorablepedicle.

Threeligaturestoomen-

tum;

rightovarysizeof

hen’seggand

cystic,also

removed.

Recovered.Perfect

health.

M.I.,aged39,

married.W.G.

Mensesbeganat15.

Married14years;five

pregnancies,last11monthsago.

Menses

nowregular.First

noticed

tumorSept.

1884,onleft

side.Tappedfourtimes,

onceduringlastpregnancy

twojweeksbeforelabor.

Abdomenvery

large,

45|

inches,uneven,

fluctuatingover

large

areas;oedemaofhypo-

gastrium;uterusre-

troverted,prolapsed,

andmoveable.

Largequantity

peritonealfluid;multilocularcys-

tomaleft

ovary;omen-tal

adhesions;favorable

pedicle;

rightovary

cys-

ticandenlarged,also

removed.

Recovered.Perfect

health.

II.S.,aged30,

married.Dr.

Beckstead, LisbonCentre,

N.Y.

Mensesbeganat16;atfirst

scanty,oflate

profuseand

protractedleucorrhoea;pain

inhips.Neverpregnant-

InJan.

’85,diagnoseda

pel-

vicovariantumor.

Noab-

dominalenlargementtill

Jan.’S?.Rapid

enlargement.Elastic,

unevencondi-

tionof

abdomen,35

in.,fluctuatesin

areas.Uterus

retroverted;

sensitive,moveable

bodyfeltin

Douglas’pouch;

tappedtwo

monthsbefore

opera-

tion.

Multilocularcystomaleft

ovary;no

adhesions;favorable

pedicle;right

ovarysizeof

pullet’segg

andcystic,also

removed.Recovered.Perfect

health.

J.B.,aged18,

married.Dr.Ball, Stanstead,

P.Q.Mensesbeganat11;

always

regular.Marriedtwoyears,

neverpregnant.

Noticedenlargementfour

months

aftermarriage.A

good

dealofpainduringlast

year.Twicetappedduring

lastthreemonths.

Uniformenlargement;

generalfluctuation;

distinctwave.Uterus

retroverted,prolapsed.

Tumordistinctinpel-

vis;

girth40J-inches.

Multilooularcystomaof

leftovary;

universalan-

teriorparietaladhesions.

Threeligaturesto

bleed-

ing

points;drainage-

tube.

Recovered.Perfect

health.

M.C.,aged25,

unmarried.Dr.Yaux,Brockville.Mensesbeganat17;

isquite

regular.Good

healthtill

twoyearsago,

thenbegan

tohave

occasionalattacks

ofseverepainin

rightiliac

region;thispain

almost

constantlastfive

months;

threemonthsagotumor

firstnoticedinrightiliac

region;painattimesvery

severe,not

relievedby

morphia;girth

25Jinches.

Tumoristense,

elastic,insensitive,

moveable,entirely

belowumbili-

cus:uterus

anteflexed,presseddowninfront

oftumor.’

T

Noadhesions;

cystwall

darkcolored;pedicle

twistedvery

thickand

oedematous,sizeof

adult’shead:contents chocolate-colored

fluid;

papillomatousgrowths

frominteriorofcyst,

whichisunilocular,and

ofright

ovary;leftovary

amassof

cystsandof

sizeofpullet’s

egg,also

removed;oozing

from

pelvis;

drainage-tube.Recovered.

Perfecthealth.

M.D.,aged20,

married.Dr.

JamesBell,Montreal.Mensesbeganat13.

Onechild

1

yearold;

suckledten

months.Menses

returnedatsixmonths;

regulartill

sevenweeksbefore

opera-

tion.Firstnoticedalump

inrightiliac

region3£

mos.

ago;steadygrowth;

much

pain,irritationof

bladder,

constipation,painanddiffi-

cultyin

defecation;great

wasting,weakness;pulse

90-100:inbedfor2months.

Irregular,nodular,

sen-

sitivetumorextending

uprightsideof

abdo-

menfrompelvisto

hypoohondrium,very

slightlymoveable;in

placeselastic,

semi-

fluctuating;

floorof

pelvisindurated;

os

uteripushedforwards

andto

rightside;

por-

tio-vaginalisobliter-

atedbycollar-likein-

durationaroundit.

Desperatelysevereopera-

tion;

adhesionstointes-

tines,omentum

andto

wholeof

pelvis;lower

partoftumora

friable

mass,inwhichneither

ovarynorfundusofthe

uterusis

distinguishable.After

enucleationof

tumor,the

operationfin-

ishedby

clampingcervix

uteriandbringingitout

atlowerangleof

abdomi-nal

incision.The

tumor,

asarcomawith

dermoidelements.

Washingout

anddrainage.

Recovered.Recovery

wasfairly

rapid,interrupted

bysepticfever

for

afewdays.In

thirdweekpoly-

uria,6to7

pints

urinedaily;great

thirst;enormous

appetite.Returned

home6weeks

after

operation;

generalandlocalcondi-

tionsexcellent;2

monthslater

signs

ofrecurrence;amonth

latermuch

emaciated,sinking

fast;recurrenceof

growth,fasoalfis-

tulaatlowerend

of

_abdominalin-

cision;

isdying.

14

OVARIOTOMIES—(Continued.)

Name,Ac.

OrdinaryAttendant.History

andSymptoms.Local

Conditions.Operation.

Recovered orDied.

SubsequentHistory

Mrs.S.

,

aged31

married.M.G.,aged38,

married..

Dr.Moison,Montreal. Dr.

Moison,Montreal.Beganto

menstruateat19.

Marriedeight

years;four

pregnanciestofullterm,

last14monthsago,

suckled

lumonths;

mensesreturnedafterweaning;fourmonths

JMjPfirstnoticeda

lumpin

leftiliac

region;three

weeksago,

aftera

walk,

suddenseverepain,vomit-

ing,fever,

retentionof

urine,constipation;full

dosesof

morphiaup

till

timeof

operation.Married13

years;

before

marriagemenses

irregular,

lastthree

yearsprofuse,

especiallylastsixmonths.

A

thin-walled,fluctu-

atingcystsizeofa

child’shead,quite

tender;uterusfixed,

retroverted,quiteten-

der. Amende,fat,

weak

person;flowing

con-

tinuously;

painsin

hips,leftlegandthigh.

Theveinsofleftleg

andthigh

distended,varicose;duringlast

sixmonths

moderateenlargementof

abdo-

men;feelssolidthro’

thethickrigid

pa-

rietes;uterusfixed.

Parietal,pelvicand

omen-tal

adhesions;

adermoid

cystofleft

ovary;

long,

slenderpedicle,

twisted

threetimesaroundits

axis;

contentscreamy,

coagulatesolid;

cystwall

dark-colored,contains

teeth,hairandbone,

hairalmostblack;

right

ovaryenlarged,cystic,

alsoremoved;

washout,

drainage;

uterussome-

whatenlarged,soft,and

ofdark-redcolor.

Abdominalwallthick,li

inchesfat;

rigidomen-

tum,adherenttolower

partsof

parietes;

acyst

oneitherside,with

broad

attachment,containing

clear,amber-colored

fluid

withcholestenne

crystals-

Cystsfreelyopenedbut

notremoved

onaccount,

ofbroad

attachmentand

natureof

contents;ovariesnot

distinguish-able;

washingout,

drainage•

j

RecoveredI 11 !-' Recovered.

Threeanda

half

monthslater,

seen

andexamined;is

undoubtedlypreg-

nant;

26thAug.,

1887,dailyexpect-

ingconfinementat

fullterm. Recovery

wastedi-

ous,butseemedto

becomplete,when

(slowlyandwith

severepain)an

abscessdeveloped

inrightiliacre-

gion.Openedby

abdominalsection.

Completerecovery

15

M.Y.,

aged83,

married.Dr.Geo.

Ross, Montreal.Begantomenstruateat11;

married9

years;

fivepreg-

nancies,last

20monthsago:

suckled15

months.Menses

regularlast

fivemonths;

noticedenlargement

four

monthsago;

rapidincrease

forone

month,thenvery

slow;slight

abdominalpain;losing

flesh.

Uniform,fluctuating

enlargement,38J-in.;

firmareasandtrabe-

culae;

uterusretro-

verted,fixed.

Multilocularcystomaof

leftovary;anterior

ad-

hesions;

adhesionofrec-

tumto

pedicle,pedicle

broad;ligaturedin

sec-

tions;

rightovaryen-

largedandcystic,re-

moved;

washoutand

drain.

Recovered.Perfect

health.

N.C.,aged22,

unmarried.Dr.J.

Stephenson,Iroquois,Ont.

Mensesregular,profuse;be-

ganat16

.Noticedenlarge-

ment10

monthsago;

rapid

increase■Generalhealth

perfect.

Unevenenlargement

ofabdomen;

fluctua-tioninareas;uterus

retroverted,lieson

floorofpelvis.

Multilocularcystomaof

leftovary;no

adhesions,favorable

pedicle;right

ovarycystic,enlarged,

sizehen’s

egg,removed;

bleedingfrom

rentin

rightbroad

ligament;afterligature,oozing;

drainage-tube.Recovered.On

removalof

drainage-tubeab-

scessformed,with

painandfever;

dischargedfreely

fora

fewmomhs;

silkligaturescame

away;complete

re-

coveryaftersome

months.

A.S.,aged43,

unmarried.Dr.A.D.

Blackader, Montreal.Mensesceased4

yearsago;

healthytill3

yearsago,

whenbeganto

havepelvic

pain.Two

yearsagoa

small

pelvictumorin

rightiliac

region,Severe

painlast

fewmonths.Steadyin-

creaseofsize.

A

rounded,firm,ten-

dertumor

sizeofa

child’shead;uterus

notvery

moveable,re-

troverted.

Desperatelysevereopera-

tion;

tumorsolid,very

friable,brokedowndur-

ingremoval;

adhesionstoparietes,omentum,in-

testinesandpelvicstruc-

turesproceedingfrom

rightovaryand

involv-

ingtube;

clampingof

rightcornerofuterus;

washoutanddrain;

microscopicexamination

showedsarcoma.

Recovered.Recovered

fromoperation,

butre-

currenceanddeath

elevenweeksafter

operation.

M.A.,aged57,

married.W.G.

Mensesceasedfive

yearsago.

Afew

monthslater,a

con-

stantthin,

pinkishdis-

charge,whichhas

never

ceased.

Uterusenlargedand

retroverted;

cervixhealthy.

Uterusextirpatedby

va-

gina.Afterits

removala

cystofthesizeofan

orangealso

removed;foundtobe

dermoid.Recovered.

Goodhealth.