dominal wall. It is to be regretted that he does not state with what material and with what kind of suture, nor to what end he does so. If the intention is to insure the application of serous surfaces to one another in the abdominal wound as well as in the uterine wound, the experience gained in ovariotomy does not seem to make this step necessary, and any superfluous step before the delivery of the child ought to be avoided. If the aim is to shut off the peritoneal cavity more efficiently from the wound in the abdominal walls where an abscess might form, I think it would be preferable to make a special peritoneal button-hole suture with catgut, as Dr. J. B. Hunter does in ovariotomy.' This forms a very reliable barrier between the wound and the peritoneal cavity, and has the advantage that it is done toward the end of the operation, when the operator is through with all the other steps undertaken in the interest of both mother and child.

From this rapid glance over the improvements which the Cesarean section has undergone in the course of the last twenty years, I trust every impartial reader will conclude with me that it is impossible to give the operation, in its new shape, the name of any particular man. We would have to combine one of a dozen or more proper names, which would make a longer word than Mark Twain's celebrated letter procession.

However this may be, the results of this improved Cesarean section have so far been of such a character as to merit our serious attention. The lists referred to in the beginning of this article contain twenty-six operations in which the above-mentioned improvements were more or less carried out. Of these twenty-six women, nineteen survived, that is, 73.1 per cent. Of the seven who died, Beumer's patient had bilateral pyelonephritis, and my own was exhausted by ante-partum hemorrhage, beside being a cripple, with remnants of extensive vertebral caries, pleuritis, and pulmonary phthisis, and a sufferer from organic heart disease.

In three other cases (Leopold's fourth, Münster's, and Drys dale's) infection had taken place before the operation was performed.

In Jewett's case, the patient had cancer of the cervix, and

1 Hunter, "Fifty Cases of Abdominal Section," in New York Medical Journal, April 5th, 1885.

erysipelas had appeared in the hospital in which the operation was performed.

Thus, of all the twenty-six cases, Ehrendorfer's patient, who succumbed to peritonitis, probably due to the fact that during the operation some meconium entered the peritoneal cavity,' may fairly be said to be the only one who died in consequence of the operation.

It is of particular interest to see that one operator, Prof. Leopold, of Dresden, has operated nine times, saving eight women, and all the children. The two maternity hospitals of Dresden and Leipzig together have had sixteen operations with fifteen maternal recoveries and the survival of all the children.

It is not to be expected that this record will be kept up to its present standard. So far, the excellent results are due to the fact that so large a proportion of the cases have been operated on by one man, and a still larger proportion by a few men, all intimately connected, all perfectly familiar with antiseptic precautions, and skilful gynecologists. It is to be expected that when the operation becomes so popular that it is performed by many, and less well-prepared operators, the results will again decline proportionately.

We must furthermore not leave out of consideration that Leopold, the chief operator in this line, does not use the operation in all cases, but substitutes Porro's whenever he has any cause to suppose that infection has taken place, or the patient suffers from cancer.'

Still, with all these limitations, the results so far are most promising, and I do not hesitate to say, compel us to place the improved Cesarean section above all its substitutes, so that it must be our first choice, from which only particular counterindications ought to keep us back.

On the other hand, I am not prepared, with several authors, to teach that the improved Cesarean section should be substituted for craniotomy, and to stamp as an abominable crime the destruction of the living fetus, if by such a sacrifice there is reasonable hope of a safe delivery for the mother. We must remember that similar antiseptic precautions to those upon which success in the new operation seems exclusively to turn, have benefited the operation of craniotomy.

1 Ehrendorfer, in Arch. f. Gynäk., 1885, vol. xxvi., p. 130.
See his three cases in Arch. für Gynäk., vol. xxviii., No. 1.

Since the introduction of the bichloride and occlusion dressing treatment,' I have three times performed craniotomy on the presenting head, once of a dead and twice of a living child. All the mothers made an excellent recovery and at no time presented any serious symptom. One of them did not even have the slightest fever; the two others had a slight rise in temperature which soon passed off.

Of the two mothers whose children were living, one was a young, splendidly built primipara, with an excellent constitution, enjoying blooming health, and most happily married. All the trouble came from an enormous child with too advanced ossification. Following the golden rule to do to others as I would have others do to myself, I would not for a moment entertain the idea of proposing to a husband under such circumstances to submit his wife to even the most perfect of all Cesarean sections.

The other mother, likewise a primipara, was an inmate of the New York Infant Asylum, a poor unmarried girl, with a flat, generally contracted pelvis. After having in vain tried to deliver her by means of Tarnier's and Simpson's axis-traction forceps, I perforated the head and delivered with the cranioclast. This patient did certainly not wish to run a particular risk in order to give birth to an illegitimate child, and when we remember how pitiful the life of these poor waifs usually is, and how small their chance of survival beyond five years, nay even one year is, I, for one, do not feel any pangs of conscience for the way in which, in this case, I made an end to the disproportion between the maternal and fetal organisms.

OVARIOTOMY FOR DERMOID TUMOR IN A CHILD THIRTY MONTHS OLD.

BY

J. F. HOOKS, M.D.,
Paris, Texas.

ADA HURST, female, aged 30 months, was brought to this place from Delta County by her parents June 25th, 1886. Two physi

1 Garrigues, "Prevention of Puerperal Infection," in the Med. Record, Dec. 29th, 1883.

cians of Delta County had been treating the case as one of ascites for several months. Dr. E. W. Rush and the writer were requested to examine the case, with the view of making a diagnosis.

In company with Dr. Bramlette, of this place, we made a careful examination under anesthesia, which resulted in a concurrence of opinion as to the existence of an abdominal tumor, and we were inclined to believe it ovarian, notwithstanding the age of the child. The child was fairly developed

for her age, and had always enjoyed good health. The abdomen was enormously enlarged, measuring twenty-nine inches in circumference at the umbilicus; above the umbilicu s, as high as the ensiform cartilage, it was much larger. The distention was so great that the diaphragm and contents of the chest were forced upward to such a degree as to materially interfere with respira

tion.

The case, as before stated, had been diagnosed "abdominal dropsy" by two physicians, and had been twice tapped by these gentlemen, only a few ounces of straw-colored fluid escaping through the canula.

The result of our conference as to the character of the tumor, the necessity of operative interference to save the life of the child, together with the dangers attending so formidable an operation upon a child of her age, were fully laid before the parents, who were advised to confer with their physicians, and determine for themselves what course they would pursue in the matter.

The child was taken home, but on the 2d of July they returned, the parents having become fully convinced that the child

would live but a short while unless some relief could be rendered. They had, therefore, fully made up their minds to have an operation performed. On the morning of the 3d of July-Dr. Fort having been requested to see the case with us-the patient was again chloroformed, and a second thorough examination made, with the view of removing any doubts, should they exist, from

the minds of the consulting physicians as to the nature of the tumor or the propriety of an immediate operation for its removal. The result of this second and more thorough examination was confirmatory of the diagnosis previously made, namely, that the tumor was ovarian, and had its origin in the left ovary. Treatment was instituted to put the child in the best possible condition to undergo the operation, which it was decided should be undertaken on the morning of July 6th.

I would state just here that the parents of this child first observed a slight enlargement of the abdomen about twelve months ago. But for the last six months the increase of growth had been very rapid. Even the few days which intervened between the first and last examinations showed a perceptible increase in the distention, and a corresponding increase in difficulty of breathing. That the child could survive but a short time in its present condition was apparent to all who saw it.

On the morning of July 6th, the patient being anesthetized by Dr. Bedford, the writer, assisted by Drs. Rush, Bramlette, Fort, and other medical men of this city, under every antiseptic precaution, proceeded to make an abdominal incision extending from just below the umbilicus to near the symphysis pubis, an incision some three or three and a half inches in length. This incision was made short, for exploration, and with the intention of evacuating the sac, and drawing it through the incision in the event it proved to be a unilocular cyst. Immediately upon opening the peritoneal cavity, quite a large pellucid sac with extremely thin walls rushed out and ruptured. This sac or cyst sprang from the larger tumor on its lower anterior surface above the pedicle. The main tumor was large, firm, and resisting, and completely adherent all over its anterior surface. I endeavored to evacuate the main tumor with trocar, but failed, as its contents were too dense, viscid, and semi-solid to pass out through the instrument. I incised the tumor and endeavored to break it up, but failed. The incision was then enlarged, and the adhesions to the parietal walls and omentum were broken down with the hand; the entire lower part of the tumor, that is extending far down on each side from its anterior surface, was firmly adherent to the omentum. It was not until the incision had been extended to near the insertion of the diaphragm that the adhesions could all be broken up and the tumor extracted. When lifted from its bed, it was found to spring from the left ovary by a short, thick pedicle, which was at once transfixed with a needle, armed with stout iron-dyed silk ligature, doubled; ligature was then cut and tied both ways, pedicle cut, and tumor removed.

There was no hemorrhage from stump of pedicle, which was mummified with a weak solution of persulph. iron, and returned to abdominal cavity; the ligatures attached to the same being brought out at the lower end of the abdominal incision.

There was considerable blood oozing from the adherent surfaces, and several catgut ligatures had to be applied to bleeding