The constituent and dynamic changes in the circulation more often perhaps pass the physiological limit than any other of the phenomena of pregnancy. The blood is a fluid tissue. Into it are poured (Osler) the commodities needed for nutrition, and from it the other tissues derive the materials they require. Notwithstanding the ceaseless change and exchange which go on, a uniformity of composition is one of the striking characteristics of health. The blood-plasma is supposed to supply nutriment to the tissues, and the red blood-corpuscles are the carriers of oxygen and carbonic acid. In pregnancy, the former is greatly diluted, and the latter greatly diminished in number. When these changes pass the limit of health, the consequences are numerous and may be serious. Cell nutrition is interrupted; formative activity is lessened; the metabolism of tissues is disturbed; waste increases, followed by impaired appetite, enfeebled digestion, loss of physical vigor, increased nerve irritability, altered and diminished excretion and secretion, with occasional cerebral and intellectual disturbances. These conditions may be associated with some one or more of a variety of resultant nervous perturbations, or other not uncommon disorder of pregnancy. The anemia of pregnancy is, to a greater or less degree, always present. As an element of causation in the production of the diseases of pregnancy it cannot be excluded, and must be accepted as the most constant and potential factor. To it, and to the mechanical disturbances of the abdominal viscera, and interference with the function of respiration, we must look for the causes of most of the morbid complications of pregnancy. When this anemia has reached a high grade, its ravages are not easily arrested during the continuance of pregnancy. Our best and most successful efforts never free us from the apprehension of recurring danger. Prevention is the sheet-anchor. To effectively accomplish this, a vigilant supervision of the patient is imperative. The diet must be regulated and adapted to existing circumstances; disturbances of the alimentary tract must be obviated; the excretory and eliminative functions must be protected; sufficient sleep must be secured; all sources and causes of anxiety, irritation, and excitement must be removed; sunlight and fresh air must be supplied; and last, though not the least important, exercise in the open air must be insisted upon. To these hygienic measures, such therapeutic treatment should be added as intelligent experience and observation have proven to be useful. The hygiene of person should be supplemented with the hygiene of habitation and sleeping-apartments. A large, dry, well-ventilated and well-lighted room, above the ground floor, should be selected for the sleeping-apartment, and this should be in a dwelling equally faultless in regard to ventilation, dryness, sunlight, and freedom from noxious effluvia, and sewer, or deleterious exhalations. As pregnancy advances, the clothing should be adapted to the changes in contour and form; all tightly-fitting garments, stays, garters, and other uncomfortable appendages should be either entirely dispensed with or so adjusted as to remove unequal pressure, and avoid the constriction of parts. DERMOID CYSTS OF BOTH OVARIES. A DIVERTICULUM BY J. E. JANVRIN, M.D., Gynecologist to the New York Skin and Cancer Hospital, Surgeon to St. Elizabeth's Hospital, etc., New York. (With Cut.) REMARKABLE as some of the developments have been in connection with the growth and removal of ovarian tumors, I have been unable to find anywhere a parallel to the one which is here recorded. Ovariotomy is indeed a very common operation at the present time, but when it involves details as unique as those which were present in the case which is here presented, no apology seems necessary for making a particular record of it. The subject of this case is a German lady whom I was requested by Dr. F. A. Castle to see in company with him. A large abdominal tumor was evident, springing from the right side, cystic in character, but with solid portions, especially within the pelvis. The uterus was of normal depth and mobility and was, apparently, entirely free from the new growth. A diagnosis based upon these points was made, and Dr. Castle kindly referred the patient to me for operation, which was deemed entirely feasible. The following history was obtained from the patient. Age 48, married, and now living with her second husband. Menstruation began at ten years of age, and was always regular until two years ago; since then the intervals have varied between two weeks and four months, the quantity usually being normal. For many years she has suffered from frequent and severe headaches which would begin as soon as she awoke in the morning and continue until sundown. During the past two years they have been especially severe. She has had one child and two miscarriages. The child was born twenty-five years ago, after a tedious labor, which was accompanied by laceration of the cervix and perinæum. Ever since that time she has had more or less pain in the right iliac region. The last miscarriage occurred ten years ago, previous to any trouble in the bowel or evidence of tumor. Six years ago, she observed one day, while at stool, that a bundle of hairs protruded from the anus. She tried to pull it away, but was unable, and stopped pulling only when compelled to do so by the severe pain which the effort caused. She refused to permit a doctor to examine her, and one day succeeded in pulling it all out, about three years after it was first observed. Since then she was not aware that it had grown again. About the same time she began to be troubled with very obstinate constipation which continued two years. Two years ago, she first began to notice that her abdomen was growing larger. She was recommended to a quack in Philadelphia, who treated her for dropsy as well as for constipation, using blisters upon the abdomen for a long time, also massage of the abdominal walls, and purging her to excess with frequent doses of aloes and scammony. The result of this treatment was unsatisfactory, and for the past year the development of the tumor has been rapid. No inflammatory symptoms have been present at any time, unless, possibly, at the time when she was undergoing the excessive purging. On May 28th (1885), I operated upon the patient with the assistance of Doctors Castle, Peaslee, Goffe, and Currier. A short incision in the median line exposed the cyst, which was free from adhesions, with the exception of one, of moderate firmness, over the fundus of the bladder. Nothing unusual occurred in the removal of this tumor, which had developed from the right ovary, contained several quarts of bland fluid, and was also the seat of three dermoid cysts which contained an abundance of sebaceous matter and hair. Upon the left side of the pelvis a tumor still remained, of the size of a very large orange, and firmly imbedded in the pelvic tissue. Some force was required to remove it from its bed, and this operation was followed by free oozing of blood, which was checked with some difficulty. The pelvic peritoneum was, of necessity, torn in the enucleation of the tumor, from which a fibrous prolongation projected in the direction of the rectum. Drawing upon this prolongation with sufficient force, the rectum was opened, a rent one and a half inches in length being made, and through this opening a small diverticulum, attached to the tumor by the fibrous prolongation, was drawn, which had growing upon it a long lock of black hair smeared with unmistakable fecal matter. The position of the wound in the rectum, at the bottom of a deep and dark cavity, made its closure a matter of the greatest difficulty. The cavity was illuminated, however, by a large mirror held at a sufficient height above the patient's body, and a continuous silk suture was at length applied. The abdominal cavity having been thoroughly cleansed, the parietal peritoneum was closed with a continuous catgut suture, excepting at the lower angle, which was left open for the passage of a glass drainage tube, the latter being carried to the bottom of Douglas' cul-de-sac. Finally the abdominal wound was closed with silver sutures deeply passed, dusted with iodoform, and antiseptic dressings adjusted. The carbolic acid spray was used in the operating room for four hours previous to the operation, which was performed with antiseptic precautions. Though very much prostrated by the operation, the patient began to rally within five hours, the temperature at that time being 101° F. per vaginam, and the pulse 102 per minute. The next day the temperature reached 103° F. at 10.30 P.M., which was the highest point reached at any time. The third day the limits were 1011° F. and 1024° F. The fourth day the variations were considerable and were between 1004° F. and 103° F. From that day until the close of the ninth, the temperature did not get much below 100° F. nor above 101° F. At the beginning of the tenth day it reached 102° F., and during the next twentyfour hours varied between that point (102°) and 1001° F. Early on the thirteenth day 1021° F. was reached, but from that time the tendency was toward the normal. The pulse began to gain in strength soon after the patient rallied from the shock of the operation, but was intermittent in character, and retained this quality until convalescence was well established. It ranged between 100 and 120 on the second day, and on the third between 66 and 90. It is interesting to note that the low pulse-rate coincided at times with the higher pointings of the temperature. Only once did the pulse rate reach 100, after the third day, and it was confined during most of the time between 75 and 95. For five days following the operation, hypodermic injections of ten minims of Magendie were required every twelve hours, which sufficed perfectly to relieve pain and restlessness. Champagne and brandy with carbonic-acid water were given at suitable intervals, and the nourishment for the first few days was confined entirely to milk. The kidneys worked well from the beginning, and the patient slept much of the time. Toward the close of the second day, the ice cap and abdominal coil were applied, and were very grateful in their effects. They were retained much of the time, that is, whenever the temperature exceeded 101° F. A very offensive bloody discharge was passed per vaginam on the fourth day, which became less in quantity and less offensive on the following day. The drainage-tube was removed on the sixth day. The quantity of bloody serum in the abdominal cavity, which was found at the different examinations, was quite insignificant. The sutures were all removed from the abdominal wound on the seventh day, and good union was secured excepting at the site of the drainage tube. On the morning of the eighth day, a dose of castor oil was given by the mouth, and this was followed two hours later by an enema of sweet oil. A large fecal movement resulted an hour later, and three hours and a half subsequently there was another, with a third, a fourth, and a fifth at short intervals. No bad results of any character followed this thorough evacuation of the intestines. On the contrary, the patient was greatly relieved, and the evidence was perfectly satisfactory that the wound in the rectum had entirely and firmly healed. Complications from this period existed in the form of a very painful irritation of the bladder, which yielded after a time to suitable internal medication and irrigation; in the formation of an extensive mural abscess at the site of the drainage-tube which burrowed into the left iliac fossa, but finally healed entirely, and in the formation of three fistulous tracks within the abdominal wound, external to the peritoneum. These latter were attended with |