very slight risk to the mother, and lead to the natural termination of pregnancy in the birth of a living child, if proper precautions 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 peritoneal cavity may save the life of the mother, and pregnancy may go on to the full term. 6. Of 3 cases on record where a pregnant uterus has been punctured during ovariotomy, the only recovery was in the one case where the uterus was emptied before the completion of the operation, and the opening in its wall closed by suture. ON INCOMPLETE OVARIOTOMY AND EXPLORATORY INCISIONS WHEN I began to publish every case where I had completed the operation of ovariotomy, and published, in separate series, cases where the operation was commenced but not completed, and cases where an exploratory incision only was made, I 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 unsuccessful 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 ovariotomy 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cases, or cases of simple incision, had been classed among cases of ovariotomy, while unsuccessful cases were left unpublished.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, without 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, nephrectomy, 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, what were the results of incomplete operations, how often diagnosis had been so doubtful that an exploratory incision was necessary before the doubt could be solved, and what risk the patient, incurred by submitting to an exploratory incision. This plan appeared, and still appears 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, including 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 compliance 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 increased. 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.-while 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 impossible 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 ovariotomy cases, I found that in almost every case doubts or suspicions entertained before the incision was made were confirmed, and I scarcely recollect a case where an exploratory incision was thought to be necessary which 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 which led to this unusually cautious mode of procedure. Anyone who will 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 case of pyæmic fever or septicemia must be encountered; but in several cases a cure has been obtained. In one case which I operated on in 1865 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 1 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 attachments 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 hæmorrhage from the opening into the cyst made by the trocar, and even from the little punctures made by the hooks which seized the cyst wall, that it was obviously unsafe to return it; and I transfixed the edges of the external parietal wound, and of the cyst wound, with 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 gradually set up, just at the point where the cyst had been pinned to the abdominal wall. Convalescence progressed. There was but a very little discharge from the bottom of the cicatrix, and a slight hardness 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. conditions favourable or otherwise for tube and antiseptic injections, the risk 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 supposed 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 practising an ars conjecturalis, and it is no reproach 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 Cæsar 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 commenced 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 ovariotomy must necessarily encounter such difficulties that he would be compelled to leave several cases incomplete, or repeatedly meet with such insuperable 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 knowledge doubts are being cleared up and difficulties lessened, exploratory incisions are becoming less frequently necessary, and incomplete are bearing a diminishing proportion to complete operations. Of late years simple exploratory incisions, made under due precautions against septicemia, 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 considerably increased. When a permanent opening of the cyst by incision, and union of cyst wall to abdominal wall by suture is accomplished, even with a drainage. In another case the patient was in good health for nearly 3 years after the operation, and then died almost immediately 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, in the Samaritan Hospital. I found such inseparable attachments that I contented myself with clearing the cyst cavity of 6 pints of purulent fluid and flakes of lymph, closing the cyst and abdominal wall round a glass tube, and covering, the end of the tube with a carbolised sponge. The patient remained in the hospital till August 16, suffering from a good deal of In any case where 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. fever, treated by the ice-cap and quinine, | be separated after death by careful while the cyst was washed out with car- dissection. bolised solutions. After 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 was kept running through the cyst by a siphon arrangement, A simple mode of drainage is described 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 1881, I 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 reformation of fluid. The painful position of a surgeon who has 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 unexpectedly 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 was found that there would have been no insuperable 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 of the patient, as they could only by Dr. Robertson in the first number of the 'Medical Chronicle,' published at Manchester, October 1884. The object in this plan of draining is the absolute exclusion of air both from the cavity containing the fluid and from the draining apparatus. Its peculiarity consists in the fixing of an air-trap to the free end of the rubber draining-tube. This trap is merely a V-shaped piece of glass tubing, each arm measuring from 2 to 3 inches. The discharge is conveyed from the trap into any convenient receptacle by a second piece of tubing. m When this apparatus, filled with an antiseptic 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. draining for an amputation, a fall of 1 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 the tube, due to the tissues being sucked In 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 the cyst cavity would of course be accurately If used as a closed around the tube. CHAPTER XIV OÖPHORECTOMY-OR BATTEY'S OPERATION THERE are no means of judging what So When Bell snipped out part of a nerve, or when the surgeons of to-day have stretched a nerve to stop a neuralgic pain, a well-known principle guided them. 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- Battey's object was to bring about premature cessation of menstruation in women who suffer from the malperformance of their monthly functions; but others, as Hegar, have given a wider range to the idea of suspending the functions and influence of the ovaries. They remove them to stop the growth of uterine fibroma or myoma, thereby lessen their hæmorrhagic tendencies, and lead to atrophy of the growths. And the amount of success which I and others have obtained in cases of bleeding uterine myoma by removing the ovaries, is quite sufficient to justify the proceeding in cases where the removal of the uterine tumour would be very difficult or dangerous. But the extension 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 practitioners. In the case of fibroid growths with 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 |