be proved that the annulment of ovarian function, even at the cost of the organs, arrests the development of the uterine growth, or checks bleeding, then the surgeon may rightfully remove the ovaries. But that the neurotic or mental conditions justifying such an operation are exceedingly rare is evident from the fact that, since 1878, I have only met with 8 patients to whom I could recommend the operation. One of these refused to the last the chance of relief from surgery, although it was urged upon her both by Battey, Marion Sims, and by me. Four operations were purely Battey's. The first of these was reported in the Transactions of the American Gynecological Society for 1880. The patient was in her 50th year and had never been pregnant. Her history was that of 14 years' suffering, with every kind of experimental treatment. There was association of severe suffering with pre-menstrual congestion, justifying the belief that ovariotomy, performed with the view of anticipating the climacteric, would be a legitimate proceeding. We had deferred the operation in the hope that at the age of 49 the catamenia would cease. But a sister, aged 54, was still menstruating regularly; and the patient felt that it would be impossible for her to go through 4 or 5 years more of such repeated suffering. After full conAfter full consideration, both ovaries were removed. The patient was very grateful for the relief afforded her. I saw her in 1884 quite well, there having been no return of catamenia since April 1880. The recurrence a few times after the operation is explained by the difficulty I had in removing every fragment of the left ovary. I may quote here the conclusions which I drew from a consideration of this case: If I meet with what I believe to be a suitable case, and a willing patient, I shall certainly do this operation again; removing both ovaries, and being especially careful that every fragment of both ovaries is removed. I should operate rather through the abdominal wall than by the vagina; and be prepared for the probability of intestines being wounded when dividing the peritoneum. In uniting the edges of the wound, I should place the sutures nearer to each other than is usual in ordinary ovariotomy, in order to guard against the occurrence of a ventral hernia.' still adhere to these conclusions. hink it would be only in an exceptional

I

case, where an ovary could be felt low down between the vagina and the rectum, that a surgeon would now do oophorec tomy through the vagina. In almost all cases the abdominal operation would be preferred, and a word of caution is necessary to anyone about to perform it under the impression that it is very facile in execution; for it is more difficult than ordinary ovariotomy. It is not as easy to divide the peritoneum without injury to the intestines. They have a greater tendency to protrusion, and cannot be replaced readily after they have protruded, The opening into the abdomen should be made large enough to admit two fingers. With these the uterus is to be felt; one finger being in front of the fundus and one behind it. Then, by carrying them outwards, first on one side and then on the other, an ovary is felt and may be brought up outside the abdominal wall. Its connections with the uterus are transfixed and tied in two parts with a silk ligature; a third ligature being placed behind the other two. The ends of all must be snipped off close to the knots, and the ovary cut away not too near the ligatures, which are then allowed to slip down into the pelvis. It is not yet decided if the fimbria and part of the Fallopian tube had better be removed with the ovary. If not quite healthy, they should certainly be removed. After the second ovary has been removed, the wound must be closed as usual after ovariotomy, but with the sutures nearer to each other, to obviate the greater tendency of omentum or intestines to separate the lips of the incision. The tension is always greater in these cases than after removing large ovarian tumours, where the integuments have been a long time on the stretch. The dressing and after treatment should be precisely the same as for a case of ovariotomy.

Between January 1878, the date of this first case, and November 1881, or nearly 4 years, I did not repeat this operation, and I had only advised it in one other case, that lady not being willing to submit to it. The lady on whom I operated in November 1881 was a widow, 37 years of age. She had suffered excessively for about 18 months from the pressure of a hard pelvic tumour, which obstructed the rectum and caused great agony danger at each catamenial period. At the operation the tumour was found to consist

and

partly of the right ovary, not much enlarged, and partly of the thickened and retroflexed fundus uteri, which I was able, but with great difficulty, to draw up above the brim of the pelvis. I removed the right ovary; the left was atrophied, and so closely applied to the side of the uterus that I could not distinguish its outlines, and did not disturb it. The patient made a recovery without any fever, and in the summer of 1884 was quite well, having menstruated regularly since the operation, at 3 weeks' interval, without any inconvenience. Here, of course, it is doubtful how far the relief is due to removal of one ovary, or to the reposition of the displaced uterus. Neither in my own operative practice, nor in consultation with others, have I seen more than 4 patients since November 1881, to whom I have advised oophorectomy, or the removal of ovaries not distinctly enlarged, on account of neurotic or neurasthenic symptoms, or of dysmenorrhoeal suffering. In one of these cases the operation was performed by a provincial surgeon. Another patient is a ward in Chancery, and legal obstacles have led to postponement. I performed the operation on the third patient in October 1882, removing the right ovary and the Fallopian tube. The left ovary had been removed in March of the same year in Paris by Péan, who wrote to me that he found it in a condition which he described as Kystique, hypertrophique et cicatriciel très prononcé.' The right ovary was, he said,ˆ à peu-près normal, and was therefore not removed. The history of the case before Péan's operation is that of an extremely sensitive, excitable, clever woman, unmarried, who, between her 20th and 30th year, was occasionally treated by Dr. Oldham for irregular menstruation, but did not suffer much pain at her periods until her 30th year. Then followed 10 years of invalid life, with great pain at her periods. An operation in 1879, when her age was 37, was done by Mr. Heath for internal piles. In 1880, Dr. Meadows and Dr. Graily Hewitt treated her for enlargement of the left ovary. This was followed by enfeebled general health and increase of pain, with failing nerve power. In 1881, 3 months' trial of electric current and German baths gave no relief; until physical and mental prostration, with recurring ideas of suicide, led Dr. Pratt, of Paris, to recommend the operation, which was performed by Péan, as I

The

have just said, in March 1882. patient rapidly recovered from the operation.

The wound healed by first intention. She walked on the 18th day, but on the 23rd day menstruation returned with excessive suffering and high fever, and she was considered in great danger for more than 8 days. She returned to England in May, 9 weeks after the operation, and consulted Dr. Oldham and Dr. Herman Weber. As her distressing symptoms increased to an alarming extent, her menstrual periods being regular, with the pain and the mental depression invariably aggravated at the periods, she consulted Dr. Playfair, who sent her to me. I operated on October 10, 1882. Mr. Meredith assisted me. Dr. Allan, of Cleveland, U. S., and Dr. Fontana, of Zurich, were present. I made an incision an inch to the right of the cicatrix left by Péan's operation. After separating omentum, which adhered along the whole line of union, I drew up the right ovary, transfixed the broad ligament with a double ligature, and after tying the ligament in two parts, cut away the ovary. As the Fallopian tube was very red, tortuous, and irregularly though slightly dilated, I put another ligature round the tube, about 2 inches from the fimbria, and cut away all beyond the ligature. I then separated all the omentum which adhered on either side of the united incision of Péan's operation, putting 2 ligatures upon omental vessels. The wound in the abdominal wall was closed in the usual manner. The whole proceeding was completed in less than half an hour. The ovary removed was about 3 times the normal size, and contained cystlike cavities, one as large as a chestnut. The patient recovered without trouble of any kind, went to Brighton 3 weeks after the operation, and I have received most grateful letters from her since. She called on me in December 1884, saying that there had never been any return of menstruation since the operation, and that in spite of unfavourable surroundings and family trouble, she was perfectly well. She mentioned a curious fact, which other patients who have recovered after ovariotomy have also observed that her hair, which she had almost entirely lost during her illness, had grown luxuriantly since the operation; and I noticed that it was fine, abundant, and without a tinge of grey.

I operated on the 4th patient August 26, 1884, at Amsterdam. She was

unmarried, 25 years old, and since her 17th year had suffered excessively from pain in the right side of the abdomen. After a great variety of medical treatment, Professor Simon Thomas, of Leyden, at the suggestion of her usual medical attendant, Dr. Van Geuns, took away the right ovary in September 1878. The pains on the right side disappeared, but recurred so severely on the left side, that in September 1879, Professor Simon Thomas removed the left ovary, but without good result. He did not remove either Fallopian tube. Menstruation recurred, and the pains became worse. In September 1880, Dr. Berns opened the abdomen for the third time, hoping that it might be possible to remove a tumour which it was thought could be felt on the left side of the uterus. There were, however, so many adhesions that he desisted, and closed the wound. During all these years the patient was always in bed, every movement causing a great increase of pain. In 1883 Marion Sims went to Amsterdam to see her. He thought the tumour on the left side of the uterus was the cause of the suffering. Being obliged to go to America, he would not operate then, but promised to do so on his return to Europe. His death greatly distressed the patient, and led to my being consulted. She and her family, as well as Dr. Van Geuns, were so anxious that some attempt to relieve her continual sufferings should be made, and the habit of daily repeated subcutaneous injections of morphia should be broken, that, although I was unable to feel any tumour on either side of the uterus, I consented to open the abdomen for the fourth time, and did so to the left of the central cicatrix. The cicatrix of the second operation was still nearer to the left ilium. I only divided the peritoneum far enough to admit two fingers. This enabled me to feel that the uterus was of normal size, movable, with no tumour on either side of it, but that a piece of omentum adhered both to the fundus uteri and the cicatrix to the extreme left, and that a coil of small intestine also adhered both to the uterus and the omentum. These I separated, but did nothing more, and closed the wound. I could not find any trace of either ovary. The wound healed by first intention, and recovery took place without any fever. There have been three menstrual periods since the operation, with diminishing pain. Very much smaller quantities of morphia

have been injected, and Dr. Van Geuns sends a very hopeful report of continued improvement.

Since the printing of this edition was begun I have removed both ovaries from a married lady, a patient of Dr. Lendon of Notting Hill, under very peculiar circumstances. She has 2 living children; cne, born alive, is now dead. After each confinement she suffered from puerperal mania; and once the consequences were tragically distressing. Dysmenorrhoal suffering was also very great. Partly to prevent this, and partly to avert another pregnancy, after some hesitation and careful consultation, I removed both ovaries on January 27, 1885. There was no difficulty in the operation, and recovery followed without pain or fever. It is, of course, too soon to say more as to the ultimate result.

neuras

The removal of the ovaries with the hope of influencing uterine growths will be further considered in the chapter on these tumours. But I cannot conclude this chapter without a word of caution against the extreme frequency with which the operation has been resorted to in this country, and at which Dr. Battey publicly expressed his astonishment, at the meeting of the Medical Congress in London. Many cases where the symptoms have been described as sleeplessness, hysteria, nerve prostration, dysmenorrhoea or thenic disorder,' have led to Battey's operation, and in the majority of such cases healthy ovaries have been removed. These are just the cases in which Dr. Weir Mitchell's systematic treatment, so successfully followed in this country by Dr. Playfair, should surely have been tried. Dr. Playfair says, 'If a case is purely neurasthenic it cannot under any conditions, I apprehend, be one even for the consideration of oophorectomy. If, on the other hand, there exist those chronic organic changes in the ovaries which afford the most justifiable ground for this operation, any attempt at their cure by this treatment will inevitably fail.' Except in cases where bleeding fibroids may call for the removal of the healthy ovaries, or where some such reason arises for preventing future pregnancy as that in the case just related, we ought at least to require some evidence of the ovaries being diseased before consenting to their extirpation in the hope of curing any of those vague nervous disorders to which women are so subject, which are

often dispelled by moral treatment or social changes, are often benefited by measures that can have but little effect except on the imagination, often return after apparent cure in any way, and leave the hapless beings the prey of unscrupulous or illogically enthusiastic experimenters.

In a paper read at the Medical and Chirurgical Society in 1882, on hernia of the ovary, Dr. Barnes contended that this condition furnishes a legitimate motive for Battey's operation. He related a case in which an ovary, accompanying a hernia in the left groin, had been removed from one of his patients in St. George's Hospital. In the discussion which followed Mr. Hulke alluded to the comparative frequency of this form of hernia, and cited a case, under the care of Mr. Lawson some years ago, in which the suffering was so great that at the wish of the patient the organ was extirpated. Mr. Langton also showed, from his own experience of 20 years at the Truss Society, that out of 4,084 cases of inguinal hernia no less than 67 were instances of these displaced ovaries. Forty-two of the 67 were congenital and 25 acquired. Those which were congenital were generally double, most of them were irreducible, and the effects with regard to the menstrual periods varied very much. Dr. Barnes attributed the larger number being on the left side, to the greater length and laxity of the left round ligament, and the greater depth of Douglas's pouch on the left than on the right side; and said that in this way other pathological conditions more frequently observed on the left than on the right side, such as hæmatocele, might be accounted for. He was of opinion that where there was pain and distress it was better to remove the hernial ovary, which was liable to become inflamed and diseased, while trusses were apt to cause distress.

At the Meeting of the Medico-Chirurgical Society of Edinburgh, November 7, 1883, Dr. MacGillivray showed an ovary and a Fallopian tube which he had removed from an inguinal hernia in a girl about 20 years of age. And at the same Society Professor Chiene showed an ovary and part of a Fallopian tube which he took away from the inguinal region of a child only 3 months old.

It is somewhat curious that in all my practice I have never met with a case of hernia of the ovary.

The last reports which I have respecting Battey's operation are those to be found in Professor Agnew's 'Surgery,' published in Philadelphia. He mentions 107 cases, of which 88 were complete double operations. Sixty-seven recovered and 21 died, a mortality of 23-86 per cent. In all, he gives the figures of 171 cases; 144 by abdominal section, with a loss of 27, and 27 vaginal, of which 5 died.

In the Ingleby Lectures' for 1881, Dr. Savage, of Birmingham, said that, while Battey, from all the information he could obtain, found the mortality to be about 18 per cent., in his own (Dr. Savage's) practice he had 'had 40 complete cases, with a result that all have recovered from the operation, and I believe that nearly every one has been cured of the disorder for which the operation

was undertaken' (p. 33). Writing again, December 5, 1884, he says, 'My figures are as follows up to this date:

REMOVAL OF THE UTERINE APPENDAGES For Myoma.

Hydrosalpinx Pyosalpinx

Chronic Ovaritis,

37 with 1 death from Tetanus

10

6

134 cases with 6 deaths.

Dr. Savage removes both Ovary and Fallopian tube, but he appears to agree with me in the impression that ligature of the spermatic artery has more to do with the cessation of menstruation after operation than the removal of the tube itself.

Dr. Fehling, of Stuttgart, contributes to the Archiv. für Gynäkologie' (Band xxii. Heft 3) an interesting article on the 'Castration of Women.' He relates 10 cases, and then expresses opinions based upon these and upon other recorded cases. As to mortality, this will diminish. Hitherto it has been about 10 per cent., but he thinks with our present experience it is not likely in the future to exceed at most 5 per cent. Next as to the effect upon menstruation. In 4 cases out of 9 he found the menopause immediately follow. The same happened in 4 cases out of 10 published by Tauffer, and in 31 out of 41 recorded by Hegar. Irregular hæmorrhages for a time followed by complete cessation resulted in 3 of our author's 9, in 3 of

K