30 operations, with a result of 26 recoveries and 4 deaths. This success naturally had a great influence in Sweden; and Dr. Howitz, of Copenhagen, and Professor Nicolay sen, of Christiania, who both assisted me many times, have done good service with their Danish and Norwegian countrymen. Writing December 26, 1884, Professor Nicolaysen, of Christiania, says that he has done 109 ovariotomies, about two-thirds of all in Norway, which altogether amount to 166 cases, with 61 deaths, a mortality of 36.7. Of Professor Nicolaysen's 109 cases, there were 35 deaths. But since 1878, when he began to apply full Listerism, the result of 74 cases has been 57 recoveries and 17 deaths, a mortality of 23 per cent. In connection with the practice in Christiania, Professor Nicolay sen makes remarks to this effect: That the great mortality among the early cases was principally due to the delay in seeking relief by operation, as most of the patients had been subjected to long-continued medical treatment leading only to anæmia, adhesions, and all the complications of old cases. This has been in a measure changed of late years, and the operations have taken place at an earlier stage of the disease. At the same time antiseptic precautions have been adopted, the carbolic spray and dressing being used. Professor Nicolay sen adds that, after having used sulphurous acid for cleansing the sponges, there has been a remarkable reduction in the mortality.' In Russia, the first ovariotomy was performed at Charkoff by Professor Vanzetti in 1846, and the second at Helsingfors in 1849, by Professor Haartmann. Both cases were unsuccessful. The first successful case was performed by Professor Krassowski, of St. Petersburg, in December 1862, and his results were afterwards so satisfactory that, in 1868, he published the well-known atlas of beautifully coloured plates. His example has been followed by many Russian surgeons. 1882 there had been 302 ovariotomies reported by 40 native surgeons in St. Petersburg and the various provinces of Russia. No account is published of many of the ovariotomies done in Russia, and the number is really much greater. All but one of the ovarian cases which have come to me from Russia recovered from the operation. In In Italy the first successful ovariotomy was performed by Professor Landi, of Pisa, in September 1868; the second, by Professor Peruzzi, of Lugo, in 1869; the third, by Dr. Marzolo, of Padua, in July 1871. Each succeeding year brings from Italy news of greater numbers of operations and of better results. In the first 100 cases performed in Italy, Peruzzi proved that the recoveries were 37 and the deaths 63, while in the second 100 these figures were rather more than reversed, the recoveries being 64 and the deaths only 36. In the third 100 there were 26 deaths, in the fourth 21; but in the fifth, completed in June 1884, the deaths were 23; and while 18 years were required to complete the first 100 (1859-77), the fifth 100 was completed in 13 months. are well represented in the woodcut on the previous page. I do not think this case can be cited as a case of ovariotomy in the sense in which this operation has been regarded, from its first performance by McDowell to the present time. Emiliani, no doubt, believed he had removed a scirrhous ovary,' and it is certain that he removed a fibrous tumour which is much more like a uterine than an ovarian tumour. The removal of such a tumour, however, could have no more bearing upon the rise of ovariotomy than the removal of a hernial ovary from the inguinal canal. It is not easy to obtain information as to the number and result of cases of ovariotomy in Spain and Portugal, but there is reason to believe that they are neither so numerous nor so successful as in Italy. In India, as early as 1860, ovariotomy was performed successfully at Tanjore by a native surgeon. In Australia many operators have emulated their English brethren. In New Zealand, Dr. Mackinnon was the pioneer of ovariotomy at our antipodes. In Canada, the few cases which have been published have been almost all successful; and there is already abundant evidence that ovariotomy may be practised successfully under the most different mates. One case was reported from Japan in 1880. It is impossible to give anything like a full historical sketch of the progress of ovariotomy in America within any reasonable limits. The initiatory work of McDowell has been already described. Atlee stood next to myself in the number of operations he performed. Kimball of Lowell, Peaslee, Marion Sims, Storer, and many other American surgeons have maintained the reputation of their country in this department of surgery. Works by Atlee and Peaslee were published in 1872, and their European brethren read with great interest their account of their own work and that of their countrymen. In a work by Agnew, there is a table compiled by Baum of 5,153 cases of ovariotomy, of which 3,651 recovered and 1,502 died 29-13 mortality per cent. Of these there were: = conditions and in the most opposite cli- | American and European surgeons. CHAPTER V THE CONDITIONS AFFECTING THE OPERATION OF OVARIOTOMY I MAY refer students interested in the statistics of ovarian disease in England to the 6th chapter of my work published in 1882. The cases which come under the hands of the surgeon fall into two groups; patients who, with symptoms calling for immediate action, ought to be given the chance of a preliminary tapping; and others who must without hesitation be advised to submit to the more severe ordeal of ovariotomy. A woman with a single unilocular cyst may suffer to such a degree from rapid accumulation of fluid and distension that she must be saved by some means from the effect of mechanical pressure. Once assured that the cyst really is single, tapping may be tried; and in my opinion it should be enforced by almost a refusal to do ovariotomy until it had been tested. But this advice as to tapping, and especially as to renewed tapping, as a means of cure must be restricted absolutely, as I have before stated, to cases in which the cyst is single and the contents clear and non-albuminous. In all cases of multilocular cysts or dermoid tumours, where the abdominal distension is sufficient to injure the general health or cause local suffering, there must be no faltering, no suggestion of alternatives or delay. Justice to the patient demands a positive recommendation of excision, and generally it should be accompanied by a warning against the danger of delay. Everyone who takes upon himself the responsibility of such counsel should have a clear idea of the base upon which it rests. And it may be traced out summarily in this form. The health has already deteriorated, and though the tumour itself be neither malignant, nor inflamed, nor suppurating, nor the seat of hæmorrhage, yet its mere presence is the cause of the patient's decline. To let things go from bad to worse without doing anything, especially as that worse is a certainty, would be acting against the very first principles of medical science. The presence of this morbid growth in the body may give rise to other diseases. It attaches itself oftentimes to the intestines, mechanically blocks the passage through them, or causes fatal contractions, and, at the very least, impairs their functions and hinders the due assimilation of food. Its continuance allows time for the balance of the action of the heart and lungs to be deranged, and for structural changes to take place, which if not immediately fatal or sufficient to mar the operation, may render recovery of health after ovariotomy slow or incomplete. i while in some the hope of success is so small, that most patients, who are told the whole truth, prefer waiting for the natural termination of the disease to voluntarily placing their lives in immediate peril. Some, however, would urge the unwilling surgeon to operate against his better judgment, and I have often yielded to the solicitations of patients who, their sufferings being great and death being inevitable at no distant period, have preferred running any risk rather than submit to a continuation of suffering. In only one case have I refused to operate when pressed to do so by a patient capable of appreciating the difficulties of the position. In this case, a woman in the Samaritan Hospital suffered, as I believed, from malignant disease, involving the uterus and both ovaries, and had a large quantity of fluid free in the peritoneal cavity. I removed this fluid, but refused to do more, although the woman threatened to commit suicide if I did not operate. After her death, the correctness of the diagnosis was fully borne out. I have heard of some few cases where patients whom I had dissuaded from the operation have been encouraged by others to submit to it; and, with one exception, every such patient has died after the operation. The exceptional case was a woman who had been several times tapped, and who had been advised both by Dr. Keith and by me not to think of ovariotomy so long as life could be made tolerable by tappings. Fifteen months after I saw her, the tumour was removed by Dr. Graham, of Liverpool, who encountered and overcame the pelvic and other adhesions which both Dr. Keith and I had recognised, and obtained the satisfaction of saving a life otherwise inevitably lost. I have thought it necessary to make this statement distinctly, because it has been supposed that ovariotomy has been restricted to favourable Time, too, gives the opportunity for cases only, and that good results had been adhesions to form, for rupture or de- obtained by refusing to operate upon any structive peritonitis to occur. With some but selected cases. Indeed, this was tumours growing on a long pedicle twist-known to be the case in the early days of ing may cause hæmorrhage or gangrene. ovariotomy in this country. The contingency of conception and pregnancy is an avoidable complication. Still it is no less to be thought of and made the subject of warning. As time advances, the natural tendency of the tumour to degenerative changes finds scope for progress. Whatever its tissues may be, they are never lastingly normal, have a precarious parasitic existence, gain their supply of blood as it were surreptitiously, and are easily thrown into the condition of atrophic decay. The expansion of the membranous compartments obliterates the vessels, fatty and other changes occur, and rupture is always imminent. The contents too, whatever they may have been at first, alter in their character and become less and less benign. And by too long waiting, sympathetic morbid action may be set up in the corresponding organ, and thus make the ablation of both imperative. In many cases ovariotomy may be performed with a confident hope of a successful result; in others the probabilities of success or failure may be about equal, Before going into the numerical examination of the question as to how far the age and condition of the patient, the size of the tumour, the existence of adhesions, the length of the pedicle, have affected the result in my whole practice, I think we may conclude that this experience has now been sufficient to warrant the exten In other words, a large tumour, sively adherent, in a patient whose heart and lungs, and digestive and eliminative organs, are healthy, and whose mind is well regulated, may be removed with a far greater probability of success than a small unattached cyst from a patient who is anæmic or leukæmic, whose heart is is anæmic or leukæmic, whose heart is feeble, whose assimilation and elimination are imperfect, or whose mind is too readily acted upon by either exciting or depressing causes. I believe this to be the explanation of the facts which have led some superficial observers to assert that the more advanced the disease the greater, and the earlier the stage of the disease the less, is the probability of recovery. I am convinced that this reasoning is based on the observation of a few exceptional cases where small unattached tumours have been removed with a fatal result from unhealthy or infected persons; or where large attached tumours have been successfully removed from persons who have otherwise been constitutionally sound. Small unattached tumours in strong healthy persons have by no means given the best results. It is possible to operate too early as well as too late-to place a patient's life in peril by operation before it is endangered by the disease; just as it is possible, on the other hand, to delay operation until the powers of life are so exhausted that recovery after a severe operation is impossible. A strong man in full health, with a limb crushed by a railway accident or shattered by a bullet, bears amputation worse than another man who, on account of diseased knee-joint, has been confined to his room for weeks or months. So a woman who has become accustomed to the confinement of a sick-room, has lost flesh, and has been brought by her suffering to dread the operation less than the disease, bears the removal of an ovarian tumour, even though large and adherent, better than one whose whole course of life is suddenly changed from the performance of ordinary active duties to the enforced quiet and confinement in bed which necessarily follow ovariotomy. SIZE The size of an ovarian tumour has not, by itself, appeared to affect the result; but size and solidity together, by affecting the length of the incision necessary for the removal, appear to be of some importance. If there be but little solid or semi-solid substance present which is generally easily discovered holding 50, 60, or 70 pounds of fluid before operation-large adherent cysts the cyst have been evacuated, through may be removed, after the contents of an opening only just large enough to admit one of the operator's hands. The but the mortality has been greater when result of such cases has been satisfactory; longer incisions have been necessary. mode of judging of the length of incision. The number of inches is a very imperfect In a small woman with a tumour of inches would extend almost from sternum moderate size, an incision of 8 or 10 to pubes; while in a large woman, greatly distended by a large cyst, an below the umbilicus, and after the conincision of this length may be made traction of the abdominal wall, the cicainches long. In examining a trix may not be more than 3 or 4 case for operation, it becomes important to judge whether a cyst or tumour can be removed by an incision which does not extend above the umbilicus. If this can be done, the probability of success is much greater than when it becomes necessary to extend the incision far above the umbilicus. ADHESIONS Writing in 1872, I reported that in 296 cases out of the first 500 there were no adhesions, or they were so slight as to be almost unnoticed. Of these patients 237 recovered and 59 died, the mortality being 19.93 per cent. In 204 cases, adhesions were very extensive: of these patients 136 recovered and 68 died-a mortality of 33 33 per cent. This would show that the mortality of cases where there are considerable adhesions is about 13 per cent. greater than in cases where there are no, or only trifling, adhesions. But a more careful examination of each case appears to confirm the conclusion at which I arrived some years ago, that adhesions to the abdominal wall, or omentum only, have but little influence upon the mortality, and that the importance which has been attached to the diagnosis of adhesions before operation has been greatly and unnecessarily exaggerated. At the same time the diagnosis of adhesions within the pelvis is of very great importance, as the attachments to the bladder or rectum may be almost inseparable without great and immediate danger to life. The same may be said of attachments to the liver, stomach, spleen, or around the brim of the pelvis, the separation of which would endanger the iliac vessels or the ureters. I formerly believed that the closeness of the connection between the uterus and the ovarian tumour-in other words, the length of the pedicle-was a grave matter, as upon its extent depended the possibility of keeping the end of the secured pedicle outside the peritoneal cavity, or the necessity for leaving it within this cavity. But during the last 5 years, having quite abandoned the extra-peritoneal treatment of the pedicle, a short pedicle, or close connection between cyst and uterus, becomes important in leading to greater difficulty in securing bleeding vessels. But it also leads to the advisability of uniting the peritoneal edges of the divided pedicle, or separated tumour, by suture, in order to avoid dangers which will be pointed out in the chapter on the operation. Some of these remarks, written in 1872, were intended to convey the result of an impression made by a general survey of the 1st 500 cases reported, and by reminiscences of what happened at and after the operations. But the information obtained from a more exact investigation of the 2nd 500 cases, and embodied in the accompanying table, does not correspond with that impression: TABLE SHOWING THE EFFECT OF ADHESIONS UPON THE RESULTS OF OPERATIONS IN THE 2ND 500 CASES OF OVARIOTOMY 25-4 to 21 per cent.; while the large increase in the mortality among the bad cases of visceral adhesion is noticeable. This may be accounted for by the greater boldness with which excisions were latterly undertaken and carried to completion. Many of the later operations finished, would formerly have been refused as hopeless, or abandoned after the first incision, and added to the tables of incomplete cases or exploratory incisions. But with regard to what have been spoken of as 'slight' adhesions—that is, adhesions to the parietes and to the fringes of the omentum-the table presents us with a mortality of 5 per cent. in excess of that of the simple cases; while the deaths after separation of omental adhesions are double, or nearly so, those among the free cyst operations, the relative percentages being 13.67 for the non-adhesions and 24.19 for the omental adhesions. Now, when we take into account that, according to my experience, nearly threefifths of the cases operated on have adhesions of some kind, and that the mortality of the group of adhesion cases, as a whole, was double that of the simple cases-26.38 to 13.67—it gives a serious aspect to the general question of adhesions. The death-rate of 37.25 in bad cases of visceral adhesion, found in one-fifth of the total number, at a time when the general mortality after my operations was rapidly coming down to 10 per cent., speaks for itself as to the gravity of the prognosis in such cases. And the other fact shown by this investigation of my 2nd 500 cases, that even with the so-called trifling adhesions—that is, cases in which the adhesions were only parietal or partially omentalthe deaths were nearly one-half more that among the adhesions classed as omental (18.54) than in the free cyst cases, and the mortality was nearly double (24-19), corrects the impression that adhesions of this kind were not of much importance. Their existence should not deter from the operation, nor make anyone falter. But these facts mark more strongly than ever the importance of avoiding everything in the early stages of the disease which may produce adhesions, of not letting the time for operating go by when the cyst is free, and of giving a proportionally guarded prognosis as to the probable result of operation when extensive adhesions are known to be present. |