physician should not let this consideration interfere too much with his best judgment in regard to the mother's interests, for it is beyond question now that her life is the more precious.

The principle object of the physician's attention is the hæmorrhage that is sure to occur during the dilatation of the os. The os must dilate, and as it does, the placenta is detached; hence, we get unavoidable hæmorrhage. Now the object in treatment is to check this hæmorrhage as much as possible. Before proceeding, there are a number of points to determine in regard to the labor: Whether it is proceeding regularly, whether the os is dilated or not, presentation, etc.

The tampon may be used, first, to check the hæmorrhage, and secondly, to aid in the dilatation of the os. The pressure exerted by a tightly packed tampon is exceedingly valuable in causing coagulation of the blood that oozes from the bare placental surface. In every instance, however, it should be thoroughly disinfected. Iodoform, I think, answers best as the disinfectant.

Where the hæmorrhage continues and pains are weak, there is no choice, and we must proceed to turn. In fact, turning is the only method of delivery considered. by many authors. The introduction of artificial dilators is strongly advocated by many, but the hand, properly disinfected, is, I think, the best dilator.

After proper dilatation the membranes may be ruptured and the foetus allowed to engage in the cervix. If there is room for the head, and it can be made to present it will be well, for it will act as a ball valve and thereby check the hæmorrhage. If, however, this cannot be accomplished, then we must turn. By bringing a foot down we can plug the os. Lomer,* in an extensive and valuable article in the American Journal of Obstetrics, advocates the Braxton-Hicks operation and the results he gives speak well for it. The recoveries for the mothers he gives at 90 per cent. But this operation cannot always be practiced, therefore we must bear in mind the other methods at our disposal.

The membranes, where they can be reached, may be ruptured. This will stimulate the uterus to greater efforts.

A method advocated by Simpson where it is impossible to rupture the membranes or to turn, is to separate the placenta entirely and deliver it, if necessary, before the birth of the child. He gives eight cases of his own and of those of which he had personal knowledge, and also a tabular statement of 147 cases in none of which was there any hemorrhage after the placenta was entirely separated.

The following case is one which I was called to attend a short time ago:

On Wednesday, Nov. 4th, I was called to attend Mrs. D., aged 36 years, mother of four children, two

* December, 1884.

living. About a year ago she had an abortion, performed by herself. This, then, was her sixth pregnancy. She is a brunette and an average woman of the class she belongs to, a mechanic's wife. She was kindly referred to me by Dr. W. F. H. Edwards, who, on account of a previous engagement, was unable to attend her. On my arrival I found the patient in bed, and was greeted with the information that she was flowing very badly. I paid little attention to this, but asked if they had saved any of the blood. A chamber was produced that contained over a pint of clotted blood. This looked serious and I immediately made an examination. I found a large clot in the vagina, another protuding from the os. On removing these I could feel a semi-solid, spongy, granular body over the internal os. I examined her further carefully and concluded I had a placenta prævia to deal with. I prescribed virburnum prunifolium, fluid extract, in drachm doses every one or two hours, with pulverized scale opium, gr. j, as required for any pain. I left to return soon again and with orders that I should be sent for immediately if the flow should increase. The viburnum and opium quieted her nicely and the next day she got along fairly well. According to her calculation her time would not be up until Nov. 17th. I thought she might possibly get along until that time. Friday the flow increased and in the afternoon I tamponed her, with the intention of stopping the hæmorrhage or stimulating the pains and thereby induce labor. In five hours I removed the tampon. The effect of it was to stop the hæmorrhage. This did not last long, however, for it began again in about 12 hours.

On Sunday, Nov. 8th, I was called in haste, about 4:00 o'clock in the afternoon. On arriving at the house I found that labor pains had set in and that the flow had increased. In order that the mother should have every opportunity possible, I determined to send for counsel. Accordingly Dr. W. P. Manton was called in. The doctor confirmed the diagnosis, and brought everything necessary for use in an emergency. The pains kept up and as they grew stronger the hæmorrhage increased. The head presented but had not yet engaged, and the os not being sufficiently dilated, and there beins no immediate. danger, we deemed interference unnecessary and determined to await further development.

This state of things continued for about four hours. The pains were irregular and the hemorrhage inconsiderable. At each contraction of the uterus the head endeavored to engage, but was prevented from so doing by the placenta.

About 8:45 o'clock the patient became suddenly pale, yawned frequently, and complained of dizziness. Examination showed the os nearly dilated and hemorrhage incrcasing, consequently operative interference became imperative. I administered ether to the patient. while Dr. Manton, after thorough antiseptic precautions, proceeded to turn, which was accomplished without dif

ficulty and the patient delivered of a still-born child with the cord around its neck.

The placenta, which was situated low down on the right side and just overlapping the internal os, was expelled with a little difficulty about twenty minutes after the birth of the child.

Although all signs of life were absent, Dr. Manton spent an hour, using all the practical methods, trying to resuscitate the child, but his efforts were fruitless.

On account of a slight odor of the lochia carbolized vaginal douches were administered three times daily for a week and afterwards less frequently.

Although convalescence was somewhat protracted on account of the loss of blood, the patient recovered without any untoward symptoms.

83 Lafayette Ave.

OVARIAN TUMORS.*

BY W. H. YOUNG, M. D., NASHVILLE, MICH. N VIEW of the frequent failures, of even the most able surgeons in the matter of diagnosis of abdominal tumors, the frequent errors into which they have fallen, and the quite unexpected discoveries which have been made during operations for the removal of some of these tumors; such cases at once assume an importance, in the mind of the physician or surgeon, scarcely equalled by any other class of diseases.

Tumors of the most diverse kinds, and originating in almost every part and organ contained within the abdominal cavity, have been mistaken for ovarian tumors, and attempts have been made to remove them; but through increasing knowledge and more accurate methods of examination, such errors are not now so frequent as formerly, yet they are still by no means infrequent. Although, in many cases, we may by means of careful examination and by methods of exclusion, arrive at an almost positive conclusion in regard to their nature and origin, yet cases will occasionally present themselves in which after we have exhausted every known means of differentiation, their structure and origin will be matters of doubt until an explorative incision or an attempt at removal reveals their true nature.

The following case will serve to illustrate some of the difficulties which the surgeon has to encounter in arriving at a diagnosis, and the responsibility resting upon him in advising the patient in regard to the necessity as well as the safety of submitting herself to an operation for her relief or cure.

Mrs. Mary Miller, aged 43, a farmer's wife, mother of four children, and of good family history. Until the time of the birth of her last child, which occurred in May, 1872, she had never had any serious sickness.

* A paper read before the Barry and Eaton County Medical Society.

During her convalescence from this confinement she discovered a small tumor in the right iliac region which slowly but constantly increased in size until December, 1874, at which time she went to Ann Arbor for treatment. (Here let me state is an illustration of an abuse which is only too prevalent, viz: the gratuitous treatment of patients in some of our public institutions, who are abundantly able to pay for medical or surgical services rendered.) During her visit to Ann Arbor the tumor was tapped by Prof. McLean and about three gallons of fluid obtained. After this evacuation of the contents of the tumor, she suffered no inconvenience from it until January, 1882, a period of seven years, when the tumor again commenced to enlarge. About this time she suffered from a circumscribed peritoneal inflammation, which confined her to her bed for a period of about six weeks. In April, 1882, she again went to Ann Arbor for treatment, but as the physicians who examined her while there did not agree in regard to the best course to pursue, she returned home without anything having been done for her. From this time until the time of her consulting me, in September, 1885, the tumor had been constantly growing, but had grown much more rapidly during the last few months. Such was the history obtained from the patient herself.

Upon examination I found a large and very irregular tumor filling the abdominal cavity throughout a considerable part of its extent, but more especially the right inspection, and had the appearance of several separate side. The irregularity of outline was plainly visible to and distinct cysts or growths with quite perceptible spaces between them. Palpation showed distinct fluctuation, but in some parts it was very difficult to determine whether the fluctuation wave passed from one of the apparent cysts to those adjacent or not. On making a vaginal examination I found the uterus drawn high up in the pelvis and a little to the right. A sound passed into it 41⁄2 inches in a direction in a line with the long diameter of the tumor.

The sound being in the uterus, the tumor, which was fairly movable, was drawn up and rotated by an assistant, which movements were communicated to the sound. By making a rectal examination nothing of importance was discovered as the tumor was too high up, and no force which I deemed proper to employ in dragging the uterus downwards by means of forceps sufficed to bring the pedicle within the reach of my finger.

Although many, if not most, of these symptoms seemed to point to a cysto-fibroma of the uterus, I determined upon an operation, purposing to make an explorative incision first, in order to clear up the diagnosis of the case, and to proceed at once to extirpate the tumor, providing such an operation should be deemed. advisable, after a more direct examination had been made.

Accordingly, on the 5th day of November, the neces

sary preparations having been made, I proceeded to make an incision into the peritoneal cavity, just sufficient to admit the introduction of a large-sized sound, which passed quite readily around the tumor in all directions, meeting with only a few small points of adhesion. The abdominal incision was now enlarged to about four inches, and the contents of the tumor, which were thick, dark and purulent, were drawn off by means of Spencer Wells' trocar. The tumor was almost entirely free from adhesions to the abdominal wall, and only a few adhesive points to the omentum, which were ligated with silk, cut, and the sac turned out. The pedicle, which was long, slender, and twisted upon itself, was tied with silk cut short, and dropped. A drainage tube was inserted at the lower angle of the abdominal incision, and the external wound closed by silk ligatures. The line of incision having been dusted over with iodoform, was covered by a thick layer of borated cotton, held in place by a bandage which completed the operation. After the patient was placed in bed the temperature was found to be 99°, pulse 84, respiration 18. During the afternoon the temperature gradually advanced until it reached 1013, which was the highest point attained. On the 7th the drainage. tube was removed, there being no effusion into the pelvic cavity. Without entering farther into the clinical history and details of treatment employed, suffice to say, that the patient made a rapid and uninterrupted recovery.

In this case there are several points of interest to which I wish to call your attention. The duration of the tumor, although not without many parallels, was unusual, and in this respect might be classed among the exceptional cases, by far the larger number of cases of ovarian tumor terminating in much shorter time. This history, together with the obscurity of fluctuation in some parts of the tumor, the position of the uterus in the pelvic cavity and its relation to the tumor and the simultaneous movement of the uterus and tumor, rendered the differential diagnosis between a fibro cyst of the uterus and an ovarian tumor extremely obscure. In fact the results of my examination seemed to point more directly to the former than to the latter. The duration of ovarian tumors is stated by various authors to be from two to five years, to which, however, there are numerous exceptions, but the exceptions occur for the most part in persons of advanced age, while on the contrary, tumors of the uterus are usually of slow growth and may have been recognized for many years. Again, the position and condition of the uterus, it being elevated lying in front of the tumor and enlarged, were just such conditions as we might expect to find in case of a uterine tumor.

In reference to the differential diagnosis of ovarian tumors Emmet says, "a fibro cystic tumor of the uterus is the only growth which, after a thorough examination, could ever be mistaken for an ovarian tumor, and it is now held that this may be diagnosed by an examination

of the contained fluid." While admitting that this is true in many cases, he says "there are exceptions where it is impossible to decide until after an exploratory incision through the abdominal walls." It may be asked why, since an examination of the contained fluid yields so important information in a majority of cases, I did not resort to explorative tapping in order to avail myself of such information as might have thereby been acquired? My answer is that tumors of the uterus are sometimes removable, without any great difficulty, and the condition of the patient was such as demanded an attempt at giving relief, even though the attempt should be associated with considerable danger, and that although examination of the contained fluid might demonstrate the true character of the tumor it could throw no light upon the difficulties which might have to be encountered in its re noval, providing it should prove to be uterine. Influenced by such considerations I decided upon an explorative incision as a means of settling all questions of doubt, without subjecting the patient to much greater dangers than would the operation of tapping.

After the tumor was removed an examination of the sac showed that although it consisted for the most part of only one cyst, yet the remains of the partition walls which had become broken down were plainly to be seen; and to this polycystic condition was due the irregularity of the tumor. In some parts the cyst wall was very thick and fibrous, while in others it was so thin as to be transparent. From the extreme thinness of some parts it is evident that she was in constant danger from rupture of the cyst either through accident or spontaneously.

The question, "to whom shall those important operations be entrusted?" has quite frequently been discussed, and the conclusion arrived at has generally been "the specialist." This solution I am quite ready to accept, providing that the term "specialist" implies something in the line of qualification beyond the mere fact that he is in some way connected with some medical college, that he resides in some city, or even that he makes gynaecology his special line of practice. The successful performance of this, as of every other important surgical operation,requires that the operator shall be a competent surgeon possessing such a knowledge of the anatomical structure of the body, and more particularly of that part upon which he is about to operate, as shall enable him to distinguish normal from abnormal conditions. He must also possess such a knowledge of the physiological functions of the tissues with which he is about to interfere, as will enable him to know what amount of interference will be likely to be tolerated and be compatible with life and health. He must also be thoroughly acquainted with the processes of repair and the conditions necessary for this to take place. To a person so qualified, ovariotomy may safely be entrusted, whether he has ever performed the operation or not. We are well aware that in the experience of the most eminent ovariotomist the

death rate has decreased as their experience increased. This might seem to be an argument in favor of the specialist, but upon closer examination we will find that the greater fatality in their early practice was due to neglect of principles which involve the success or failure of any and all surgical procedures. Their experience has taught them the importance of what was formerly thought to be unimportant detail. Now we are taught to believe that nothing is too unimportant to receive our most earnest attention which can in any way contribute to jeopardise the life of the patient. In order to be a successful operator it is necessary, also, to be an accurate diagnostician, so as to be forewarned of probable complications and difficulty, and, therefore, prepared to meet them. We cannot all be Keiths or Taits, but we can all follow their example, and the observance of those principles which have contributed to their success will also contribute to ours. When we hear specialists, or would-be specialists, say that we are the only men to whom important operations should be entrusted, it smacks something of egotism. While I am ready to admit that practice will inspire dexterity and confidence, I am quite confident that care, with the other necessary qualifications, will largely compensate for the lack of practice.

I

BY DR. GEO. TYE, CHATHAM, ONT.

DESIRE to offer a few observations on Fever, a subject always full of interest to the general practitioner of medicine on account of its frequency. I refer more particularly to the so-called Typho-malarial Fever. Does such a fever exist as a distinct disease? If not, then the name should be abandoned, for in all cases the nomenclature of disease should express existing conditions as exactly as possible. The use of one name for different conditions, even though they be associated, leads to confusion of ideas, prevents correct diagnosis, and in many instances may lead to erroneous practice. It may be justly said that this question was settled long ago, for Dr. Woodward was in a great measure responsible for this term during the war of the rebellion. then evidently believed that such a disease existed and with a distinctive pathological basis. Ten years later, at the International Congress in 1876, he admits that there is not such a disease, but for convenience gives the name to two concurrent fevers in the same individual. He says: "Typho-malarial Fever is not a specific or distinct type of disease, but the term may be conveniently applied to the compound forms of fever which result from the combined influences of the causes of the

He

of the Section in Medicine was, "Typho-malarial is not a specific or distinct type of disease, but the term may be conveniently applied to the compound forms of fever which result from the combined influence of the malarial fever and of the typhoid fever." This finding rejects the disease but retains the name, so misleading and objectionable.

Robert Bartholow discusses this subject ably and extensively in a paper in the Medical News of September 1884. He says: "The term typho-malarial is therefore a complete misnomer, a misleading phrase which should be abolished from our nosology, and should no longer appear in our text-books."

Dr. Wilson, in his work on Fever, says, "This term is an unfortunate one and has given rise to no little confusion concerning the nosological portion of the various forms of the disease to which it has been applied. It is needless to state after what has been said of the etiology of enteric fever that a hybrid disease to which the name is applicable does not exist."

Abundance of evidence of this character can be produced to prove that this so-called disease does not exist. Yet the idea still haunts a portion of the medical mind like a shadow whose substance cannot be found.

At the last meeting of the Ontario Medical Association, held in London in June last, in a discussion on fever I denied the existence of Typho-malarial fever, and pointed out the evil consequences that might follow such a belief.

This view was disputed by some eminent medical men present who said they believed there was a third fever existing between our malarial fevers and typhoid fever.

The official nomenclature of our Ontario Health Report contains a place for typho-malarial fever.

Only a month or two ago, Dr. Ellsner, of Syracuse, published a paper entitled "Typhoid Fever as We See it in Central New York," in which a number of typical cases were well presented, and no matter how far the clinical symptoms varied from the model type of the text-books, the post mortems always found the lesions constant. In the next issue a medical gentleman in another part of the state informed the author of the paper that these cases were all typho-malarial, although he possessed the evidence that the lesions were those of enteric fever.

In this country we have two distinct causes of fever: one source, malaria, using that word in a special sense; the other, the typhoid germ. The malarial element is evidently due to emanations from the soil, where vegetable decomposition is taking place extensively. What this germ is we are not yet sure. The other source, the typhoid germ, is developed most abundantly from animal.

*Read before the Detroit Medical and Library Association.

natural history is now pretty well known, and the facility with which it is propagated and carried by water was well

shown in the Plymouth outbreak. Whenever the conditions for either fever exist, then there will be manifestations. The conditions are often associated, especially in this part of America; hence it follows that they often occur in the same place, at the same time, and in the same subject, because both the etiological factors are present.

Now, it is well known by experience, and does not require argument to satisfy us, that both these factors are greatly modified by the increase of population. The malarial cause disappears with cultivation and drainage of the soil, in direct proportion to which the change is effected. It is true that its manifestations are often more extensive and more virulent while these changes are in progress. Meteorological conditions greatly influence the production of this cause; hence it follows that these fevers must present considerable variation, both in form and degree. The typhoid element is more constant yet greatly influenced by surroundings. The sanitary improvements now so happily inaugurated, especially in your own State, not only prevent, but ameliorate the ravages of the disease. Given two subjects in whom all the conditions are equal, but the hygienic surroundings of the one good, of the other bad, then the clinical features of the one will differ from those of the other. I believe that these germs undergo cultivation in the progress of an epidemic, and their intensity becomes attenuated.

During a practice of nearly twenty years in western Ontario, I have witnessed a large amount of malarial fever, especially during the first ten years. The quotidian and tertian forms were prevalent; these were introduced by marked and prolonged chill, with violent shaking. Indeed, the name shakes was perfectly descriptive of that stage, these chills were followed by high fever, often delirium, finally subsidence of the fever and then a profuse sweating. These fevers have now almost disappeared, the shaking is rarely experienced, only a slight chill, scarcely any delirium, except in children, and the sweating is not pronounced, frequently absent. A second variety was ushered in with chill, but no shaking, high fever, intense headache, vomiting, gastric pain, muscular pain, and abdominal tenderness; sometimes diarrhoea. There were distinct remissions, but not intermissions as a rule. The patient was often jaundiced, more or less.

These cases continued a variable number of days, sometimes continuing two or three weeks. They always ended at variable times; never enough cases terminating about the same time to establish a rule. These continued forms sometimes terminated in distinct quotiden or tertian ague. This continued form was much more prevalent in the country than in the towns and villages. These cases were called bilious remittent, and were well named, for the functions of the liver were greatly deranged, as were most of the abdominal glandular organs.

133

These cases are now rarely seen, and much shorter in duration, because the factor which produced them is diminished in intensity.

During the early part of this twenty years typhoid fevers were rarely seen, but they steadily increased in frequency until now these fevers have changed places. Some years climatic influences favored an unusual development of the malarial element and complicated the typhoid cases, as it frequently does pneumonia, the puerperal state, or any other condition in which vitality is lowered. When these complications occurred diagnosis was not easily made for several days and they were termed bilious fevers, and when the typhoid fever was established then it was said that the bilious had run into the typhoid, or it was typho-malarial, and thus the medical attendant was saved from an error in diagnosis, for the doctrine of metamorphosis, and of typho-malarial fever give such latitude that error was impossible—and the compound name was quite popular.

From this incomplete diagnosis arose the false doctrine that typhoid fever could be aborted. Large doses of quinine sometimes effected a cure in a few days, and those medical men who did not understand the pathology of typhoid believed that could sometimes cure enteric fever. Sir Andrew Clark, in speaking of this fever, happily remarks, when the ship is in a storm, although we cannot stop the storm we can manage the ship. Yet there are some who attempt to stop the storm and neglect the ship.

I have been able to find records of but few post mortems, as to the distinct lesion of enteric, in the so called typho-malarial fever, these were negative as to pigmentation of the liver, or swollen condition of Peyer's patches, or the distinct lesion of enteric fever. So that there is no pathological basis. Dr. Woodward thought for a time that he had found such a basis, but abandoned it. It is sometimes urged that cases of continued fever cannot be typhoid because there is constipation instead of diarrhoea, but I need not say to you that this is true of quite a large percentage of undoubted cases of typhoid, and it is certainly manifested by copious hemorrhage. I have met many cases in which there was constipation with hemorrhage, the constipation itself being often due to extensive ulceration. Sir William Jenner, in a lecture on typhoid fever, says: "The most important and not unfrequent cause of inaction of the bowels is a deep ulceration of one or more of Peyer's patches. A single deep ulcer will paralyze the bowel and so cause constipation. If this was diagnosed as typho-malarial, purgatives would be admissible, but if true enteric fever their action would probably be fatal by producing hemorrhage or perforation.

After all, is this a practical question? I think it is eminently so, because all diagnosis should be as definite and as scientifically correct as possible, because the diagnosis is the guide to treatment. A malarial fever may