me. An examination revealed an enlargement on both sides of the uterus, which was very sensitive to pressure. An operation was advised, which was made at my "Home" May 7, 1889, and a double pyosalpinx removed. Patient had an easy recovery; was able to sit up on the thirteenth day after the operation, and will soon be well. Present: Drs. Carson, Fishburn, and Zurmehly. Remarks. This list of cases makes an exceedingly interesting group, any one of which would make a long paper if I would describe all the interesting symptoms. But I will only detain you to refer to some of the most prominent symptoms which were present in all the cases, and to two of the cases that differed from the others. Case I was in a wretched state of exhaustion and emaciation; her weight would not exceed eighty-five to ninety pounds, when her former weight had been 130 pounds. She had constant fever for many weeks before the operation. She recovered more rapidly than one could be led to believe who had not seen much of this work, and in six weeks was able to walk without pain, and went home, a distance of a couple of hundred miles, and is now in the enjoyment of perfect health. Case IV was also in a feeble condition, greatly emaciated, and had constant fever; even when she was at her best, the evening temperature was 102°. She died from peritonitis; yet I believe if she had had the vitality of the average patient she would have recovered. All the cases had been treated for months and years by local and constitutional treatment, and many of them had become bed-ridden. They all gave a clear and unmistakable history of abdominal inflammation; not only one attack, but many. All date the commencement of their illness to an attack of inflammation in the abdomen. In all could be felt by the bimanual examinatfon an enlargement upon one or both sides of the uterus, tender upon pressure, which could not be pushed upwards. All the cases proved to be pyosalpinx except one,-of abscess of the ovary. In all the cases the adhesions were firm and extensive. The pain in these cases is due to the pathological condition actually present, and while that remains unrelieved it is obvious that relief can be only temporary. The retroflexion and other misplacements of the uterus met with in all of these cases was a natural result following the repeated attacks of inflammation, and could not be cured by any local application made to the uterus. The cases illustrate the benefit of operative interference in chronic inflammation of the uterine appendages. In looking over the text-books on dis eases of women, we find long chapters on the displacement of the uterus and pelvic cellulitis (so-called), which are discussed with great care and the most trifling detail dwelt upon and elaborated to the fullest extent; while the more important subject of inflammatory diseases of the Fallopian tubes and ovaries has been treated of as of but little importance. While it is true that some of the most recent works devote a short chapter to this subject, most of them dismiss it with a few words. I am glad to say, however, that some of the German authors of recent date give minute and complete description of the pathological anatomy of the tubes, showing that they already realize that it is a subject worthy of their careful consideration. It is this scarcity of literature on the subject that has led me to inffict upon you this extended and tedious report. With my limited experience I will not theorize, but simply offer this report as a small contribution to the fund of knowledge that may in time dispel the misty obscurity that envelops the subject of diagnosis of inflammatory diseases of the uterine appendages. 154 West Eighth Street. THE celebrated and eccentric Doctor Mounsey, the Chelsea doctor, as he was nicknamed in his day, died at Chelsea Hospital, December 16, 1788, aged ninety-five, and left this amusing epitaph to be placed over his grave: Here lie my old bones, my vexation now ends, I have lived much too long for myself and my friends. As to churches and churchyards which men may call holy, USEFUL IF TRUE. - A fly always walks upward. Put a fly on a window and up he goes toward the top; he can't be made to walk downward. My friend made a window screen, divided in half. The upper half lapped over the lower, with an inch space between. Well, as soon as a fly would light on the screen he would proceed to travel upward, and would thus walk straight out of doors. On reaching the top of the lower half he would go outside. Not being able to walk down he had no way to return to the room. By this means a room can be quickly cleared of flies, which always seek the light. A REPORT OF TWO INCOMPLETE OVARIOTOMIES; ONE FATAL. BY JOHN J. BUCHANAN, M. D., PITTSBURGH, PA. Read at Allegheny County Medical Society, May 21, 1889. In two cases of ovarian tumor in which I have been called to operate, I have been unable to complete the operation on account of the extent, locality and tenacity of the adhesions. The first operation was performed on July 13, 1885, and resulted in the death of the patient on the thirty-second day. The second was done five weeks ago, and the patient is now convalescent. These have been by far the most instructive of the cases upon which I have operated, and a brief history of them may be of interest. Case I. Patient aged twenty years, married one year, was of slight build and considerably emaciated, two and a half months before operation the abdomen began to perceptibly enlarge. In one month the enlargement was so considerable, and her distress so great that her attendant drew off a portion of the fluid by inspiration. Refilling rapidly occurred, and at the end of another month her condition urgently demanded operation. The tumor was immovable by external or combined examination and the uterus was firmly wedged in the pelvis. When the abdominal wall was incised, the peritoneum could not be identified, and the tumor was opened and its contents evacuated. The cyst was found to be universally adherent, and so tenacious were the adhesions that, in the effort to separate the cyst from the abdominal wall, the former was torn to shreds. The intestines were tightly attached above and the bladder below. In the effort to release the vesical adhesions a slight rent was made in the fundus of the bladder. This was sutured and thereafter gave no trouble. Enucleation was tried and failed. The hand in the cyst found it plastered over and tightly adherent to the pelvic walls and viscera. After the most persistent endeavors to release the cyst it was reluctantly decided to stitch it to the abdominal wound and drain. Glass tubes were placed in the sac and in the peritoneal cavity. The peritoneal tube was allowed to remain seven days, and on its removal the opening filled up at once; the tube in the cyst remained eleven days, and was then replaced by one of soft rubber. During the first thee days after the operation the discharge from the tube in the cyst was odorless; on the fifth day a putrifactive odor was observed, due probably to decomposition of blood-clot in the cyst cavity. Despite frequent washings with carbolic solution, this odor persisted till on the twelfth day fecal matter was found in the discharges from the cyst. From this time forward her alvine discharges were almost entirely through the fistula. The cyst cavity did not collapse; exploration with the finger and by reflected light showed the cyst wall in a state of gray slough with granulations pushing through; the size of the cavity about six fluid ounces; the wall hard, rugous and insensible, except in the right iliac fossa where the surface was soft, yelvety and tender to the touch. She had a severe chill on the seventeenth day, and gradually declined in strength till the thirty-second day, when she died. No post mortem examination was made. Two months Case II. Patient of Drs. Pershing and Riggs, of Wilkinsburg; aged thirty-five years, married; the mother of two children, the younger nine months old. At the time of her last confinement she was attended by Dr. Pershing, and nothing abnormal was developed. later she discovered an immovable growth in her right ovarian region, about the size of a small egg. This increased but little in the next four months. A few days before operation it was seen for the first time, and was found to be about the size of an adult head. During the two weeks previous it had doubled in size. Her temperature was 103°; she was confined to bed, suffering considerably. Her attendants used the hypodermic needle for purposes of diagnosis and secured a yellow puriform liquid, which subsequently congealed. Microscopical examination showed it to be made up largely of fat globules with a few leucocytes. The cervix uteri was crowded forward in the pelvis and perfectly immovable. A diagnosis of adherent dermoid ovarian cyst was based on the rapid increase in size, the inflammatory symptoms and the nature of the fluid withdrawn. An immediate operation was decided on and performed with the assistance of Drs. Werder, Pershing and Riggs. Identification of tissues was very difficult. The great omentum was much hypertrophied and infiltrated and attached below to the fundus of the bladder; it was tightly adherent in front to the abdominal wall and behind to the cyst. The cyst was universally adherent; not one square inch of free surface could be found; the adhesions were of the firmest character. The great omentum was loosened from the cyst, secured with clamp forceps above and an elastic ligature below, and cut transversely between. A sound was now passed into the bladder and it was found that the elastic ligature embraced not only the great omentum, but also a portion of the fundus of the bladder. The ligature was at once loosened and the cut omental surfaces seared with the Paquelin cautery. The cyst was forcibly loosened over a considerable surface on either side and ruptured in the effort. The fluid evacuated was of the same nature as that withdrawn by the needle, and there was also secured a small bunch of long black hair, thus verifying the diagnosis. As soon as the rupture occurred the cyst was freely opened in front. There was two distinct cavities, the larger below. It was impossible to prevent the fluid from entering the peritoneal cavity. Five or six gallons of boiled water was used to wash out the peritoneal and cyst cavities. What was evidently a tooth could be felt in the bottom of the cyst wall. After every justifiable effort had apparently been made to overcome the intestinal adhesions, a plait was taken in the cyst wall on either side and the margins of the opening in the cyst stitched to the lower part of the abdominal incision, a glass drain being left in the peritoneal cavity and one in the cyst. The peritoneal tube was removed at the end of twenty-four hours, and the tube in the sac was replaced by a rubber one on the third day. Supuration occurred in and about the cyst, but the highest temperature during the first ten days was 100 °. Some obstruction to the discharge of pus from the cavity between the bladder and the cyst occurred during the third week and caused an elevation of temperature. In other respects her recovery was uneventful. The sac collapsed and sloughed. It was washed out three times a day with boiled water, and occasionally with sublimate solution. During the first two weeks there was some discharge of oily matter with the pus, but none since. She is now up and about the house, and the discharge from the sinus is diminishing. In connection with the history of these two cases, the question arises-Could these cysts have been removed? Mr. Lawson Tait at the close of last year said: "I am now in position to say that no cystic tumor of the abdomen exists which cannot be removed. In my second series I have only to plead guilty to six uncompleted operations in 1,000, whereas, in my first series, the number was thirty, with the same mortality in each-fifty per cent. Even in these six I now know, for post mortem examination revealed the fact, that I could have finished *General Summary of Conclusions from a Second Series of One Thousand Consecutive Cases of Abdominal Section.—British Medical Journal, Nov. 17, 1888. |