Discussion.

Dr. O. S. McCown, Memphis: The subject of gall stones is one of interest to the general practitioner as well as the surgeon. In my practice I recently had a case in which, being positive of the diagnosis, Dr. W. B. Rogers was called in to operate. A stone was found in the duct, but while the gall bladder was full of bile, there were no stones in the viscus. The patient was relieved until about six months later, when she was again attacked with symptoms of gall stones, and later passed several large stones. I would like to know if these were newly formed.

Dr. John L. Jelks, Memphis: I would like to ask Dr. Smythe if he anchors the gauze in the gall bladder in his operations or not?

Dr. William Britt Burns, Memphis: I have had the pleasure of seeing several cases of gall stones with Dr. Smythe. It has been shown that a greater percentage of cases of heart disease have gall stones than do those without. Where ox gall is given 23 per cent. of fat is lost in these cases, but where it is not given 60 per cent. of fat is lost, making me therefore think that its administration is good practice in addition to surgical measures. Pancreatis is a disease of which little is known. Obstruction of the pancreatic duct by ligature will produce fat necrosis; hemorrhagic spots are also found in those cases in which fat necrosis exists. In acute pancreatis the spleen is atrophied, showing that there must exist some relationship between these organs.

Dr. Jere L. Crook, Jackson, Tenn.: We are indebted to Dr. Smythe for bringing forth such an interesting subject. I would like to know the number of stones he found in his cases, having seen a case in which 140 were counted, but stopped at that number as we became tired.

Dr. Smythe, closing: With considerable experience I have not found stones in the hepatic duct, but I have no doubt that they exist. To Dr. Jelks I will say I hardly recognize the condition as necessitating the anchoring of gauze in the gall bladder, but follow the method already laid down. In reply to Dr. Crook, I have never counted the number of stones in my cases, but the sister at the hospital informed me that in one of my cases she had counted 208 stones. The diminished plasticity of the blood is necessarily a point of great interest, as the patient may bleed to death if ligature of vessels is not practiced.

REPORT OF TWO CASES OF OVARIAN CYST.*

BY ROBT. W. TATE, M.D.

BOLIVAR, TENN.

IN presenting the following cases of ovarian cyst, it is not my intention to attempt to advance any new ideas, but to illustrate that by observing the principles of modern surgery, laparotomies may be performed successfully in the country under circumstances that seem most unfavorable.

It is well for the general practitioner in the country to be

* Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 19, 1901

on the lookout for almost any abdominal tumor, and to be able to diagnose large cysts from ascites, peritonitis or pregnancy-especially the latter condition; for cysts occur in the married as well as in the unmarried, and usually in young

women.

Suspicion of pregnancy is cast upon any young woman with an enlargement in the abdomen, and often the physician will relieve great anxiety among friends, and also save his own reputation, by giving a positive opinion whether the case is one of pregnancy or a pathological enlargement.

The history of the function of menstruation in these two cases is as contrary as any two histories could be, one suffering from amenorrhea with but few symptoms, the other from a most distressing dysmenorrhea.

The differential diagnosis between ovarian cysts and other tumors in the abdomen is sufficiently described in all textbooks on gynecology, so I will not dwell upon it, but I think the signs of a large cyst are brought out clearly enough in these cases to make the diagnosis easy.

Case I. Mrs. S. M., white, 29 years of age. Family history negative. Personal history: married; commenced menstruating at the age of 14, and menstruated again in six months, but not again until May, 1900, and March, 1901. At the time menstruation was expected she had some pain in her back and hips, also some leucorrhea. The menstrual flow was very slight, lasting only one day at most. She had been married thirteen years, but had never become pregnant. Her general health was always poor. There was dyspepsia, her bowels were constipated, and she suffered a great deal with headache, which did not come on with any regularity. She first noticed the abdomen more prominent about two years ago, and suspecting pregnancy her health seemed to improve. She could not remember upon which side the swelling began. After increasing in size for one year the abdomen remained about the same for several months, and it then began to increase more rapidly. Her general health again began to fail, and she would have repeated attacks of colic, which were not accompanied by vomiting, fever or abdominal tenderness, which excluded localized peritonitis; she also suffered with heartburn, fainting spells, shortness of breath and strangury. She had not been able to perform any of her household duties for twelve weeks, remaining most of the time in bed, resting in

semi-recumbent position. Both feet had been swollen for several weeks.

Examination June 6, 1901. The patient was emaciated but of large frame, being 5 feet 6 inches in height. The lungs were free and clear and the heart normal, also the urine. The abdomen was very much enlarged and the lower border of the chest expanded. The swelling was smooth and spherical; the umbilicus was flat, not protruded. Breathing was entirely thoracic. The abdominal walls were tense, and there was also slight tenderness over the abdomen. Fluctuation was general over the enlargement. There was no aortic pulsation, which is sometimes noticeable. Upon percussion, dullness was general over the anterior surface, the upper line being convex, with resonance in the flanks. The area of dullness was not changed by position. There were no signs of pregnancy. Upon vaginal examination the uterus was found to be small, very high and retroverted. There was some bulging on both sides, probably due to the intestines being crowded down into the pelvis.

An operation was advised and performed the same day. I will say here that the environments were not ideal. The house was one of those one-room log cabins commonly seen throughout our rural districts, having everything in it that could be accumulated in thirteen years of married life. The dining table used as an operating table was brought to the threshold of the west door, that being the only place to obtain light. After preparing the patient by administering a full dose of magnesium sulphate and obtaining in two hours two copious evacuations from the bowels, and the bladder being emptied, the operation was begun. Asepsis and antisepsis were carried out as far as possible.

Through a five-inch incision into the abdominal cavity the cyst wall was recognized. There was one small omental adhesion found on the anterior cyst wall, which was ligated and cut. The cyst was tapped on the upper angle of the wound. After the escape of some straw-colored fluid and no collapse of the cyst, three more were tapped through the first. The posterior cyst was lying to the left of the vertebral column and anchored there by another cyst lying over it, giving the impression to the hand in the abdomen that it was connected with the left kidney and very adherent to the posterior abdominal wall, but after tapping all the cysts through the first and the contents were eliminated, the sac slipped out of the wound easily.

The pedicle, composed of ovarian ligament, fallopian tube and broad ligament, was an inch in diameter. It was grasped

with a large clamp, transfixed and ligated, then cut between the clamp and ligature, thereby preventing any blood from entering the abdominal cavity. The stump was cauterized with carbolic acid and returned to the pelvis. The pelvis was sponged dry and the abdomen closed with silk and silkworm gut, leaving no drainage. The wound was dressed with aristol. The cyst was multilocular, with smooth, glistening surface. There were four large distinct divisions, each containing fluid of a different character, ranging from bloody to clear serum; also in each there were innumerable small cysts the size of a bird egg.

The after care of the patient was attended to by Dr. Milstead of Crainsville and Dr. Davis of Masseville, Tenn., who rendered me very able assistance during the operation.

Her recovery was uneventful. There was some vomiting after the anesthetic (ether). The temperature rose to 101°F., which in a few days became normal. On the eighth day the stitches were removed, the wound in the abdomen having healed by primary union.

Case II. A. B., colored. There was nothing in the family history worth mentioning, except that her mother died at the age of 35 of consumption. Personal history: Aged 19 years; single; first menstruated at 12 years of age, which continued regular and without pain until 16 years old, and then pain caused her to remain in bed one day before and one day after commencement. Her general health was good at other times throughout the month. She has had a cough for two years, which grows worse in the winter, and then she expectorates freely. She coughs more at night, and has had night sweats during the winter of 1900, their severity being judged from the fact that they were cured by placing a pan of water under the bed, as suggested by a colored friend. Her digestion was good, but bowels always constipated. She first noticed the abdomen enlarging three years ago and sought medical treatment, but was not benefited, the physician suspecting pregnancy and administering placebo. The tumor grew regularly and slowly until eighteen months ago, and then seemingly it grew more rapidly. For the last six months she has been in poor health. Has had more or less constant pain in both sides. of the lower abdomen, but worse in the right side. She was not able to lie on this side. At the menstrual period she would suffer terribly with pain in the lower abdomen, and sick stomach with headaches, often being fearful of losing her mind, so great was her suffering. This would last through her entire menstruation-five days.

She was first seen September 26, and examined. The heart was normal, also the kidneys. The lungs showed some slight variations from the normal, but not enough to accord with the history. One thing was rather interesting: there was absence of liver dullness anteriorly when she was lying on the back, and present when she was upright. The same thing was noticed posteriorly. The abdomen was distended by a fluctuating tumor which gave the objective symptoms of a cyst, to within two inches of the ensiform cartilage. There was tenderness over the abdomen, especially on the right side. There was no history of attacks of localized peritonitis. The uterus was about normal in size, retroverted, the fundus pushed to the left side. The signs of pregnancy were sought for diligently, but were absent.

Sept. 28 an operation was performed. An incision three inches long was made in the median line into the abdominal cavity and the smooth, shining surface of the cyst recognized. No adhesions being found the cyst was punctured and two and a half gallons of slightly turbid white liquid drawn off. The sac was easily withdrawn. The pedicle was about two and a half inches broad and ligated with a chain ligature. The stump was cauterized with pure carbolic acid. The left ovary was examined and found to be undergoing cystic degeneration, so it was removed. The incision into the abdomen was closed and dressed as in the other case.

Following the operation there was some shock, which was easily overcome by the administration of strychnin hypodermatically, and normal salt solution by enerua.

The evening of the same day and during the following day the patient complained of pain in the parotid glands. The third day was begun by menstruation, which lasted four days. The evening temperature on the fourth day was 1021°F., pulse 100, respiration 20. Muriate of quinin and urea grs. 3 every four hours was given hypodermatically, and in a few days the temperature reached normal.

The stitches in the abdomen were removed the eighth day, that is, at the first dressing, the wound having healed by primary union.

Discussion.

Dr. J. P. Runyan, Little Rock, Ark: Results in this operation are very good, and there is no reason why they should not be in uncomplicated ovarian cyst, where the operation is a very simple procedure. When an ovarian cyst is permitted to run on too long, it frequently leads to a serious condition, especially when the pedicle becomes twisted. (The speaker detailed a case in which an ovarian cyst had been mistaken for a fibroid tumor, but when the operation was performed it was found to be an ovarian cyst with twisted pedicle