tending from the cyst to other parts should be tied before dividing them. This applies especially to adhesions of the omentum. Large bands should be tied with prepared silk ligatures. The finer bands may be tied with catgut. In my own practice I use silk altogether. Intimate adhesions which have to be separated by traction leave bleeding surfaces, and if any large vessels are found they should be tied if possible. General oozing can usually be stopped by pressure with a sponge. Hæmorrhage deep down in the pelvis from vessels large enough to be ligated can be reached by throwing in the light from the mirror and using a long artery-forceps. The ligature can be easily tied by using the counter-pressure instrument employed in tying the sutures in the operation for restoration of the cervix uteri.

To check oozing from surfaces like the uterus, liver, or spleen, pressure with sponges is to be performed as stated already. An application of persulphate of iron is made by some operators, and the thermo-cautery has also been commended. Both are objectionable, and should be avoided if possible.

After-Treatment. The description of the operation ended with the giving of a small hypodermic injection of morphia, and placing the patient in a warm bed in a room at a temperature of about 70° F. She should be kept warm so as to induce a general circulation, and moisture of the skin from gentle perspiration. Keith insists upon keeping the hands covered because the perspiration will not come if the hands are exposed, and if it does start all right, putting the hands out from under the bedclothes will stop it. If there is nausea, sips of hot water should be frequently given. When all goes well there is very little after-treatment needed and the less employed the better. The stomach should rest until the patient feels a desire for food or drink, and no food should be given by the stomach until flatus has passed from the bowels. Solid food is not given until asked for by the patient. Pain, if severe, should be relieved by hypodermic injections of morphia. Excessive vomiting may be controlled in the same way. Flatulence which gives distress and does not pass off is most effectually managed by a solution of quinine administered by enema. Dr. Keith told me about the use of quinine in this way, and I have used it very often and with the most satisfactory results. Six or eight grains dissolved in aromatic sulphuric acid, with about half an ounce of water with acacia enough to make the mixture bland, is the formula used. When about to use it warm water enough is added to raise the temperature of the mixture to that of the rectum.

This I have found will relieve flatulence if it can be relieved at all, and is at the same time a good way of supporting the patient. In fact, I believe that its action in relieving flatulence is by restoring the tone of the intestines.

Should the stomach remain irritable and the patient be weak, she should be supported by soup and brandy administered per rectum. The bowels should usually be moved by enema about the fifth or sixth day.

The patient may sit up about the fifteenth day, and return to her usual duties in about four weeks. The time must vary in each case according to circumstances.

The management of the various complications which may arise after ovariotomy will be discussed with the histories of cases which will be given hereafter.

Some points of interest regarding diagnosis and treatment will also be brought out in the clinical records.

CHAPTER XXIX.

ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS.

IN giving the histories of ovarian neoplasms it has been deemed best to omit simple and typical cases, because they would add nothing to the description already given. The following complicated ones, on the other hand, will tend to convey clearer ideas of the peculiar cases which are frequently met in practice, and the approved methods of management adopted at the present time.

Monocyst of the Right Ovary; Firm Adhesions to the Abdominal Wall; Necrosis of the Posterior Wall of the Cyst; Ovariotomy; Recovery. The patient was fifty-four years old, and the mother of four children. After the birth of her last child, the attending physician told her that she had a small tumor on the right side of the uterus. There was considerable intermittent pain in the region of the neoplasm from the time that it was first discovered up to the time that she came under the care of my associate, Dr. Palmer, four years afterward. The growth of the tumor was slow, scarcely noticeable for the first three years, but very noticeable during the last year.

When she first came under the care of Dr. Palmer the tumor extended above the umbilicus, and fluctuation was well marked. There was evidence of circumscribed peritonitis, and, although the tumor was movable, adhesions were being formed. The peritonitis was quite pronounced at this time, and the constitutional symptoms were well defined. She was treated for this, and in about two weeks the acute symptoms subsided, but she still remained weak. The doctor sent her home in the hope that she would gain strength, and the tumor being still small there was no urgent necessity for its removal. In a month she returned to the hospital not improved. She was losing flesh, the parts were still tender, the appetite poor, the pulse weak, and the temperature kept above 100° F.

Another effort was made to get her into better general condition, but without success. She lost strength gradually, and it was de

At

cided that the only chance for her was by removing the tumor. this time the adhesions were firm and involved all parts of the abdominal wall which were in contact with the tumor.

Just before the operation the pulse was 120 and the temperature 101°. When the abdominal incision was made, the adhesions were very firm and vascular, except in a small space just above the symphisis pubis. The cyst was emptied by tapping, and the lower portion, which was not adherent, was drawn out, and the pedicle grasped with strong fixation forceps, and divided. The adhesions were now easily reached and separated. The pedicle was then ligated, and the bleeding stopped by pressure with sponges. By managing the pedicle in this way, the tendency to bleeding from the site of adhesions was lessened very decidedly. When all bleeding had stopped the wound was closed and dressed in the usual way.

An examination of the cyst showed a portion of its posterior wall (about the size of one's hand) perfectly bloodless, of a dirty gray color and friable, indicating that it was necrosed. No doubt the death of this portion of the sac had taken place many days before the operation, and I presume was the cause of the constitutional disturbance.

From the facts in this case and from those observed in other cases of necrosis of the cyst-wall, I believe that the dead tissue causes a form of septicemia, certainly in this case there was nothing else found to cause the high temperature and pulse, and the subsequent history confirms this view.

The operation was performed between eleven and twelve o'clock. She soon recovered from the ether, and showed no depression. At seven in the evening her condition was better than before the operation. The pulse was 112, temperature 99.5° F. and respiration 20. During the night she had slight pain in the abdomen and was given a hypodermic injection of morphine. She slept well, and had no vomiting. On the second day there was some slight distention of the abdomen from gas; this was relieved by six grains of sulphate of quinia in solution, given by the rectum.

From this time onward her progress was very satisfactory. The temperature never rose above 99° F. Five days after the operation the bowels were moved by enema. On the twelfth day she left her bed, and four days later was able to walk about the ward. About four weeks after the operation the left leg became swollen, and remained so for about a week. The cause of this was not certain.

She was discharged from the hospital at the end of the fifth

week feeling perfectly well and having gained flesh and strength surprisingly.

Ovarian Cyst between the Broad Ligaments, Multiple Cyst of the other Ovary; Ovariotomy and Hysterectomy; Recovery. This patient was under the care of my friend, Dr. F. H. Stuart, and most of the facts in the history of the case-before and after the operation-are given here as I obtained them from him.

The lady was fifty-six years of age, and had passed the menopause about six years. At the age of thirty-nine years she had a pelvic abscess which opened into the bladder, and she was then sick for a long time. About three years before the time when this history was taken she noticed a tumor in the right iliac region.

She was first seen by Dr. Stuart, April 30, 1886. He found the uterus high up behind the symphysis, attached to an elastic tumor, which was immovable, and by external examination appeared to be larger than a fetal head and extending up into the right iliac fossa. There were two other tumors of smaller size, one above and one to the left of the larger one. These appeared to be adherent to the first one, and were also rather immovable. I saw the patient the next day with the doctor, and confirmed the diagnosis of ovarian cysts. On account of the adhesions, and as the patient was not suffering any great inconvenience, we thought it best to await further developments.

She passed a very comfortable summer, but increased steadily in size, with a corresponding increasing discomfort in locomotion. About the 1st of December, 1886, she began to have frequent and painful urination, and some fever. After a few days of quiet and some quinine (as there was a decided intermittence in the irritability of the bladder), she became again quite comfortable.

Immediately before the operation the physical signs were as follows: The general outlines of the enlarged abdomen were irregular, three cysts could be mapped out, and fluctuation was distinct in each. The most dependent cyst was about the size of the uterus at the seventh month of utero-gestation, and occupied the center and lower region of the abdomen. It was not movable to any extent, and appeared to be separated from the other cysts except at the upper and right side, where it seemed to be adherent but not firmly so. The two other cysts occupied the upper and left lower regions of the abdomen, raising the diaphragm and causing the lower ribs to project slightly. These two cysts could be moved together in the abdomen, but were closely united forming one tumor. The fluctua