In reference to the time when ovariotomy should be advised, Professor Peaslee, in his Treatise upon Ovarian Tumors and Ovariotomy, laid down the following rule: "When the general health has become somewhat impaired, and not till then, the time for ovariotomy has arrived."

This precept of Dr. Peaslee, given in 1872, has since been, in the main, accepted by American writers upon ovariotomy. Drs. Thomas and Emmet, however, in their late publications, give this rule with much less emphasis than did Dr. Peaslee, and with some very important exceptions.

While this teaching has produced a very general impression among the profession at large that ovariotomy should not be undertaken until the patient's health is considerably deteriorated, yet among ovariotomists at the present time a different sentiment is fast gaining ground, many of them advising the operation while the patient is still in robust health. The wisdom of this course of action is already apparent in the rapidly increasing per cent. of success.

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Spencer Wells in the edition of his work published in 1872 gave essentially the same rule in regard to the best time for ovariotomy as that just quoted from Dr. Peaslee. But in 1882 he says: I have become more and more disposed to advise the removal of an ovarian tumor as soon as its nature and connections can be clearly ascertained and it is beginning in any way mentally or physically to do harm." Yet a glance at the last hundred cases in Mr. Wells's published table would persuade the reader that he really in practice followed the first clause of his rule rather than the second, for among this hundred there appear seventeen cases in which the tumor weighed ten pounds or less, one of them weighing only four pounds. Now it is very improbable that ovarian tumors of this size could be doing any appreciable harm, either mental or physical. It is more probable, rather, that they were removed as soon as their character could be clearly as certained.

One great argument in favor of delay is, that after the tumor has become sufficiently large to distend and press for a time upon the peritoneum, it so changes the character of that membrane as to render it less liable to a severe grade of inflammation, and that the patient, therefore, is in less danger of death from peritonitis.

Referring again to Mr. Wells's last hundred reported ovariotomies, we find that not one of the hundred died of peritonitis, though there were eleven deaths, and in seventeen cases the weight of the tumor was only ten pounds or less.

In his series of one hundred cases from January 1, 1869, to January, 1871, there were ten deaths from peritonitis. The average weight of the tumors in these fatal cases of peritoneal inflammation was twenty-two and one third pounds, while the average weight in the whole series was twenty-one and one third pounds.

Of about forty cases of ovariotomy that have come under my observation, but two died of peritonitis, and in both instances the tumors were large and had exerted considerable pressure upon the peritonæum.

So far as these histories teach anything, they show that the size of the tumor is not an important factor in determining a fatal result from peritonitis. They also indicate the recent rapid decrease in the frequency of this formidable sequel to ovariotomy, the series of fourteen years ago embracing ten deaths from this cause, while the later contains not one.

The experience of other ovariotomists in this regard, as I learn by inquiry and from their written statistics, coincides with that of Mr. Wells.

Peritonitis, therefore, has well nigh ceased to be a prominent cause of death after ovariotomy, although the operation as a rule is performed much earlier than ten years ago. There are several causes, I think, that have contributed to this favorable result. Important among them is the improved method of treating the pedicle, namely, by short ligatures and replacement within the abdominal cavity, a mode of treatment that has very generally been substituted for the clamp and long ligatures brought out at the lower angle of the wound. Another is the great care now exercised in preventing the entrance of any extraneous matter into the abdominal cavity, or if this has been unavoidable, its thorough removal, together with the great pains taken to render the condition of the peritoneum an aseptic one.

Another reason given for deferring the operation until the patient is debilitated by the disease is that thus a certain amount of comfortable life is secured to her which would have been lost in the event of a fatal issue. At a time when about one third of the whole number who submitted to the operation died this argument was a cogent one. But now, when not one in ten, excluding the delayed and tapped cases, die, and when, in the near future, not one in twenty will die from the operation, this plea for delay loses its great force.

The dangers, too, that constantly increase and always menace a patient with an ovarian cystoma, are so great as to far outweigh all the advantage that any postponement of the operation can bring.

Although adhesions of the cyst wall to surrounding structures may form at any time during the growth of an ovarian tumor, yet in the majority of cases they do not occur before the cyst has become large enough to entirely fill the abdominal cavity, and are most common in those cases where the tumor has reached an age of two or more years. They are, therefore, complications that an early operation would generally avoid. While adhesions, however extensive they may be or however closely they may attach the cyst to the abdominal parietes, omentum, intestines, or brim of the pelvis, are not a contra-indication to ovariotomy, still they convert an operation that in itself is really a very simple one to one of great difficulty and hazard. I have seen three cases in which an attempted ovariotomy could not be completed on account of immediate adhesions to important viscera. In two of the three the disease had existed about three years, without much impairment of health, and without giving very great inconvenience. For this reason, in accordance with the rule we are discussing, they were advised to defer an operation until some more urgent necessity for it arose. consequence was that they each, for three years, carried about with them an ugly, mortifying deformity, and then died of an affection of which they might have been cured three years before.

The

In passing from this well-worn topic of adhesions to the discussion of degenerative changes that take place, the following case is presented as an illustration of the former, and especially as an example of the insidious general poisoning that may follow degenerations of even the interior structure of an ovarian cystoma:

Miss C. N., Rockville, Conn., aged nineteen; operation September 19, 1879. The tumor was noticed one year before. Her general health had apparently been

unimpaired until three months ago, when she began to lose flesh and strength. Latterly her failure in health had been rapid. September 18th we found her with a pulse 110, a rapid respiration, and a hectic flush upon each cheek. No abnormality of the patient's lungs could be found, and her attending physician, Dr. Kisley, as well as myself, was at a loss to account for her condition of hectic. All was explained, however, when the contents of the tumor were withdrawn. The liquid had the physical appearance of pus of considerable consistency, and in amount was about nine quarts. The tumor had evidently been a multilocular cyst whose division walls had become degenerated and broken down. Hence the blood-poisoning that would undoubtedly have ended the patient's life very soon had not removal been effected. The cyst was adherent to the parietal walls anteriorly and at each side. The pelvic and intestinal adhesions were also extensive. Many of them were firm fibrous bands, with blood-vessels of considerable size, while in several places the cyst was agglutinated to the intestinal surface. The separation of these adhesions was attended with many difficulties and occupied two and one half hours. The patient finally recovered after a very tedious convalescence, and is now in good health. Tracing the natural history of an ovarian tumor through its entire course, it will be found to have caused death in one of two ways: either by its size interfering with the normal functions of the abdominal and thoracic organs or by degenerative changes that have occurred in its structure. But cases of the former class are rare, and especially so, because the great size is usually relieved by tapping when the tumor becomes oppressively large. Such a tumor that would have become fatal at last on account of its size alone now becomes so, if it has been tapped, by reason of degenerative change. Practically, therefore, an ovarian cystoma, subjected to no surgical interference except tapping, produces death by structural degeneration of its tissues.

These parasitic growths, as Mr. Wells terms them, differ in their histological character from the normal tissues in which they take their origin, and the deviation becomes more and more marked as their development progresses. Like most other adventitious growths, their vitality is feeble and their tenure of life, as a rule, is short.

In any given case we cannot predict when this process of degeneration will begin, and oftentimes when it has advanced very far towards the decay and death of some tissue of the cystoma it gives no sign by which it can be recognized, and we then have a dead tissue in the living body, diffusing a subtle and deadly poison through the whole organism. In many instances the progress of this septicemia towards a fatal result is rapid, in others slow, as in the case just described.

Again, our first warning of cystic degeneration may come from some accident; a not uncommon one being rupture of the cyst walls, and the escape of its contents into the abdominal cavity, producing a very fatal form of peritonitis.

The following case is an illustration of an accident more rare than cyst rupture, and due to degenerative change affecting the pedicle:

Mrs. S., Lowell, age forty-five; operation June 19, 1881. She had always been in good health until October, 1880, when after a cessation of the menses for three months she noticed an enlargement of the ab

domen. The patient regarded herself as pregnant, in which opinion she was confirmed by medical advice until June 12th, when a careful examination revealed unmistakably the presence of an ovarian tumor. It was at this time that the operation should have been performed, yet as her general health was seemingly unimpaired, the removal of the tumor was delayed. Two days after Mrs. S. had a severe attack of pain localized in the right lumbar region.

The pain speedily subsided, but similar attacks followed at intervals of a day or two, and when they occurred the patient became pale and the extremities cold. Meanwhile the tumor very sensibly increased in size, and at the same time the patient's strength rapidly failed. The tumor was removed one week from the time of the first examination. When the cyst was tapped with a "Wells' trocar," a large quantity of clotted blood passed through the tube. Very soon when the withdrawal of liquid had removed all tension from the cyst walls, and as I was drawing the sac out through the incision, there appeared a stream of fresh blood through the tube. The clamp was at once applied to the pedicle and further hæmorrhage stopped. Its application required only a few seconds, still a large quantity of blood must have been lost.

The cause of the attacks of pain and the accompanying pallor, with coldness of the hands and feet, was now apparent. The internal portion of the pedicle had become broken down by degenerative changes, and one or more of the large blood-vessels had been opened, thus pouring blood into the sac from time to time as much as the distensibility of its walls would allow. It was from this cause that the tumor had increased so rapidly in size and the final great hæmorrhage, added to those preceding, had so exsanguinated the patient as to prove fatal just as the operation was being completed.

In June, 1881, at the request of her attending physician, I saw Mrs. of Milford, Mass. She had an ovarian cystoma of recent development that extended two or three inches above the umbilicus, but not distending markedly the abdominal walls. Her general health had, seemingly, been unaffected by the growth of the tumor. Therefore, in deference to the generally accepted rule of practice that ovariotomy should not be resorted to while the patient is in vigorous health, the removal of the tumor was deferred. Some three months after the sac ruptured, and Mrs.

died in seventy-two hours of peritonitis. All the perils of ruptured cysts, bleeding pedicles, and septicemias from broken-down and dying tissues of the tumor can be averted by an early operation.

And does not the avoidance of all these dangers far exceed in the welfare of the patient every possible advantage, if there be any, that can come to her by delay? In short, is not an early interference, while the tumor is both small and recent, the wisest and most prudent course?

Mr. Lawson Tait, in his work upon Diseases of the Ovaries, presents a very strong argument in favor of the early removal of ovarian tumors, based upon their pathological character and manifest malignant tendency. After describing the great variety of epithelial cells found in cyst cavities, their mode of development, and their varied departures from the normal epithelial cell, he concludes that most ovarian tumors have, at least, an element of malignancy, and that their prompt 1 Page 144 et seq.

Keports of Societies.

COLLECTION OF THREE GALL-STONES

passed by a lady, fifty-five years of age, at intervals of a

E. M. BUCKINGHAM, M. D., SECRETARY.

timetres in its broadest diameter; the largest, one and four tenths. Each attack lasted about two hours, the

ROUND-CELLED SARCOMA OF THE MEATUS AUDI

TORIUS.

DR. J. ORNE GREEN exhibited a photograph from a patient twenty-three years old with the following history There had been otorrhoea since scarlet fever six years before, and when first seen by Dr. Green the meatus was filled with a growth like a polypus, fungous granulations covered the seat of an abscess which had burst over the mastoid, which as well as the petrous bone proved to be carious, and the patient was weak. After four or five days of supporting treatment there were a chill and fever. In consequence, he was etherized, au incision made into the bone, freeing grumous pus, and a drainage tube inserted, the growth being also removed. The septic symptoms now disappeared, but the progress of the growth was rapid, nodules appearing below and in front of the ear. Later, brain symptoms developed with oedema of the eyelid and cheek, and lastly coma that existed for three weeks previous to death, which occurred six months after first coming under observation. No autopsy was allowed, but the piece removed at the beginning was examined by Dr. Gannett and found to be round-celled sarcoma.

PECULIAR CASE OF VALVULAR DISEASE OF THE HEART.

DR. W. P. BOLLES presented the specimen, the history of which had been one of valvular disease with enlargement, dyspnoea, jaundice, and death. The cardiac sounds were those of mitral insufficiency, a loud and distinct murmur accompanying the systole, while there was no direct murmur. Ou autopsy, however, there was found to be not only insufficiency, but also a high degree of stenosis, only the tip of the finger being admitted. A large old ante-mortem clot was worn smooth toward the centre of the auricle, and was adherent at all other places. Remains of emboli existed in the lungs and a suppurating cavity in the right lung corresponded with a history of pneumonia ten weeks before. It was interesting that the patient had never had rheumatism, and that while there were no cardiac symptoms until within one or two years, yet that she had been told, thirty years ago, by the late Dr. Reynolds, Sr., that she had a very bad heart.

DR. F. C. SHATTUCK remarked that this case is an illustration of the fact recognized by all recent writers on heart disease, that valvular disease and especially mitral stenosis - may be unattended by murmur. The presystolic murmur, when present, is very characteristic, but it is not infrequently absent and sometimes comes and goes. In the advanced stages of cardiac failure the auricular contractions are often so feeble that they cannot throw the valve into vibrations sufficiently forcible to give rise to any audible murmur.

DR. H. I. BOWDITCH thought that such histories should make us chary of needlessly giving a diagnosis and thus causing useless alarm.

DR. FRANCIS MINOT remarked that possibly the knowledge may have prolonged her life. DR. O. W. DOE showed a

region, and was followed by jaundice, which disappeared in from two to three days. The patient had been leading an unusually sedentary life for two years past.

The treatment was by ether, morphia subcutaneously, and hot applications to the epigastric and hypochondriac regions.

DR. CHARLES W. WILLIAMS reported a

CASE OF FOREIGN BODY IN ORBIT.

T. W., seven years old, while playing with some boys was hit over the left eye with a stick. There was a cut through the skin about one quarter of an inch long; it was a little to the inner side of the eye, and a quarter of an inch below the eyebrow. The nurse reported that it bled freely, but nothing more than water dressings were applied, as it was supposed to be only a black eye. When seen, five days after the accident, the eye was closed, the upper lid swelled even with the eyebrow. The cut in the skin was still open, and discharging a small amount of pus. A probe could be passed backward about half an inch, but no foreign body could be detected with certainty. There was neither redness nor extravasation of blood under the ocular or palpebral conjunctiva, and the vision was nearly normal, o, and corresponded with that in the other eye. Poultices were applied for two days. On a second examination with a probe a suspicion of grittiness was detected. The child was etherized, and first some small splinters of wood, then a roundish piece, about half an inch long by quarter of an inch thick, was removed from the bottom of a pocket, extending about half an inch directly backward from the cut to a point between the orbital roof and the sclera, and just to the inner side of the superior rectus muscle. On questioning the boys more carefully it seemed that the stick which hit the eye had been used as a trellis for plants, and the sharp end which was buried in the ground had penetrated the lid. This partly decayed wood, absorbing the blood and moisture from the orbital tissue, had become so soft that a probe failed to detect its presence with certainty until it grated against a bit of sand which was attached to the wood. After the removal of the wood the wound was poulticed for two days; the discharge had then ceased, and the swelling of the lid was nearly gone; vision as before,. At no time did the child complain of any pain in or about the eye. He ate and slept well, and enjoyed his play. DR. H. L. BURRELL showed a

TUMOR OF THE UTERUS.

The patient was fifty-nine years old, and had not menstruated for twelve years. Four years after the cessation a small lump appeared in the right inguinal region. In a year there were three or four smart uterine hæmorrhages. There was dyspnoea, probably from bronchitis, but no pain. Dr. Burrell had made an exploratory incision after death to see if an operation would have been feasible, and found that it must have been very difficult. A cyst on the right side was bound to the right iliac vessels. Both the round ligaments were very tense, and held the uterus fixed as if bound to the rectum or spine. There proved to be no