ABDOMINAL SECTION IN DISEASE OF THE UTERUS, OR OF THE UTERINE APPENDAGES. BY LAWSON TAIT, F.R.C.S., SURGEON TO THE BIRMINGHAM AND MIDLAND HOSPITAL FOR WOMEN, BIRMINGHAM, ENGLAND. FROM THE MEDICAL NEWS, September 27, 1884. THE OCTOBER ISSUE OF The American Journal of the Medical Sciences, Will contain the following original papers. I. Cholecystrtomy; with a Report of Two New Cases, nncl a Table of all the hitherto reported Cases, and Remarks. By J. H. Musser, M.D., and W. W. Keen, M.D., of Philadelphia. II. Some Observations on the Bacillus of Tuberculosis. By Harold C. Ernst, A.M , M.D., of Jamaica Plain, Mass. III. A Case of Subscapular Abscess, with Remarks. By Albert N. Blodgett, M.D., of Boston. IV. Dermatitis Herpetiformis: Its Relation to so-called Impetigo Herpetiformis. By Eouis A. Duhring, M.D., of Philadelphia. V. Mumps as a Cause of Sudden Deafness. By Leartus Connor, A.M., M.D., of Detroit. VI. Digitalis: Its Physiological Action. By Samuel Nickles, M.D., of Cincinnati. VII Colotomy, with a Collection of 351 Cases. By Wilmer Rtdg- way Balt, M.D.,of Phcenixville, Pa. VIII. Report of a Case of Bilateral Dislocation of the Sixth Cervical Vertebra from the Seventh, without Fracture of the Body of the Vertebra. By J Wiest, M.D., of York, Pa. IX. Prevention of Ophthalmia Neonatorum By Henry J. Garrigues, A.M., M.D., of New York. X. A Case of Resection of the Pylorus for Carcinoma. By Randolph Winslow, M.A , M D., of Baltimore. XI. A Contribution to the Clinical Study of Rotheln or German Measles. By W. A. Edwards, M D., of Philadelphia. XII. On Calculus Impacted in the Ureter, and the feasibility of Re- moving it by Surgical Operation. By Henry Morris, A.M , ERA S. XIII. Modern Antiseptic Surgery, with Cases. By F. C. fuller, A M., • of New York City. XIV. The Occurrence of the Ascaris Mystax (Rudolphi) in the Human Body, with a Case. By Howard A. Kelly, M:D., of Philadelphia. XV. A Case of Glioma Retinae. By John L. Dickey, AM., M.D., of Wheeling, W. Va XVI A Case of Imperforate Rectum in which Lumbar Colctomy was Performed. By John II. Packard, M.D., of Philadelphia. For Subscription Price, see third page of cover. HENRY C. LEA'S SON CO., PHILADELPHIA. ABDOMINAL SECTION IN DISEASE OE THE UTERUS, OR OF THE UTERINE APPENDAGES. BY LAWSON T A I T, F.R.C.S., SURGEON TO THE BIRMINGHAM AND MIDLAND HOSPITAL FOR WOMEN, BIRMINGHAM, ENGLAND, A LECTURE DELIVERED, BY INVITATION, AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL, SEPTEMBER 1$, 1884. PHILADELPHIA: HENRY C. LEA’S SON & CO., 1884- WM. J. IJUKNAN, PiUNTfcK, 628-634 Filbert St. ABDOMINAL SECTION IN DISEASE OF THE UTERUS, OR OF THE UTERINE APPENDAGES. Gentlemen : I really do not know what Dr. Parvin has brought me here for, unless it be that there is a ten- dency in your country, to a much greater extent than in my own, to overwhelm your visitors with kindness of every description. I have been constantly told since my arrival in this country, that I have come to the country of big things. I certainly believe that I am now in the city of biggest things in the country of big things. I have to-day seen the biggest store, and have eaten the biggest oyster that I have ever seen. I am told that this is the biggest medical amphitheatre in the world, and it certainly is larger than any in England. Now I am asked to do the biggest thing of all, to talk about patients whom I never saw until this afternoon and then only for a few minutes. This is a very big thing, and I am afraid that I shall fail in the attempt. If I should make mistakes in diagnosis, please understand that it is because I have caught the American disease of hurrying through every- thing at a rate which none but an American can keep up. You very well know, I am sure, that one of the most 4 obscure things that a man can attempt in the shape of diagnosis, is the diagnosis of disease inside of the belly. An illustration which I frequently use with my patients is this. I say to them : “ This is a table. There is a cover on it. I can tell you that it is a table, but until the cover is removed, I cannot say of what kind of wood the table is made.” The man who ventures on accurate diagnosis in abdominal disease is just the man to get into trouble. There is no region of the body where diagnosis requires more caution than in that of the abdomen. One reason of this is that any mistake will almost certainly be discovered. As a distinguished American surgeon said to me a short time ago, we are not so well off as the physician. He hammers on the chest, finds certain abnormal sounds and says that such a condition is present. He may be mistaken, but the patient probably moves away and the error in diag- nosis is never discovered, but in abdominal surgery, the surgeon after giving his opinion usually at once pro- ceeds to the operation, and any mistake is almost certain to be discovered. A series of patients are coming in, and my friend, Dr. Parvin, has asked me to make some remarks on them. OVARIAN TUMOR. Here is a patient who, as far as I can see, is the victim of a disease which is very common with us, and I suppose as common with you. At first sight, it looks like an ovarian tumor. The first thing which attracts my attention is a scar from a puncture, and here I see the remains of another puncture of an older date. I next notice the uniform shape of this abdomen. There is a symmetrical uniformity about this abdomen which is suspicious. When you see a perfectly uniform en- 5 largement of the abdomen, begin by suspecting that it is not due to an ovarian tumor. The chances in such a case are greatly in favor of one of three things. In the first place, pregnancy, which you must always eliminate ; in the second place, a small tumor with malignant growth and ascitic effusion, which is the most likely of the three; and, in the third place, the presence of a parovarian tumor. I next place my hand on the tumor,—and here let me give a caution. When you are dealing with abdominal disease either for the purpose of diagnosis or treatment, you cannot be too gentle in your manipulations. If at all rough in your manipulations, the first thing you do is to frighten the patient and obscure the diagnosis. The abdominal muscles will be contracted, and you will not be able to learn a great many things which it is de- sirable that you should learn. If in treating abdominal disease you handle the parts roughly, you run a risk of doing harm. I touch the abdomen gently, and I have already learned a good many things. I learn, in the first place, that this certainly is not pregnancy, although I knew that before. I learn, in the second place, that it is not a parovarian tumor. I learn, in the third place, that it is probably a small tumor with a large amount of ascitic effusion. I feel in the lower part of the abdomen a semi-solid mass, and above this a mass which is not solid. Our business is to determine what relation the mass not solid bears to the mass which is solid. Above, we obtain on percussion the resonance of the intestine. There is a matter here which obscures the diagnosis. That is the fact that she has been tapped. I get an intestinal note above, and there is evident fluctuation, but from these two factors I cannot positively determine which one of two conditions is present, and it is a rather important thing to know which we have before giving advice. 6 The two conditions to which I refer are the following : This may be a large cyst which has been emptied by tapping, or it may be merely ascitic fluid. If it is a large cyst which has been partially emptied, or which, having been emptied, has become partially refilled, it is a case of multicystic cystoma, which can be dealt with in a satisfactory manner. In the second place, it may be a small cyst covered with a large effusion of ascitic fluid. If this be the case, it will be necessary to engage in the discussion of a number of points before making up our mind. I have looked at the patient’s face but I find nothing there to guide me. I have examined the pelvis, but I find there nothing but negative indications. The uterus is small and tolerably free. On the left side there is a small tumor which may be one of two things, either the left ovary in a state of incipient enlargement, or a small mass of papilloma. This maybe a single ovarian tumor and the condition here may be the result of malignant proliferation on the outside of the tumor, or on the parietal peritoneum, or the peritoneal coat of the viscera. It is important to know which of these two is the more likely. With a half-full abdomen like this, one cannot pretend to give an opinion. The fluid has been removed and reaccumulation is taking place. Although it is impossible to give a positive opinion, I have a suspicion that the fluid which was removed was not removed from a cyst. There is a small tumor in the lower part of the abdomen, and I think that the fluid which was removed was ascitic and that there is here a condition of papilloma. Suppose it is impossible to come to an exact conclu- sion, what ought to be done? Open the abdomen in either case; for, unless you are absolutely certain that the disease is incurable, it is, in my judgment, a surgical crime to allow a patient to go to the grave with an ab- 7 dominal tumor, without an effort being made to save her. This should be done even when papilloma, which is a most unfavorable condition, is suspected. (The patient was now removed.) For reasons which are obvious, it is better to speak in the absence of the patient. I do not know who is re- sponsible for the tapping in this case, and it does not much matter, for the practice of tapping is still largely carried out in my own country, and I presume the same is the case in this country. Therefore I never very much blame a man for tapping in these cases. My opinion, which coincides with that of most operators, is that a woman with abdominal disSase, unless the affection is clearly malignant, should not be tapped. This rule should be adopted for many reasons, to some of which I shall refer. In the first place, speaking from my own experience in the removal of ovarian tumors, I can say this: that for a number of years (five or six) I have not lost a case of ovariotomy which had not previously been tapped. It is perfectly certain that tapping in- creases the risks of ovariotomy to a much larger extent than anything else. There is no kind of adhesion, there is no kind of complication, there is no kind or size of pedicle, which makes any difference. The worst cases recover as well as the simplest, provided they have not been tapped. I cannot tell why this is, although I sus- pect that there is a chemical reason for it. The chemi- cal analysis of the contents of ovarian tumors has been abundantly discussed, but as yet no satisfactory results have been obtained; but it has been found that the materials removed from the interior of ovarian cystomata are extremely rich in some mysterious forms of albumen. I have carefully examined the fluid contents of these tumors by various elaborate methods, and I am of the opinion that the albuminous elements of no two ovarian tumors are exactly alike. If this peculiar albuminoid 8 substance is removed to a large extent, the blood is de- prived of something which renders the other ingredients more coagulable. The patients who have died after ovariotomy, and who have been previously tapped, have died from the formation of a clot starting in the pedicle and reaching to the cavities of the heart. In this fact we have one indication that tapping should not be per- formed except under exceptionable circumstances. The certainty with which ovarian tumors come under notice at an early stage, and the ease with which the diagnosis is usually made, render it important that the rule that tapping should not be performed should be recognized. It is the duty of every practitioner of medicine, when he sees a case which he suspects to be one of ovarian tumor, either at once to proceed to its removal, or at once to place the patient under the care of some one who will do justice to the patient and to the art of surgery which he represents. I say that as soon as an ovarian tumor is recognized, you should refrain altogether from tapping, and immediately remove the tumor. The patient whom we have had before us has been tapped. I do not know whether the fluid removed was ascitic or from a large cyst. My suspicion is, as I have already said, that the fluid was ascitic. Among other things which lead to this opinion is the position of the punctures, which is above the point at which tapping of an ovarian tumor usually takes place. The surgeon who tapped this woman no doubt felt this solid mass at the bottom of the abdomen, and probably felt more certain of obtaining fluid at the points where the punct- ures were made than lower down. This is presuming that you elect to tap at the same point that we do, i. e., midway between the umbilicus and the pubes. At this point some critics might ask “ What do you make of those cases in which tapping was done over and over under the old practice, and sometimes under 9 the new, for some patients will not submit to the radical operation ?” In regard to the latter point, there is no difficulty with that now. During the last five or six years I have not had a patient come to me with an ovarian tumor, who has refused to have it removed. I can assure her that the chances are 98 out of 100 that she will get well, no matter what the age, no matter what the appearance of the tumor, and no matter what complication may be present, provided it is not malig- nant disease and that there has been no previous tapping. What became of those cases which were tapped so often ? Recently I discovered on a tombstone in the south of Eng- land, an inscription stating that the person buried there had been tapped for ovarian dropsy forty-seven times. That is the largest number of tappings that I know of, and of course, being on a tombstone, the statement is certainly true. My answer to the question proposed is that these were not cases of ovarian tumor. They were tumors of the parovarium. The facts concerning these apparent exceptions, are really in favor of the view which I have expressed in regard to the tapping of ovarian tumors. The contents of pariovarian tumors contain little or no albumen. These cysts are generally filled with a limpid fluid consisting of simple water with a few salts. Sixty or seventy per cent, of the paro- varian tumors which I have examined have contained no albumen. If you get hold of a large cyst secreting a non-albuminous fluid, and remove that fluid repeatedly, the removal of the fluid will not drain the system much, for it is an easy matter to replace water with a small proportion of salts. This apparent exception therefore proves to be an argument in favor of the view which the writings of Dr. Bantock and myself have been largely instrumental in bringing before the profession that tapping is not to be allowed. Suppose you get an ovarian tumor, when should it JO be removed ? The arguments are all in favor of early operation. The patient is not distressed with the suffer- ing entailed by carrying around a large mass; she is not subjected to the likelihood of the development of the condition of papilloma which we suspect in this case ; she is not subjected to the anxiety and worry, especially if unmarried, which her appearance will always cause, and the incision will be shorter than when the abdomen is large. The mortality of early operations is almost nil. If the tumor is removed be- fore adhesions form or other complications occur, I be- lieve that the mortality would be absolutely nil. My own experience leads me to believe that if the practice were uniform all over the world of removing ovarian tumors as soon as discovered, the mortality would not be one per cent. This is a matter on which, even in England, there is a good deal of difference of opinion. When you find an opinion expressed adverse to the one which I have just stated, you will find that it is ex- pressed by one whose hair is white. I do not mean by this to say that young men are always right, or to im- ply that old men are often wrong. We have a saying in England that “ young men think old men to be fools, but old men know that young men are fools,” but a qualification of this exists in the fact that the world moves on, and as one generation succeeds another, the wisdom of those who have gone before is added to by those who are now at work. I shall not now enter into the various steps of the operation, and indeed without a display of the pro- cedure it would be almost a waste of time to do so. Suppose that we were certain that this patient was suffering from papilloma, that the disease of which we are so much afraid was developing around the tumor; even if I were certain that such was the case, and I were responsible for the treatment of this patient, I 11 should proceed to the removal of the tumor. The reason for that is a very curious one, and one which I cannot pretend to explain, but of the facts of which I am quite certain. I cannot say, without referring to my case-books, how many ovarian tumors I have removed, but in a considerable percentage both of parovarian and ovarian tumors, and also of cases of myoma, and also in cases where there has been no tumor at all, I have opened the abdomen, sometimes knowing what I should find and at other times not knowing, and I have found this curious velvety, warty condition of the peri- toneum. One of the most extraordinary cases which I have ever met with, was one sent to me by Mr. Oliver Pemberton, of Birmingham, whose name is probably familiar to many of you. In this case there was great enlargement of the abdomen, supposed by several who had examined her to be a parovarian tumor. As soon as I placed my hands upon the abdomen, I was certain that there was no tumor, but simply an enormous effu- sion of ascitic fluid. In such cases as this I never tap, I always make an opening in the abdominal wall large enough to admit the introduction of two fingers, and thus obtain an intelligent idea of the condition of the abdomen, which cannot be obtained by gazing at the fluid falling from the end of a canula. There is no more danger in this than in tapping. So far as my own practice is concerned, tapping is absolutely discarded. In the case to which I have referred, I made the ab- dominal opening, and slipped in two fingers, and at once found that I had to deal with universal papilloma of the peritoneum. I inserted a drainage-tube, and allowed it to remain two or three weeks, and completely cured the patient. She is now in robust health some four years after the operation. In another case, in a woman fifty-seven years of age, I removed a large ovarian tumor. Large masses of papilloma were also found. Two of these, each being larger than the fist, could not be removed, and after the operation could be distinctly felt through the abdominal wall. She is now sixty-five years old, in good health, and the tumors have disappeared. It is certain that there are two kinds of papilloma, one of which is malignant, and which will kill the pa- tient in a few weeks or months, and another kind which is not malignant, and which can be cured by removing the tumor or by opening and draining the cavity. I have submitted pieces of papilloma,, some of which were obtained from cases which had been cured, while others had come from cases rapidly fatal, to the most experienced microscopists, and they have been unable to detect any difference between the two varieties. This curious condition, presenting as it does such ex- tremely different features, so far as results are con- cerned, offers a very favorable field for careful research by pathologists. In this case, even if I knew positively that there was present an ovarian tumor complicated with ascitic fluid and large papilloma, I should still urge that if it is possible to remove the tumor, it should be done, for there is a chance that the patient will be cured. I just now used the expression “ if it is possible to re- move the tumor,” and that reminds me that I want to speak of one other matter in this connection. When you make an exploratory incision, you must carefully consider what you are going to do. You must prospect (I believe that is the word you use in this country) very carefully. You must not begin the operation for the re- moval of an abdominal tumor unless you are going to finish it. The most deadly things are operations which are half done. If a part of the mass is removed, and it is then found impossible to complete the operation, the chances are seventy out of a hundred that the pa- 12 J3 tient will die. After I start an operation, I finish it, if it is in the power of a human being to do so ; and this, I believe, is the point where experience tells in this special kind of work. Do not begin unless you are confident that you can complete the operation. If you have the courage of your convictions, and the experi- ence necessary to do a difficult piece of work, go ahead and finish it. The chances of recovery will be infinitely greater than if you leave the thing half done. REMOVAL OF THE UTERINE APPENDAGES. The next case is one which would involve a great deal of talking, and one of which I cannot speak anything like exactly, for that would involve an intimate knowl- edge of the past history of the patient. For the purposes of instruction, however, I may assume what is doubtless the fact, that in this girl the sufferings are real and in- tense, and that everything short of surgical interference has been employed. I might with advantage talk of a case which I treated in the State of New York, in which the condition was to some extent similar to that of the present case, and in which the history was more com- pletely known. For that matter, a supposititious case might be discussed, for it would be easy to introduce into it those questions which are worthy of notice. This is all the more advisable because we have the tracks very well cleared in abdominal surgery on almost all points which are under discussion with the exception of one. The patient who has just been admitted to me comes under that category. She is twenty-one years of age and has a pronounced crop of acne all over her face. When a woman enters my consulting-room, and I see acne, I always ask if she has been taking bromide of potassium. This is the T4 fashionable drug for every conceivable uterine ailment, and yet I have never heard of any one who was willing to swear that he had ever cured anything with bromide of potassium which was worth curing. Still it is the one pump-handle which we have, and we work it pretty hard. When a woman comes to me with a yellowish- purplish face, covered with acne, I always ask if she has been taking bromide, and as a rule she says that she has taken large quantities of it; and, looking over her prescriptions, I find that she has been taking bromide of potassium, bromide of sodium, bromide of ammonium, and the last one I have heard of is bromide of nickel. These women wander from one physician to another. She, after a time, falls into the hands of one who puts in a pessary—for what, goodness knows. I saw a lady not many years ago from whom I removed both Fallo- pian tubes filled with pus, which had been there clearly from a miscarriage which she had had many years previ- ously. Among other ways, she had been treated largely with pessaries. She had a large tray filled with pessa- ries, which she kept as a sort of curiosity. She had each pessary labelled; and she would pick up one and say, “ This was given to me by Dr. A. It hurt me a good deal, but I bore it for some months.” Taking up another, “ This I got from Dr. B. It hurt me so much that I could not wear it long.” Taking up a third, “Well, I believe that this one must have been invented by the devil himself. I could not wear it at all.” These patients wander about from one specialist to another, getting from each one his pet pessary. Finally they go to a surgeon, who dilates the cervix with some con- trivance, or he will divide the cervix in one way or another without giving any benefit. Then, after going for a long time from one doctor to another, she at last goes to a surgeon who has a reputation for performing operations. I do not mean to say that all these women *5 who wander from one consulting-room or one hospital to another should be submitted to operation. I have never said this and never carried it out in my practice. What I do say is this, there are a large number of these patients which can be cured only by a surgical opera- tion. Because at the outset of this new kind of work some mistakes are made, we are not therefore to close the doors against suffering women. Given the history of a woman who has wandered about as I have described in a somewhat exaggerated form,but nonetheless true, who has been subjected to every conceivable method of treatment, and she comes to you, and you are persuaded that her sufferings are real and not imaginary, you are justified, in my opinion, in making a small incision in the front of the abdomen to examine the belly, and to pass the fingers down into the pelvis to see if there is anything wrong there. The first question is clearly, How do you recognize the fact that the patient’s sufferings are real ? I cannot answer that question. All that I can say is, that never in my experience have I had a woman submit to the operation without finding sufficient cause to justify it. Of course, I, as all ought to do, place my statement and views, with what I propose to do and the results of the operation, immediate and prospective, clearly before the patient, and, as I say I have never known a woman to submit herself to the operation without finding suffi- cient cause to justify its being done. You say that this puts the responsibility on the patient. Well, that is what we do in every case. The patient cannot be re- lieved of all responsibility. A man comes to you with a diseased knee-joint. You lay before him the advantages and disadvantages of excision and of amputation, and then you ask him, “ Will you have your limb amputated, or will you run the risks of excision?” There are few cases in which we can relieve the patient of all responsi- 16 bility, and in these doubtful cases the patient must take a large share of the responsibility. In these cases, I always say : “ Let us have a complete consultation with any one, or any number of your previous attendants. I will not take the responsibility of this operation with- out consultation with some one who is as responsible as I am.” Having placed the matter thus before the patient, she must take her share of the responsibility. It is perfectly impossible to imagine that in these cases there is any ground for the criticism which has been made, that women are haviftg their uterine ap- pendages removed for improper purposes. It would be impossible for this to be done without the matter being discovered. The proposal to remove the uterine appendages in order to prevent pregnancy has been made to me by women, but surely we have some kind of conscience. I do not suppose that because I have obtained a position of some eminence in this kind of work that I have been robbed of the conscience which I once possessed. When I say an operation is to be performed, it is done in a sort of semi-public manner. So far as I know, in English surgery, this charge has never been substantiated—indeed, it is never publicly made, it is only hinted at behind our backs. Again, we are told that these operations are some- times done for another kind of immoral purpose, i.e., for the purpose of obtaining the fee which comes at the end of the proceeding. Well, this is rather a dangerous argument to use, because, if it were used against myself, I should at once publish a list of the men who had given bromides, used pessaries, and divided the cervix and ask how about their treatment in regard to the matter of fees. I do not know that they would come off as well as I should. To return to our patient. This girl is twenty-one years of age; she has to make her own living, and this 17 is a very important matter, indeed. If a woman comes to you whose husband has a large income, or whose friends are wealthy, the case presents altogether a dif- ferent aspect. To the rich, luxury always contributes largely to the relief of pain. If a woman, whose hus- band has ten thousand a year, has a chronic inflamma- tion of the ovaries, she will suffer far less than a woman who has to make her living and has the same disease. If a woman comes stating that for one week out of every four she is unable to work, you are bound to perform an operation for her relief. This girl has gone through a long course of treatment. She suffers at her periods, but at other times is tolerably well. The indications for treatment are clear. If a woman tells you that there is one week out of every four that she cannot work, it is clear that the arrest of menstruation will afford relief. As far as I can judge from the history of this patient, the operation which has been suggested is justifiable. You perform the operation, and what do you find ? I have always found disease of the uterus or uterine appendages of some kind. These diseases are far more numerous than many imagine, and it would take a long series of lectures to discuss them thoroughly. On the left side, in this girl, there is a feeling as though there was a mass. I think that, in all probability, it would be found that the ovaries, like the uterus, are infantile in size and probably adherent. Suppose, however, that the ap- pendages turn out to be absolutely healthy: I should still say that the operation was capable of being justified by the history of the case. Now as regards the consequences of this operation ; and these are the immediate, that is to say the risks of the operation, and the future consequences which the operation will involve. Of the immediate risk of the operation, I need not now speak. The future aspects of her life demand a little more attention. In the early 18 days of vaccination, I think about the year 1792, a dean of St. Paul’s preached a sermon against vaccination, arguing that vaccination was a terrible thing, because it tended to induce the growth of horns upon the head and cloven hoofs. We have been told that the removal of the uterine appendages induces certain changes, bringing on a masculine appearance, and other changes which are entirely theoretical. This mistake arises from applying to these cases the facts as to the results of emasculation of males and females before the age of puberty. It is perfectly well known from the prac- tice in eastern countries, where the sexual organs are removed before the age of puberty, that such operations do result in the retention in the individual of the youthful conditions. The eunuch on whom the operation is per- formed before the age of puberty, retains his youthful appearance through life. Of course, this is easily under- stood, but it is entirely different when the operation is performed after the changes of puberty have taken place. Having performed the operation on a large number of women, I have never seen any alteration at all except that involved in improvement of health. When a woman is worn down with pain, loss of blood, and drugs, and you stop that drain, there is immediately noticed an alteration in the appearance for the better. Such statements as are found in the first edition of Sir Spencer Wells’s work, and the still more exaggerated statements contained in the second edition of his work, are entirely without foundation. What are the results? In the great majority of cases there is an immediate relief from suffering and loss of blood. In some cases the relief does not come imme- diately ; but after a time, in a few cases, relief may not come at all; but this is no argument against the opera- tion, any more than it is against many other operations. Take the operation of cataract. This is not always a 19 success. It is probable that in about ten per cent, of all operations for cataract, suppuration of the globe takes place, and the result may rank as a mortality. In other cases escape of the vitreous or some damage to another structure will result in such chronic inflammatory change as to leave the consequential results of the operation so bad that it may be classed as a complete failure. There is no realm of surgery out of which I could not pick abundant illustrations to show that in no other branch is success any greater, if as great, as in that of which I have spoken. Immediately after the operation the pa- tient suffers from the climacteric; but this is inevitable in the life-history of every woman who lives to the age of fifty-two. I do not think that these women, who go through these troubles early in life, suffer any more, or even as much, as those in whom it comes at the natural time. Some do not suffer much, while others suffer a great deal. So far we have not had any trouble, except from one thing, and this is a distressing one. It occurs after all sorts of abdominal operations, after exploratory incisions, after the removal of one ovary for cystoma, after the removal of both ovaries for cystoma, and after hysterec- tomy. I refer to the occurrence of acute melancholia. All the cases of mental alienation that I have seen fol- lowing these operations are seven in number, and all have taken the direction of this most unfavorable form of insanity—acute melancholia. I cannot say that any one of them is likely to recover. I do not know that this is a necessary result in a certain number of cases. I have performed abdominal section some 960 times, and in this number I have met with 7 cases of acute melancholia. Of course, a good many of these cases died, especially in the earlier years of my practice. We may state that acute melancholia occurs in about one per cent, of those submitted to abdominal section. I 20 do not know that anything like this follows other surgi- cal operations. This is the only after-result of an objec- tionable character with which I am acquainted. MYOMA OF THE UTERUS. The next subject which Dr. Parvin has submitted for consideration is that of myoma of the uterus. There are two patients outside, but I do not think that it is necessary to bring them in, for you cannot see anything, and you cannot feel anything. I have examined the patients in the waiting-room. One woman is forty-eight years of age, and does not suffer much from hemorrhage or very much in any way. The tumor is hard, shrivelled, and solid, and thus it is placed in the category of cases in which nature has cured the disease. In all probability, nature will not remove the tumor, but nature has so relieved the symp- toms and so diminished the size of the tumor by shrink- age that nothing more will be required. The other patient is forty years of age. She has had only two hemorrhages, and it is very likely that she can be tided over the climacteric without any surgical inter- ference. Usually, we do not operate on women for fibroma after the age of forty-six or forty-seven unless it is perfectly clear that the use of ergot combined with ab- solute rest is insufficient to tide her over the climacteric. When, however, the disease appears in young women, say from thirty-five to forty, or as I have seen it in a girl of nineteen, an important question comes up for careful discussion, and here again the patient must accept a good deal of responsibility in the answer. If a patient spends one week of every month in bleeding and suffer- ing pain, becoming anaemic, restless, and irritable, unable to look after her affairs, and you cannot relieve 21 the sufferings or arrest the hemorrhage except by opera- tion, then this question must be considered. Is it worth while for that patient to go on suffering for a series of years when by an operation, the mortality of which is only four or five per cent., she could be relieved ? On this point different men will express different opinions. If I were the patient, I should have the operation done. Holding that opinion, I advise the patient to have the operation performed. Concerning myoma of the uterus, we have a number of traditions which are being rapidly destroyed. One tradition is that myoma is not a serious thing. We have been in the habit of finding, at our post-mortem exami- nations, a large number of myomata which have never given any trouble, but I need not say that the tumors which do not give rise to trouble, are not the ones which trouble us. The tumors which cause trouble are the ones which we see. If a tumor gives rise to hemor- rhage and pain, the woman consults a physician, who recognizes its presence. There is another tradition, that the occurrence of the climacteric arrests the growth of uterine myomata. It is now perfectly clear that a certain class of uterine myoma arrests the progress of the climacteric. Fre- quently we find women going on for years after the usual time of the climacteric, without any appearance of diminution in the size of the tumor, or in the amount of the hemorrhage. There is a peculiar kind of uterine myoma which causes but little pain or hemorrhage, but which goes on indefinitely increasing in size, and seems to be unaffected by the climacteric. In uterine myoma, provided the use of ergot and rest does not give relief, one of two procedures may be adopted. The uterine appendages may be removed and menstruation, which seems to be the immediate process by which the growth is encouraged, arrested. 22 It is a fact established beyond discussion, that in the great majority of cases operated on hemorrhage is im- mediately arrested, and the tumor shrivels up, and may disappear. The removal of the uterine appendages is an operation to be recommended in a certain class of cases. In some cases in which the disease is not arrested by the removal of the uterine appendages, there is the far more dangerous operation of removal of the entire uterus, or hysterectomy. I have now come to the end of the category of cases about which Dr. Parvin asked me to speak, and I have occupied more time than is usually allotted to clinical lectures. I am afraid that I may not have made myself perfectly clear, for I have absolutely no experience in teaching. I never gave a clinical lecture in my life until last week, when I addressed an audience similar to this in Albany. It is a misfortune that, in England, those of us engaged entirely in special practice never have any opportunity for teaching. The teaching seems to fall chiefly into the hands of those not busily engaged in practice, while those actively engaged in their profession are removed from all opportunity of teach- ing. I hope, therefore, that you will attribute any lapses in the sequence of my illustrations, or want of clearness in my narrative, entirely to my lack of experience, and accept my appearance before you, not as that of a British teacher, but purely as that of a British surgeon. The American Journal of the Medical Sciences. (Continued.) In addition to the original communications before noted, The American Journal contains a large number of reviews of current medical literature fiom the pens of able and impartial critics. The remainder of its 300 octavo pages is occupied by a digest of the latest advances of medical science classified under appropriate heads. In short, the present issue may be regarded as a typical number of the only journal now published in the English language which can accommodate elaborate contributions. Founded in 1820, The American Journal now completes its sixty-fifth consecutive year of faithful and honorable service to the profession. 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