ON THE TREATMENT OF OVARIAN DROPSY.

Archives Générales de Médecine, Vol. 50, p. 487.-A case is quoted of an operation by Mr. Arnott, of the Middlesex Hospital, in which he punctured the vagina, and a discharge from the cyst continued for sixty-four days, when a complete cure was effected, and the opening in the vagina perfectly closed.

The Editor in his remarks alludes to another case, similar in its nature and results to the one above mentioned, as having been published in the Revue Médicale by M. Recamier.

Archives Générales de Médecine, Vol. 31, p. 427.This is an account of an operation for extirpation of ovarian tumour, attempted by Dr. Ehrhartstein, in which from an aperture in the external wound serum continued to drain for some time, which afterwards changed into a milky fluid, and did not disappear till the ninth week after the operation, when the wound cicatrised, and the patient was cured.

Archives Générales de Medecine, Vol. 20, p. 92.-A case is given by Dr. Dieffenbach, of Berlin, where the adhesions were such that he merely punctured the tnmour after incision; a sanious matter continued to discharge itself through the wound for some time after, and the patient ultimately recovered.

ON THE THEAEMENT OF OVARIAN DROPSY.

There was a discharge from the cyst which lasted nine months, during which the tumour had gradually disappeared; she then died, as it would appear, from general cachexy, under which she had laboured long previous to the opening being formed. The state of this patient's health a year before the operation was such, as under any circumstances, to render it improbable that she

would live more than a few months.

London Medical Gazette, Vol. 8, p. 291.-A case is given of discharge of the contents of an ovarian sac through a spontaneous opening in the vagina, which ulcerated, and no doubt allowed any new formed secretion gradually to escape. The consequence was almost complete disappearance of the tumour. By Dr. Elliotson. London Medical Gazette, Vol. 31, p. 572.-Dr. Waters gives a case of periodical return of an ovarian tumour and its entire disappearance two or three times after a copious discharge of a thick, yellowish, ropy fluid, viâ recti et vagina. After the last discharge no return of the tumour had taken place, and the patient's health was in a satisfactory state.

Lancet, Vol. 2, 1839.40, p. 12.-Dr. Ingleby gives a case of cure of ovarian dropsy, consequent on ulceration into the bladder, and permanent discharge per urethram, for upwards of a year, of albuminous fluid, shreds of coagulable lymph, and hydatids.

Lancet, Vol. 2, 1839-40.-Dr. Ingleby gives a case of rupture of ovarian cyst into the intestinal canal, as evinced by the vomiting of the contents mixed with fæcal matter, which he describes as lasting for some days, and followed by a cure.

Lancet, Vol. 2, 1842 43, p. 422.-A case of spontaneous permanent cure of ovarian dropsy, by a discharge from the cyst per vaginam, of several days' duration.

Medico-Chirurgical Review, Vol. 24, p. 206.-Gives three cases of cure by accidental rupture of a cyst into the vagina, and discharge through that opening; there can be no doubt that the discharge was continuous for a longer or shorter period.

Many more cases of the above description might be adduced if necessary, for the further elucidation of this very interesting mode in which nature operates successfully for the cure of this formidable disease.

With respect to the ACCIDENTAL CASES to which I have alluded, it appears to me that many cures have resulted from the bursting of the cyst into some portion of the intestines, or the bladder, as well as into the peritoneal cavity, under which circumstances a discharge of the fluid takes place, continuing for a longer or shorter period, and thus terminating as in the cases above detailed, in a more or less permanent cure. Instances of this kind are by no means rare. As to those cases where an accidental external opening has been made into the cyst through the parietes of the abdomen, as in the well-known case of the goring

by a bull, &c. &c., a permanent cure has also been

effected on similar principles.

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The foregoing abstract professes to do no more than give a sufficient number of cases to exemplify the principle of the operation in question, and justify the conclusion I have arrived at. It is worth mentioning that the farther I extended my search the more I became convinced that this operation has been regarded either with needless alarm or culpable indifference. Is presenting these as cases in point, it is to be observed, that with the exception of the first three on the list, it does not appear that the surgeons contemplated or understood the rationale of the operation. In their descriptions they seem to overlook the main fact, or mention it in a way to show they attach little or no value to it. Hence some of the cases must have laboured under serious disadvantages arising from careless or injudicious after-treatment, or from the non-employment of subsidiary means, calculated to promote a successful issue of the operation. The cases are, however, not the less on that account to be received in evidence, but rather the more, and I have no doubt that many of the cases on record in which the cure has been ascribed to different causes, or not attempted to be accounted for unless on some vague general principle, would, if more circumstantially detailed, exhibit the particular characteristic feature of the examples I have collected.

My list more than bears me out in the ratio I originally laid down, and even the two deaths may be accounted for, as indeed they were, by circumstances totally independent of the open state of the ovarian cyst or the discharge. It may be said that more extensive research would furnish many cases in which death has occurred, either during a discharge so superinduced and maintained, or after its cessation. I much doubt whether many such could be adduced-I have not been able to find them. Still I admit a few might be met with, but they cannot be considered as applicable unless it can be shown that the fatal issue might be fairly attributed to the discharge so established and circumstanced; and even could this be demonstrated, I feel confident it would not disturb my ratio, as a counterbalancing proportion of successful cases would also be discoverable.

such as Morgagni, Cruveilhier, Delpech, Lizars, &c. &c., Among the numerous writers on ovarian disease, few seem to have regarded this operation favourably. They either magnify its dangers or underrate its value. The cases they adduce in evidence against it do not

apply. Instead of judiciously aiding nature in her friendly efforts, they interfere with, and obstruct ber stances, such as canulas, leaden tubes, bougies, &c., by means of stimulating injections or irritating subleft in the wound-a wound which, of all others, requires to be managed with the utmost delicacy and

caution. What can be more contrary to the true principles of surgery, and what other than disastrous or negative results could be expected to follow such

of a compress and bandage, and removed once or oftener in the twenty-four hours, according to the amount of secretion.

In my case, after the suppurative process had been established, the quantity of matter being for some time considerable, I placed the patient on a prone couch to allow of its gravitation towards the external

practice? Cases treated in this way I exclude from the category. The errors of art must not be placed to the account of the operations of nature. Dr. Bright is one of those few authors who seems to have formed correct views on the subject, though not perhaps to have thoroughly appreciated its importance. He expresses himself to the effect that in some cases the wound does not close, and that suppuration con-opening and its gradual escape. More or less inflamtinues for months or years, and that such an occurrence so far from being fatal, prolongs existence. This judicious observer no doubt speaks from experience.

I have again to thank your correspondent, INQUIRER, for the present opportunity, which I gladly embrace, to make a few additional remarks on my own case, suggested by a re-consideration of its details. On making the incision, I should not in any future case consider it advisable to remove a large portion of the cyst, with a view to diminish the extent of the secreting surface. I should leave its gradual contraction to nature. In all the cases above given, where nature operated, the sac remained entire, and no bad symptoms followed. There is besides an objection to it where the sac is free from adhesions. By removing a considerable portion of a large cyst, I should have a wound of many inches in extent to bring into adaptation with one of inferior dimensions. A puckering of the edges of the cyst would inevitably follow. These puckerings could not be applied to the lips of the external wound; union therefore might be incomplete, thereby endangering protrusion of the abdominal viscera, and an escape of matter into the peritoneal cavity,-two very serious accidents which must be most carefully guarded against. I should simply remove as much of the sac as would leave the opening in it as nearly as possible corresponding with that of the external wound, and unite the lips of both, accurately and smoothly, by the uninterrupted suture. I am now alluding to sacs free from adhesions at the point of operation.

But when the sac is adherent at this point, all this labour and difficulty are saved. Here it is worthy of note, that the very circumstance which most seriously complicates the major and minor operations-so called-viz., the existence of adhesions which must be torn or cut through, is not a source of danger, but rather a great advantage for the successful accomplishment of the present plan; and indeed could it be possibly ascertained by auscultation or otherwise, that adhesion to the walls of the abdomen existed at any particular point, I should select that point for my incision, provided it presented no extraordinary anatomical obstacle.

After the operation all that is required is to introduce a tent of lint into the wound to prevent its closure, foment the whole of the abdomen with warm water, and keep the patient very quiet for a few days, allowing no escape of the fluid except at the time of dressing. The plug should be kept in firmly by means

matory action must be expected to ensue after the operation; this should be allowed to subside, and no risk incurred of its increase by leaving canulas in the wound, as was done in cases operated upon with no result by Mr. C. A. Key. The mere introduction of pieces of leather, softened by steeping in oil, as substitutes for the lint plug, produced so much irritation during the chronic discharge in my case that I was compelled to have recourse to leeches and fomentations.

With respect to the cases in which nature herself performed the operation, I cannot help observing, how

wonderful and beautiful are her resources under such extremities! and how long and vainly has she laboured to indicate to us a safe and simple mode of treating ovarian dropsy! After hundreds of experiments, and ages of experience, we cannot, I feel assured, act wiser or better, even in the present day, than simply to watch her movements, and imitate her example. Observe how cautiously she makes her external opening, and instead of violating the system by such a sweeping act as that of the major or minor operation, she almost imperceptibly sets up a new action in the cyst, adapts the treatment to circumstances, and gradually obliterates the cavity.

I trust, Sir, that I shall not be considered as needlessly obtruding myself on the notice of the profession by bringing this case so prominently forward, and entering so minutely into its details. I have been influenced simply by a wish, and animated by a hope, that others may be induced to try a similar method, and reap a similar reward. I shall be glad to see the subject elucidated by other more gifted individuals. The enquiries of your correspondent seem so reasonable, and the operation itself of such vast importance to the interests of suffering humanity, that without loss of time, and at considerable personal inconvenience, I have endeavoured to reply to the best of my ability, and indicate more clearly than at first, what appears to me, the best and safest course to be persued in the practice of OVARIOTOMY.

I remain, Sir,

Your very obedient servant,
W. H. BAINBRIGGE.

Liverpool, January 1, 1847.

CASE OF HEPATITIS RESULTING IN ABSCESS.

(Read at the December Meeting of the Bath Pathological Society.)

J. B. a woman, aged 53, of a very full habit of body, and accustomed to live freely, applied to me on the 18th of October, 1845, suffering from congestive dyspepsia. She was generally speaking healthy, but had suffered in her lifetime from inflammatory disease in the chest. She was freely purged with mercurials and saline aperients; low diet was enjoined, and in a few days she was well again; but on the 4th of November, without any assignable cause, (except perhaps an excess of diet, which was not acknowledged,) she was suddenly seized with rigors, followed by the usual symptoms denoting acute inflammation of the liver. The pain was so very acute and so sensibly increased by the slightest touch or pressure, as to lead to the supposition that the peritoneal coat of the right lobe was principally engaged. From the first onset of the disease the urine was completely loaded with lithate of ammonia, so much so as for the first few hours after it was passed, to have the appearance of a brick-red liquor, without any sediment, but afterwards the deposit was thrown down and the fluid assumed a yellowish tinge.

The disease was met very actively, with the usual treatment, which it is not my purpose to dwell upon. I will just observe, that she was freely bled, locally and from the arm, afterwards blistered, freely purged, her system brought rapidly under the influence of mercury, and a strict antiphlogistic regimen enforced; by these means the pain was mitigated, but the inflammation instead of subsiding altogether as was desired, gradually assumed a sub-acute character, and was

not to be overcome.

Under these circumstances, abscess was the result naturally to be expected, and accordingly about the beginning of January, 1846, she was again seized with rigors, followed by pulsation or throbbing in the hypochondrium. By the 10th of the same month, the side was tumefied, and fluctuation was readily perceived. The patient, however, was much exhausted; her pulse was 96. On the 11th it had risen to 120, was hard and jerking, betraying in itself the existence of pus, pent up in the system. On the 12th she was troubled with constant bilious vomiting; ber countenance was anxious, and it appeared that if she were not relieved in a few hours, death must be the inevitable result. Still she had naturally a good constitution, and there was reason to think, that if freed from accumulating pus, she might rally. Her pulse this day was not to be counted, as she had been hurried getting up to stool; the evacuation being of normal character. I must not omit to mention, that at this time, since the setting in of suppuration, the urine had regained a healthy appearance, and was free from all deposit.

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advice, selecting the softest and most depending situation, on the outer side of the hypochondrium, I passed a trocar obliquely upwards and inwards into the cavity of the abscess, and evacuated nine ounces (by weight,) of pus, mingled with bile, and then placed a

small tent of lint in the wound.

The patient was faint, and suffered much from bilious vomiting, but on the whole was relieved. She slept and took nourishment, and in the evening her pulse was 100, soft and equable.

On the 13th I removed the plug, as no pus had escaped through it, and took away five ounces more of similar looking pus to that evacuated the previous day.

The patient still suffered for some days from bilious romiting, which was very troublesome to manage. The abscess continued to discharge freely and the fluid evacuated seemed to consist of as much bile as

pus, and the urine again threw down large deposits of the lithate of ammonia. Once or twice I thought it contained bile, but this was not tested.

The sinus was very difficult to keep open, the external orifice getting frequently glued up, but as soon as any quantity of pus re-accumulated, she became evidently feverish, and altogether worse. However, she gradually improved, and on the 12th of February, a month after the puncturing, I explored the sinus, and found it three inches and a half deep; but as far as I could detect, the cavity of the abscess was nearly obliterated. On the 16th the discharge had almost ceased, and I allowed the orifice to remain closed, in

hopes that the sinus would become sound throughout its extent. On the 22nd, deposits ceased in the urine, though on the 25th, it was again loaded.

The patient was now able to move into an adjoining room, though her pulse kept at 105, and she continually complained of cold, and had nearly lost the use of her limbs from paralysis. Shortly after this she was not under my eye. There I learned that some degree of pain recurred in the side, and it became again tumified, the sinus re-opened and a similar evacuation, as regards quantity and quality, was discharged as on the former occasion.

went into the country, and

She returned home after an absence of fifteen weeks. When I examined her, I found the wound still wept a little serum, her pulse was 100, and she was nearly hemiplegic, but her appetite was good' and tongue clean. I gave her very little medicine and she began to improve. In Angust her pulse came down to 84; her side was free from all tumour or tenderness; the sinus was quite closed; her general health much improved; and she was recovering the use of her limbs. When I saw her a few weeks ago, she was enjoying a very fair state of health. She has again returned to the country and I was informed a few days since, that she continues to regain more of her original good health, and has discarded her crutches; but I must not omit to mention, that occasionally, slight tumidity recurs in the side, and a fluid resembling pure serum

My friends Drs. Bowie and Fergusson, and Mr. Underhay, were so good as to see this case with me, and Under these circumstances, with concurrent valued agreed as to the necessity of puncturing the abscess.