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Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, Nov. 13TH, 1866.

DR. JAMES ALDERSON, F.R.S., PRESIDENT.

A CASE IN WHICH OVARIOTOMY WAS TWICE SUCCESSFULLYPERFORMED ON THE SAME PATIENT.

BY T. SPENCER WELLS, F.R.C.S.,SURGEON IN ORDINARY TO HER MAJESTY’S HOUSEHOLD, AND SURGEON TO

THE SAMARITAN HOSPITAL.

THE author commenced by alluding to three cases in whichovariotomy had been performed twice on the same patient.The first was by Dr. Atlee, of Philadelphia, sixteen yearsafter the previous operation by Dr. Clay, of Manchester. Thesecond was by the author, nine months after an operation byanother surgeon. The third was by Dr. F. Bird, fourteen

years after one of his own operations. The first case was suc-cessful. The second and third were not. The case now re--lated is believed to be the first in which ovariotomy has beenperformed successfully twice on one patient bv the same sur-geon. In this case the author removed the left ovary of anunmarried woman, twenty-four years of age, in February,1865. The tumour weighed twenty-nine pounds. The rightovary was then healthy. The patient recovered, and remainedwell more than a year. But, in about fifteen months, diseasebegan in the right ovary, and advanced so rapidly that ova-riotomy was performed for the second time eighteen monthsand a half after the first operation, and a tumour, weighingeighteen pounds, was removed with complete success. Afull account of both operations was given, with a descriptionof the tumours removed; and some remarks were added uponthe comparative frequency of disease in one or both ovaries,and upon the appearance of disease in one ovary after theother had been removed. The author showed that the rightand left ovaries are found diseased with equal frequency;and that in from one-third to a half of the cases wherethe disease has gone on to its termination in death, bothovaries are diseased But he asserted that both ovariew H.rfi

affected in much smaller proportion in the earlier stages of thedisease. In the first 150 cases in which he performed ovario-tomy he only removed both ovaries in seven, and in onlythree others was disease in an early stage suspected in theovary not removed. In three the ovary not removed, but ex-amined and found healthy, had become diseased afterwards.In two of these cases the disease was malignant. The rule

appears to be established that after a successful ovariotomy

the patient is restored to good health; and although thereare occasional exceptions to this, it is satisfactory to knowthat if the remaining ovary should become diseased, the firstoperation need not add much to the difficulty of the second ;and that of four cases in which a second ovariotomy has beenperformed two have proved successful.

Dr. ALTHAUS related the case of a woman who had beensuccessfully operated on five times for Cæsarean section. Dr.Althaus asked Mr. Wells whether he thought Caesarean sectionor ovariotomy the more formidable operation.Mr. BAKER BROwx said that the case just narrated was im-

portant in many points of view. First, the actual cautery wasused to the pedicle ; secondly, it showed the inconvenience ofsecuring the old pedicle by a clamp; the old pedicle was adhe-rent to the abdominal walls. It was this very adhesion of the

pedicle to the abdominal wall which caused him to discontinuethe use of the clamp and to substitute the actual cautery to thepedicle, as first applied by Professor Clay, of Birmingham, toadhesions. Thirdly, it showed that the use of a clamp to thepedicle often resulted in its adhesion to the abdominal walls-a result which he had found extremely inconvenient in manycases. Mr. Brown said that whilst giving every credit to Dr.Clay, of Vlanchester, who had been our pioneer in this country,credit was due to Professor Clay, of Birmingham, for the in-troduction of the actual cautery, and he (Mr. Brown) tookcredit to himself for adapting the actual cautery to the treat-ment of the pedicle ; and by himself and others, aa Mr. SamuelHey of Leeds, and Mr. Harper, it was found to be peculiarlysuccessful. In his own hands, in less than two years, out offorty-one successive cases since he had used the actual cautery,he had had thirty-six recoveries and only five deaths, and inall those five he had been obliged to use ligatures.

Dr. WRIGHT inquired of Mr. Baker Brown whether in his

experience of the application of the actual cautery it had oc-curred that so soon as the clamp was loosened the vessels ofthe pedicle burst out bleeding. Mr. Brown having answeredin the affirmative, Dr. Wright remarked on the importance ofthis, since it appeared that when the hot iron was employedthere still remained the possible contingency of subsequentbleeding, notwithstanding its use.Mr. SOLLY asked what statistics Mr. Brown had obtained,.

reckoning all cases.Mr. BROWX said that his results stood at present thus

Completed cases, 107, with 72 recoveries and 35 deaths; whilstof incompleted cases and partial extirpation, 15 cases, only 3recovered, and 12 died ; and of 10 cases of exploratory inci-sions, where no further steps were taken, 6 recovered and 4died ; showing 132 cases in all, with 81 recoveries and 51deaths. He had seen several cases where the second ovarywas diseased with cystic growths, and had in most of themcut or burnt through the cysts, so as’to empty them of theircontents, and those cases did well. He was surprised to hearthat in cases where actual cautery was used there had occurred,some weeks afterwards, peritonitis and death. In no one of hiscases had there been any bad subsequent results ; on the con-trary, the patients were well in six or seven days, outside theirbeds, and made a rapid recovery-much quicker than by othermodes of operation. He had now abandoned the clamp outsidethe wound, and either used the actual cautery or the long liga-ture of Dr. Clav.

, Mr. PHILIP HARPER was very desirous to place upon recordhis own experience in the use of the actual cautery as a meansof dividing the pedicle in ovariotomy. He had had many op-portunities of observing its great value, for, in addition to thecases in which he had seen Mr. Baker Brown use it, he had re-sorted to it many times in his own practice, and the conclusionto which he had arrived was that in a large proportion of casesit was an unfailing means of preventing haemorrhage, and con-duced to the rapid recovery of the patient. He was surprisedto hear that Mr. Wells had met with two cases in which sometime subsequently peritonitis had come on and was imputed tothe use of the cautery. It was the first time such effects hadbeen brought to his notice, and he must conclude that theywere dependent upon some constitutional peculiarity or acci-dental circumstance, more probably the latter. There werecertain points in the use of the cautery which must be promi-nently brought forward. The character of the pedicle was ofgreat importance. In some cases it was large and thick, andits vessels, though numerous, were moderate in size. In these,cases the cautery was always efficient. In other cases the-

pedicle was broad and thin, supplying a tumour of simple se-condary multilocular character, and with vessels of mediumsize. Here the cautery was generally efficient. In other casesthe tumour was extremely multilocular, colloid or adenoid in

type, and the pedicle thin and small, with one or a couple of’ vessels the size of the femoral or larger, and here the cauterywould not be efficient. However carefully used, upon the re-moval of the clamp sharp bleeding arose. In a lady uponwhom Mr. Harper operated a year ago the tumour was of this’character, and the pedicle contained one large artery, whichpoured forth a large stream of blood upon the removal of theclamp. It was seized, a ligature passed around it, tied tightly,and the ends cut off closely. The pedicle was allowed to fall,back into the pelvis. The lady made a rapid recovery, and wasstill in robust health. In another case there was a large arteryat each side of the pedicle, which it was necessary to tie sepa-rately, and recovery was perfect. Another important pointwas that in burning through the pedicle it must be done slowlyand without any sawing or half-cutting movements. The clampmust be removed very slowly, and the cauterized surface shouldnot be touched even with the fingers, but allowed quietly andgently to drop into the pelvis. High as was the value to be,attached to the simple clamp in certain cases, he believed thatthe cautery would entirely supersede it in the great majorityof cases, and that the more its value was tested, the greaterwould be the reliance placed upon it, the more rapid and satis-factory the recovery of the patient, and, most important of all,the death ratio after the operation would be materially lessened.In reply to Mr. Spencer Wells, Mr. HARPER said that he had

twice tied vessels after the use of the cautery in eight cases.Dr. ROUTH bad been present now at over 200 cases of ovario-

tomy, complete or incomplete. He must say, therefore, speak-ing from no small experience, he believed no system was so goodand so safe as the actual cautery. An attempt was made todisparage the actual cautery because ligatures had to be used

I sometimes in addition. But ligatures were sometimes neces-sary even when the clamp was adopted. Moreover, what ob-

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jection could be made to using a small silk or wire ligaturewhere an artery in the pedicle was found very large ? Where,however, the arteries were of the size of the radial or ulnar,the actual cautery quite sufliced ; if as large as the femoral, itwas safer to apply also a small ligature. No one would thinkof trusting to actual cautery in an artery as large as thefemoral elsewhere. Again, in some cases, as in very fat sub-jects, it was inadmissible, the fat taking fire on the applicationof the red-hot iron. Mr. Wells had done well if by the clamphe managed to get his patients convalescent and able to enjoya chop by the thirteenth or fourteenth day ; but if the sameresult could be obtained on the sixth and seventh when theactual cautery was used this was a better cure. He had neverseen or heard of any of those unfortunate results mentionedby Mr. Wells where the actual cautery was used after apparentrecovery, and all he could say was that, using the argumentumad hontinena, if he had a relative affected with ovarian diseasehe would insist on the operator using first the actual cautery.Besides, he could conceive that a woman on whom ovariotomyhad been performed and the clamp used might suffer in herpregnancy by the impediiiient in the way of its developmentoffered by a pedicle adherent to the abdominal walls, and inMr. Wells’s case the operation was rendered more difficult, headmitted, by this very adherent pedicle, which would not haveoccurred if in the first ovariotomy he had used the actualcautery.Mr. SPENCER WELLS, in reply to the question of Dr. Althaus,

said that a second Caesarean section performed on the samepatient was not, like a second ovariotomy, more difficult orhazardous than the operation performed for the first time ; onthe contrary, it was a very much simpler proceeding. ACæsarean section performed for the first time was a much more efatal operation than a first ovariotomy ; but as the opening inthe uterine wall often-perhaps generally when sutures arenot used-remains unclosed, and the edges of the opening ad-here to the abdominal wall, operators who had performedCassarean section twice or more on the same patient found thatthey had little more to do than cut through the integumentand take out the child without any second opening of the uterus.He considered the observations made by Mr. Harper as to theuse of the cautery of great practical value. Of eight cases inwhich this surgeon had used the cautery to the pedicle, liga-tures had also been required in two, or in one-fourth of thecases. This was about the proportion in which he (Mr. Wells)had also found the cautery ineffectual in completely suppres-sing haemorrhage. He, nevertheless, thought it a valuable ad-dition to our means of dealing with short thick pedicles, towhich the clamp is not suited; but he very much preferred theclamp where a pedicle is small and long, so that its separationand all subsequent changes may go on outside the peritonealcavity. He had seen two instances in which patients, afterapparently recovering and going home three weeks after ovario-tomy—the cautery having been used-had soon afterwardsbeen attacked by peritonitis. One of these attacks had provedfatal, and Dr. Sutton, who examined the body, found very ex-tensive adhesions of the intestines to each other and to theremains of pedicle. It was true that all this might be quiteunconnected with the use of the cautery, as chronic peritonitishad existed before the operation; but he could not help think-ing that there was some such connexion, as he had seen un-pleasant effects in other cases where the ligature had been usedand left within the peritoneum. He had never seen any suchill effects when the pedicle had been secured by the clamp, or

the extra -peritoneal methcd had been carried out either by theclamp or ligature. The objections raised to the clamp on theground of any interference with pregnancy or parturition mustbe imaginary or exaggerated, as ten of his patients had borneliving children after ovariotomy-two of them had two children,- and he had not heard of any unusual suffering or difficultyeither during pregnancy or labour in any one of the cases.

Reviews and Notices of Books.Statistical Sanitary, and Medical Reports : Army Medical

Department. Vol. VI. For the year 1864. (Blue-bool:,1866.)

THE Army Medical Reports, commenced in 1859, have nowreached the sixth annual volume. We have often had occa-sion to refer to these Reports, and always in terms of com-menda.tion. We can speak equally well of the present volume;

’ indeed, we doubt whether it is not better than any of its pre- decessors. The Statistical Report, by Dr. Balfour, appearsnow to be almost absolutely perfect; while in both the Sani- tary and the Medical Reports there are a number of importantabstracts and original papers of very great merit. Amongstthose in the Sanitary Report we must place in the first rankfive essays on outbreaks of Cholera during 1865. The cholerain Malta is described by Dr. Adams and Mr. Welch, of the1st Battalion, 22nd Foot, in one of the most careful and com-

prehensive reports we have ever read. It adds greatly to ourprecise knowledge, and illustrates with new instances almostall our previous etiological and pathological conclusions. Wemust refer to the report (for this is not the place to enter on a

critical analysis of it) for the evidence of the transportabilityof the choleraic virus, for its conditions of spread, and itsmode of action. The military suffered more than the civilians,in the proportion of 2 9 to 1.6 per cent. of population; and, asusual in cholera epidemics, the per-centage of deaths to caseswas greater in the population most severely attacked. Amongthe civil population the deaths were 62 per cent. of attacks;and among the soldiers, 72. We observe that this fact hasbeen very improperly twisted into a condemnation of themedical treatment of the soldiers as compared with that of thecivilians; but we need hardly waste the time of our readersby confuting such an opinion. Suffice it to say that, in addi-tion to many other explanations which might be given, theauthors distinctly state (p. 339) that among both the civiliansand the military many cases of real though slight cholera wereleft out of the returns for fear of creating alarm, and thus theproportion of deaths to attacks was unduly raised in bothcases. In other words, the figures 62 and 72 per cent. ofdeaths must be taken with great reserve; and it would be inthe highest degree fallacious to use them as tests of the suc-cess of treatment. The Cholera Reports by Drs. Rutherford,Lawson, and Barrow contain some highly important evidenceof the transportability of the poison: the evidence recordedby Dr. Barrow of the carriage of cholera from England toHalifax by the steamship England, and the origin of thedisease in the pilots and their families, seems to be withoutflaw. The fifth Report on Cholera refers to an outbreak atNeemuch, in India, by Dr. W. T. Martin, and is also a docu-ment of the highest value. It describes with much detailthe measures taken during a prolonged cholera season to arrestthe disease, and, as an illustration of the way cholera must befought against, is most instructive.Although these Cholera Reports are naturally those which

have most immediate interest for us, there are many otherpapers of scarcely less importance. Dr. de Chaumont’s ReportI on the Ventilation of the Hilsea barracks and stables andHerbert Hospital is of especial moment at the present time,when the question of the cubic space and ventilation of theworkhouse infirmaries is under consideration. Dr. A. Martin’s

Analysis of the Ceylon Drinking Water, and Dr. Woodward’sI Medico-Topographical Report of Japan, are both excellent ;

and Dr. Parkes contributes his accustomed valuable annualreview of the pro6ress of Hygiene.In the Medical Report we observe a number of valuable

essays. Dr. Davidson’s Remarks on the Taenia Echinococcus’ and its Larval Condition, and Dr. Stewart’s note on

Dracunculus, contain some original observations. Dr. Belcher’s

paper* on Cholera at Baroda might more properly have beenplaced with the other cholera papers in the preceding section.Deputy Inspector Lawson communicates a paper on "PandemicWaves,’’ which is illustrated by maps and a multitude of

figures. Dr. Lawson endeavours to show a connexion betweenterrestrial magnetism and epidemics of fevers. We fully re-cognise the labour and ingenuity displayed in the paper, butwe confess to an utter incredulity on the subject.

Professor Longmore contributes two practical papers onTransport for Wounded Men and on Resection. Dr. Fyffe, of