child seventeen months afterwards. Dr. Charles Clay, of Manchester, deserves the credit of giving the original impetus to ovariotomy in Great Britain. His first operation was performed in 1842, and was successful. Up to the end of 1871 he had operated two hundred and fifty times, with nearly 73 per cent. of recoveries. But to Mr. T. Spencer Wells, of London, and Dr. Thomas Keith, of Edinburgh, belong the honors of being the most celebrated and successful operators in our day. I have just returned from visits to these distinguished men, and shall try to convey to you as accurate an idea as I can of the impressions produced. Mr. Wells was originally a surgeon in the British navy, and afterwards served in the Crimean war during 1855 and 1856. He commenced his remarkable career as an ovariotomist in February, 1858, and during the first three years operated on ten cases only. Since 1858 he has operated nine hundred and eleven times! Of his first five hundred cases three hundred and seventy-three recovered. Of his last series of one hundred cases eighty-three recovered. In that series he had twice a run of twenty-seven cases without a single death, and once a run of twenty-one successful cases. The following is a brief summary of Mr. Wells's mode of operating: (1.) He uses a mixture of chloro-methyl vapor and atmospheric air (containing from two to four per cent. of the vapor) as an anesthetic. It is administered by means of Dr. Junker's apparatus. The operation is performed on a table, to which the patient is fastened by a strap over the thighs. The abdomen is covered with a thin sheet of rubber cloth, long enough to allow of its being held up so as to protect the patient's face from the spray, and with an oval opening eight inches long by six inches wide in the middle. This opening is coated all round with adhesive plaster, so that it may adhere to the skin. (2.) He is exceedingly careful to secure clean quarters, clean air, clean instruments, and clean assistants. (3.) He uses the antiseptic spray (one of carbolic acid to twenty of water) during the whole operation. All the instruments, ligatures, and sponges are immersed in a similar solution. The operator and his assistants bathe their hands in another portion of the same solution. (4.) He endeavors, if practicable, to limit the length of the incision to six inches, and does not allow the fluid of the cyst to enter the peritoneal cavity. (5.) In all suitable cases, in securing the pedicle, he employs the clamp in preference to the ligature; in other words, he prefers the extra-peritoneal to the intra-peritoneal method. (6.) But if, on account of the pedicle being too short, thick, or broad, the intra-peritoneal method is adopted, he always uses a blunt needle to penetrate the pedicle, which is tied in two or more portions and cut off at some distance from the ligature. (7.) The greatest pains are taken to cleanse the abdominal cavity. Soft sponges are used for this purpose. A large flat sponge is then slipped in over the bowels, and the wound sewed up. Ligatures of strong Chinese silk, about eighteen inches long, are threaded at each end with a medium-sized needle. Each needle is introduced from within outwards, including the peritoneum. When the whole number required have been inserted, the lips of the wound are separated to remove the flat sponge (which receives drops of blood from passing the needles) and to ascertain that no blood, serum, sponge, or forceps have been left in the abdominal cavity. The sponges and forceps (to arrest bleeding during the operation) are counted before and after the operation. (8.) He places a dry dressing of thymol cotton over the external wound; then long strips of adhesive plaster (going two thirds of the way round) are applied, and the whole abdomen is supported by a broad flannel bandage. But no words can express his wonderful skill in diagnosis, his adroitness in operating, his coolness and self-poise in emergencies, and above all the confidence which his mere presence inspires in the patient. Mr. Wells has performed ovariotomy a second time on the same patient in eleven cases, nine of whom recovered. He always examines the other ovary before closing the wound, but prefers to leave it unless seriously diseased. He has also operated in ten cases of ovarian tumor in which the patients were pregnant at the time, nine of whom recovered. One of the points especially deserving notice is the fact that Mr. Wells not only reports all his fatal cases, but faithfully prints even his mistakes and accidents (such as leaving at one time a sponge and another time a pair of forceps in the abdominal cavity). He takes especial pains to ascertain the subsequent history of all his patients, and records the details with a minuteness which has never before been attempted in any department of surgery. It has more than once been broadly hinted that he selects his cases with a view to favorable statistics; but nothing could be farther from the truth. He says: "I have operated lately, and shall soon be driven to again, in very unfavorable cases almost hopeless—by the feeling that it is impossible to resist the prayer of a dying woman to try and save her life." cases Dr. Thomas Keith, of Edinburgh, performed his first ovariotomy in 1863. Since then, up to last July, he has operated two hundred and seventy-three times. Up to the close of 1871 he had opérated one hundred and thirty-six times, of whom one hundred and eleven recovered. "There were but three monocysts in the first one hundred cases." The late Dr. Peaslee truly says: "Since the reports of his cases show that they have by no means been usually of a promising character, but very often quite the reverse, to him must be awarded the highest order of skill, both as an operator and in the after-treatment of cases." This was written in 1872. Since then his success has been still greater, as the following facts show of the last one hundred cases ninety-three have recovered; during the last seventy cases only three deaths have occurred; and of the last thirty-six cases all have recovered. I had not the pleasure of seeing Dr. Keith operate, because he had no patient during the short time that I was in Scotland, but he showed me his instruments, explained his method, and took me to his private hospital, where I saw the patient he had operated on two weeks before. Dr. Keith uses sulphuric ether exclusively as an anæsthetic, preferring it to chloroform, as safer and less likely to be followed by emesis. I asked him if he could tell me on what his great success depended. He replied, "Just cleanliness." But without doubting that the extraordinary pains taken to insure cleanliness tell markedly on the result, I am satisfied that even more depends on his personal magnetism the absolute confidence which the patient reposes in his extraordinary skill and judg ment. worn out. Dr. Peaslee says of him: "When he had operated one hundred and thirty-six times, he had never made a mistake in diagnosis." He has now performed ovariotomy two hundred and seventy-three times without making a mistake in diagnosis. He often operates on the most desperate cases. He He says: "Ten years ago (1864), when cases of ovariotomy were few, a young woman in the last stage of ovarian disease came to me a long journey from the north. She arrived completely It did not seem possible that in such a condition life could be prolonged many days, for the pulse was almost imperceptible, there was vomiting and diarrhoea, oedematous limbs, and albuminous urine, while a profuse fœtid discharge was going on from an opening near the umbilicus.. . . To remove a putrid cyst in such a condition of feebleness did not at that time even occur to me; yet since then I have operated more than once under circumstances not less unfavorable. Soon again (December, 1864) there came another case of very large tumor. The patient had been jolted for some hours in a coach, and in the hope of relieving the pain thus set up tapping was performed after her arrival. The pain was not relieved, abdominal distention from flatus became excessive, and typhoid symptoms rapidly set in. Fearing a repetition of the slow-death process, ovariotomy was performed during the semi-delirium of septic fever. This was probably the first time that surgery broke in upon an acutely inflamed peritoneum. Recent lymph was present everywhere; adherent bowel and mesentery hedged in a thick-walled cyst, the base of which was in a complete state of slough. Inflammation had gone on to gangrene, and there was intense putridity. After an operation which went on for two hours the patient was placed in bed, cold, vomiting, and nearly pulseless. It seemed as if we had simply killed her; yet she got rapidly into heat, the restless delirium at once disappeared, and there were warm perspirations, much sleep, and a recovery without a drawback. Since then I have ten times met with cases of acute suppurating cyst. Of the ten acute cases operated on eight recovered." - Dr. Keith uses the antiseptic spray in the same way as Mr. Wells. He is assisted by surgeons engaged in general practice, often just from the general hospital, and he insists only on thorough cleansing (washing the hands and using the nail brush in carbolic acid solution) before handling the patient. Every instrument used in an operation is first washed in the antiseptic fluid, then taken to pieces (for example, forceps) and polished as carefully as when it left the maker's hands. I visited the hospital in which the majority of his operations have been performed. It is a private house in an airy part of the city, and it is a singular fact that his success has been even greater here than in the patients' own houses. Dr. Keith devotes a great deal of care and attention to the after-treatment, and this can be more thoroughly attended to in a small private hospital than at home. The time has gone by when the operation needs to be defended. The splendid results already detailed sufficiently demonstrate its "right to be." But there are a few facts and inferences deducible therefrom to which I may be allowed to call your attention. In a recent lecture before the Royal College of Surgeons, Mr. Wells says: "Ovariotomy more certainly saves life from threatened death, restores a woman more certainly to perfect health, renders her more fit for all the requirements of daily life, than almost any other surgical operation. She can scarcely be said to be mutilated; she may menstruate regularly, and bear children of either sex, or twins, without any unusual suffering either during pregnancy or labor. Lord Selborne showed the total gain of life of the three hundred and seventy-three survivors of my first five hundred operations to be ten thousand eight hundred and seventeen years of average healthy life, instead of the one thousand four hundred and ninetytwo years of miserable endurance which they might have passed before death without operation. Of the four hundred patients operated on since the five hundred, three hundred and six are cured, making the total recoveries six hundred and seventy-nine. Multiplying this number by twenty-nine years, the average estimated gain of each patient, the total gain amounts to nineteen thousand six hundred and ninety-one years." At least an equal number of lives have been saved in America by ovariotomists; so that in round numbers forty thousand years of life have been gained by the operation in England and America. Another interesting point is the fact that menstruation may continue for years after both ovaries have been removed. The late Dr. W. L. Atlee, in his work on Diagnosis of Ovarian Tumors, gives the details of three cases in which there could be no doubt that menstruation con tinued after the removal of both ovaries. Mr. Spencer Wells removed both ovaries at once in twenty-five cases. He says: "Many of these double operations have been performed in women past the age of menstruation; but in several cases young women have had both ovaries removed, and in them there has been no return to menstruation as a rule. In three young women there has been a periodical return of something like menstruation, if not true menstruation. From circulars returned to me, and from other sources, I am able to say that thirty-five women who were unmarried at the time of the operation have married since; that fourteen have had one child; six, two; three, three; and three, four children. Two have had twins. Of two hundred and fifty-nine women who were married when the operation was performed, twentythree have had one or more children since. . . . . I have ascertained from the husband or medical attendant of some of my own patients that sexual desire and gratification have certainly not been less than before operation. In several patients whose menstruation before operation had been painful and irregular, it became quite regular and normal afterwards." RECENT PROGRESS IN OTOLOGY.2 BY J. ORNE GREEN, M. D. Sewer Gas and Ear Disease. A number of observations are given by Cassells, which go far to show that sewer gas may exert a very deleterious influence on the ear, may in fact be the direct exciting cause of inflammations of the tympanum and of catarrhal inflammation of the naso-pharynx. Although these cases cannot be referred to the group of aural affections, described above by Weber-Liel, they are closely allied to them. The first cases described by Cassells occurred in his own family. He had noticed for some weeks that the air in his nursery was not perfectly pure, without, however, suspecting the drainage. His three children, during this time, appeared unwell, but the only affection that could be found was slight pharyngeal catarrh. One after the other, within a short time, these three children now suffered from acute inflammations of the tympanum. The repeated attacks in all the children led to an inspection of the house, when it was found that there was an escape of sewer gas from the water-closets near the nursery; this being remedied, the health of the family has since been perfect. A short time after this Cassells saw three ladies in one family, all of whom were complaining of occasional dullness of hearing and slight Italics are mine. 2 Concluded from page 23. Edinburgh Medical Journal, April, 1878. |