enlargement. After a careful examination I was forced to the conviction that it was a typical case of neuralgic ovaries, with nerve storms radiating from them and breaking upon every other organ in the body. It was by far the worst case of pernicious menstruation that I have ever seen. Dr. Deakyne himself had come to the conclusion that no relief short of spaying would do her good, and he had therefore called me in. I agreed with him in this opinion, and we received the hearty concurrence of the poor woman, who was willing to face death in any shape for a promise of relief. The operation was performed on May 26th, just after she had passed through a catamenial tempest of unusual severity. Drs. Deakyne, T. M. Drysdale, E. L. Duer, L. A. Dix, and Henry F. Baxter kindly helped me on the occasion. There was no difficulty whatever in catching the ovaries through the vaginal incision and in removing them, but the hæmorrhage was freer than usual. Both ovaries seemed congested, and one bore a beautiful false corpus luteum. For four and twenty hours great relief was experienced, and everything looked promising, but on the next day a slight peritonitis set in. It was limited to the pelvic regions, but having no strength she died on the fourth day.

While deeply deploring the result, I do not look back upon this case with any misgivings as to the propriety of the course pursued, for I do not believe that anything short of the extirpation of her ovaries would have cured her. But I do not wish to be understood as recommending this operation for every case of ovaralgia, for I have seen too many cases cured by rest, by a milk diet, by massage, and by electricity, which is the treatment that I would recommend as a very efficacious one in the milder forms of this very stubborn disease.

CASE IV. This was a married lady, thirty-eight years old, whose brain gave way from over-anxiety and from over-nursing a sick child during the summer of 1875. The first token of insanity was night terrors, which began to afflict her for two or three days before the appearance of her catamenia. These steadily grew worse until I saw her in September, 1878. At that time she presented the following symptoms: Several days before the appearance of her menses, to use the language of her husband, who is a clergyman, "hallucinations on every subject take complete possession of her, and she becomes so violent as to need locking up." These attacks last during the continuance of the menses and for a week afterwards. The remaining part of the inter-menstrual period, which lasts from a week to ten days," she eats and sleeps enormously, like a plowman," and exhibits mere traces of her hallucinations. She has been an inmate of several insane asylums without benefit. Two distinguished alienists, however, held out hopes to her husband that with the change of life reason would return. Deeply impressed with this opinion, and with the conviction that the

climacteric could alone cure his wife, and having heard of one my cases of spaying, he brought his wife to me for the sole purpose, if I deemed it best, to bring on an artificial menopause.

I found a congested and a hypertrophied womb, measuring 3.5 inches, and the left ovarian region exquisitely tender; the ovaries, however, could not be outlined. These were all the discoverable lesions, but in view of the history of the case, and of the opinion of the two experts who had had her for several months under their charge, I consented to remove her ovaries.

This was accordingly done by a vaginal incision on November 23d, and I was aided in the operation by Dr. Joseph Parrish, Dr. Charles H. Thomas, Dr. B. F. Baer, and Dr. Angle. She did not have a single bad symptom following the operation, although she twice jumped out of bed, and had to be forcibly put back and held down. Her pulse and temperature never rose above the normal. On the eighth day, by dint of a little coaxing, I succeeded in persuading her to let me remove a single stitch that had been put in. After that she could not be kept in bed without undue violence, and I thought it best, as the less of the two evils, to let her get up. No harm whatever followed, but I am sorry to say that, although she has not to my knowledge menstruated since, her mental condition has not been improved.

Now, although this case was a failure, I cannot but think that the principles which governed my conduct are sound ones, and should I meet with a case of insanity limited to the catamenial periods I should not hesitate to remove the ovaries. So impressed, indeed, am I with the soundness of these views that it is my intention, in the course of a few days, to extirpate the ovaries from an epileptic young lady, whose first fit began at her first menstruation, and whose present fits pivot around the monthly flux as a centre.

How shall the operation of spaying be performed? By the abdominal incision the ovaries can always be removed; by the vaginal one, very generally. Each operation has its advocates, but I am a warm upholder of the latter, because it is the safer. I have elsewhere 1 collected and tabulated fifty-one cases of spaying, with fifteen deaths. In thirty-one cases the adominal incision was employed, and was followed by eleven deaths; while out of twenty cases in which the ovaries were taken away through a vaginal incision, only four died. This smaller rate of mortality is attributable to the greatly lessened exposure of the peritonæum, and to the dependent drainage opening. By this operation, however, the ovaries cannot always be caught and removed. They may be carried up by a large fibroid tumor and lie beyond the reach of the finger, or they may be, as Sims 2 and Thomas 3 found them, so

1 Goodell's Lessons in Gynæcology, page 277.

2 Transactions American Gynaecological Society, vol. i., page 352.
8 British Medical Journal, December, 1877.

bound down by firm adhesions as not to be dislodged. In my four cases I had no difficulty whatever in reaching the ovaries and in removing them per vaginam. So impressed, indeed, am I with the greater safety of this mode of operation that I shall always attempt it. Should it fail, the abdomen can afterwards be opened, and the abandoned vaginal incision be utilized, if needful, as a drainage opening. The abdom inal operation should be performed under the spray, and every detail of Lister's should be scrupulously carried out. Of the great value of antiseptic surgery in cases needing the exposure of the peritoneal cavity there can be no question whatever. The wonderful successes of Keith and Thornton amply prove it. Not quite three weeks ago I removed, from a lady sent to me by Dr. A. H. Sheaffer, of Lewistown, a large fibro-cystic tumor of the womb through an incision extending from near the ensiform cartilage to the symphysis pubis, and needing twenty-three sutures to close. The tumor had no stalk, but springing directly from the womb had to be enucleated from its peritoneal capsule. Yet, thanks to the spray, the patient recovered without a single bad symptom, and with less constitutional disturbance than that which usually follows the removal of a small surface growth like an adipose tumor. In the vaginal operation I have not yet tried the spray, but I intend to do so, although Sims found that the constringing action of the carbolic acid incommodiously narrowed the calibre of the vagina.

If the abdominal incision be performed, the incision should extend from near the navel to a point as low down as is compatible with the safety of the bladder, and then each stalk should be tied with gut, and dropped within the cavity. In the vaginal operation, the patient should be placed on her back, and not on her side. I am satisfied that it was the lateral posture that helped to kill my third patient, for as soon as the peritonæum was opened the air rushed out and in during every inspiration and expiration, an untoward circumstance which cannot happen in the dorsal posture. A duck-bill speculum is introduced, and the perinæum pulled downwards. The post-cervical mucous membrane is next caught up by a uterine tenaculum, and it and the underlying peritonæum are snipped open for about an inch with a pair of scissors, of which I have found Kuchenmeister's to be the best. The index finger of the left hand is then passed in, the womb pushed down from above by the right hand, and each ovary brought down to the incision by the finger hooked into the sling made by the oviduct. The ovary is now seized by a fenestrated forceps and brought into the vagina. The stalk is transfixed by passing a needle, armed with a double gut thread, between the ovarian ligament and the oviduct, and each half securely tied. The ovary is then removed, the ligatures cut off at the knot, and the stumps returned into the pelvic cavity. In order to hinder the chance of the protrusion of a bowel-loop, I have, in three instances,

closed the vaginal opening with one suture, and that either of silver or of gut; but in the case with the incision left unclosed no protrusion took place. The hæmorrhage during the operation was in only one of my cases quite free, but it was venous, and needed no ligature.

There is one drawback to this operation. For some reason the removal of both ovaries does not always bring about the cessation of the menses. From a careful collection of all the published cases of double ovariotomy occurring during menstrual life, I find that out of one hundred and thirty-two cases there were fifteen in which regular monthly fluxes kept on, and nine in which such fluxes were either irregular or lessened in amount. The cause of this unexpected continuance of the menses has been attributed by Koeberlé to a portion of ovarian stroma unwittingly left behind, but I think it is often owing to the existence of a third or accessory ovary. Kocks found a third ovary attached to a womb removed by him for cancer. The specimen was exhibited at the Medical Congress held last year at Cassel, and verified by Dr. A. R. Simpson, who happened to be present.2 Puech has collected several such cases, while the lamented Beigel, in three hundred and fifty post-mortem examinations, found eight women with a third or accessory ovary, containing true ovarian stroma.1 These accessory ovaries range in size from a hemp-seed to that of a cherry, and are usually attached by a slender stalk. They very generally lie on the boundary line separating the peritoneum from the serous covering of the ovary. Beigel encountered three attached to one ovary, and Waldeyer as many as six. "On microscopic examination they were found to consist of normal ovarian tissues, and to contain Graafian follicles in every degree of development, as well as relics of corpora lutea and follicles which had dwindled without rupturing. The author concludes that both conception and also the pathological changes of normal ovaries may originate in these bodies. They may also have a bearing on the recurrence of menstruation after the complete removal of the ovaries." I cannot but think that this is the explanation of Atlee's two remarkable cases, in each of which one ovary having been removed, the other became so diseased as to need repeated tappings, and yet each woman. not only menstruated, but gave birth to a child."

Does the extirpation of the ovaries after puberty unsex a woman? So far as can be ascertained it does not; at least no more than castration after puberty unsexes a man. In the one the ability to inseminate is lost, in the other, the capability of being inseminated but in both 1 Centralblatt für Chirurgie, No. 49, page 839.

2 Edinburgh Medical Journal, January, 1879, page 512.

8 Annales de Gynécologie, January, 1879, page 78.

4 Obstetric Journal of Great Britain, July, 1877, page 286, from Wiener medizinische Wochenschrift, May 26, 1877.

❝ Ovarian Tumors, pages 38 and 39.

the sexual feelings remain pretty much the same. Koeberlé, who has a large experience in double ovariotomies, avers that "the extirpation of both ovaries does not produce a single marked change in the general condition of the woman. She has simply attained the menopause abruptly." This opinion tallies with that expressed by Wells, Hegar, Peaslee, and Atlee, and is certainly confirmed by the history of my own patients, who are not conscious of any physical or psychological changes whatever.

The operation of spaying is yet in its infancy, and time is needed to develop its resources. But I cannot help feeling that in carefully selected cases it will prove the sole means for curing many mental and physical disorders of menstrual life which have hitherto baffled our science, and are a standing opprobrium to our profession.

DYSTOCIA FROM DORSAL DISPLACEMENT OF THE ARM.

BY C. H. BROCKWAY, M. D., LYNN, MASS.

THE above cause of obstructed labor may not be an uncommon one, but it is difficult of diagnosis, and has been seldom described by accoucheurs.

Simpson observed it, and advised the difficult manœuvre of bringing down the arm, and so converting the case into a hand-and-head pres

entation.

Tyler Smith quotes Simpson, but cites no case as having fallen under his own observation. He adds, "It would be well if accoucheurs meeting with such cases should put them on record." Playfair, in his excellent work on obstetrics, describes a case occurring in his own practice, in which he tried to get the head through the brim with forceps, and failed. He finally delivered by turning. So little attention has been given to this complication by obstetrical writers that I thought it might not be unwise to record my own experience in reference to it.

On the evening of May 26, 1878, I found Mrs. R. J., age twenty years, in labor with her first child. The lady, who was well built, had been in excellent health throughout her gestation, except that during the two weeks preceding labor she complained of pain in the abdomen on moving about, and as that region was very protuberant I ordered a well-fitting bandage to be worn until labor should begin. I saw her at nine P. M. of the day above mentioned, and learned from the nurse that she had suffered with well-marked pains since noon; these continued until four A. M., the day following, when the os was fully dilated, and the waters broke.

With a view to stimulating the womb to more active contraction, I then began gently to manipulate it externally, when I was surprised to