In cases of small ovarian cysts an at tempt should be made to save a small portion of healthy stroma. Under no circumstances should an ovary be spared when the opposite one is the seat of car cinoma, papillary cystoma, or superficial papilloma, even when the organ is appar ently perfectly healthy. Gersung (Cen tralb. f. Gyniik., No. 5, '99).
Statistics of 304 ovariotomies per formed in fifteen years in Sella Ma's wards, as early as possible and removing the tumor undiminished in size whenever it could be managed. Silk was employed and the abdominal wound closed in three layers. The mortaliiy was 0.5 per vent.; of the recoveries, 97 per cent. were per manently cured and 71; per rent. had sound abdominal cleat rices. Removal through the vagina resorted to whenever practicable; however, of the last GO vag inal ovariotomies, the tumor could be totally extirpated only in 19; in 10 this method had to be given up and the ab dominal operation performed. The mor tality of the purely vaginal operations was 1.94 per cent. only. Burger (Fest schrift f. Prof. Schauta; Monats. f. Geburtsh. u. Gyniik.; Brit. Med. Jour., Nov. 17, 2900).
question of drainage is not considered as one of so great im portance as a few years ago. Then it was the custom to drain in the majority of cases; now, to drain in a very slight minority. It is only in those patients in whom there is extensive tearing up of the peritoneum, with the probability of ooz ing or serous effusion, that the operator would consider it necessary to drain. Drainage may be accomplished by the introduction of a glass drainage-tube, which must be carefully attended to for the next forty-eight hours, or the use of gauze drain, which serves a useful pur pose, in that it may be employed to com press a large bleeding surface. In cases in which there is large tearing up of the peritoneal cavity, the plan advocated by Clark, of elevating the foot of the bed so that the fluid shall no longer be retained in the pelvis, where the peritoneum is most injured, but be thrown back into the peritoneal cavity, where it should come in contact with healthy peritoneum capable of absorbing it, is the method of procedure practiced in preference to drainage. It has received the name of postural drainage. This method of treat ment has an advantage, also, in reliev ing the patient of much pain and discom fort, arising from the gravitation of fluid to the most dependent portion. The elevation of the injured part renders it more difficult for blood to be sent into it, and consequently the patient suffers less distress.
Closure of the Wound.—The principle of closing the wound is to bring and re tain the various parts of the wound in their normal relation. This is effectively accomplished by employing both inter rupted and continuous suture, introduc ing a continuous suture with catgut to close the peritoneum, then introducing a series of interrupted silk-worm-gut su tures which shall pass through the ab dominal walls, and pick up the edge of the peritoneum. The placing of these sutures is followed by a continuous cat gut suture uniting the aponeurosis of the wall. The tying of the interrupted su tures holds the surfaces in apposition, prevents the accumulation of fluid in any dead space, and permits the sutures to be tied only sufficiently tight to hold in ap position the surfaces.
Dressing.—After careful cleansing of the surface the wound dressing consists in placing a piece of gauze wet with 1 to 2000 bichloride solution around the sutures, and over this several layers of sterile gauze and cotton, which are held in place by tapes attached to pieces of plaster and fastened on either side of the dressing; and, finally, a well-placed bandage.
After-treatment.—The patient is kept quiet in bed, carefully moved from side to side to render her detention less irk some. Until she recovers from the ames thetie, she is given nothing by the mouth other than small quantities of hot water, concentrated beef-extracts, and at the end of twenty-four hours, in an ordinary case, may be given a cup of tea and a little soft toast. This is followed later with an egg, chewing some beefsteak, and at the end of the third day a light diet.
Any indication of accumulation of gas in the intestine is early relieved by the administration of an enema consist ing of an ounce each of magnesia, glyc erin, and water. This failing to afford relief, is followed by a large enema of son p-suds in which an ounce of turpen tine beaten up with the yelk of a couple of eggs, and strained, or an ounce of tincture of asafoetida may be substituted for the turpentine. _Nausea and vomit ing may be overcome by giving draughts of hot water, thus washing out the stom ach; the administration of small doses, frequently repeated, of tincture of nux vomica, or a combination of acetanilid and caffeine, or the use of oxalate of cerium. If the patient regurgitates small quantities of dark-greenish material, and this is continued in spite of the large draughts of hot water, the stom ach-tube should be introduced and the stomach irrigated. The patient should be carefully watched during the opera tion by both nurse and physician to an ticipate the appearance of complications or abnormal symptoms.
The summing up of the testimony of the various experimenters seems to in dicate that a properly transplanted ovary may continue to perform its full normal function and that one may not only expect to prevent the symptoms of the menopause after a patient's ovaries have been removed. but may reasonably expect a pregnancy in a certain per centage of cases. Personally there is little doubt that the recorded cases of pregnancy after double ovariotomy are cases of pregnancy from accidental ovarian grafting, a portion of ovary having remained on the distal side of the ligature, with establishment of ad hesion circulation or contact circula tion.
It is important to determine now just what method of ovarian transplantation gives the best opportunity for the ovary to continue its function. In all proba bility, a certain proportion of the women whose ovaries have been removed in the past could have had ovarian grafting done, either from a piece of remaining healthy ovary or from a segment of an ovary from another patient, the opera tions having been so timed that the one who was to furnish the ovary could have been operated upon at the same m'ance with the one who was to receive the ovary.
The special dangers to he anticipated from ovarian grafting would seem to be no more than the dangers from simple uncomplicated laparotomy.
The ovary that is to serve for a graft is placed in a basin of physiological sa line solution at a temperature of about 100° F. immediately on its removal. The broad ligament is the preferred site for grafting, as nearly as possible at the point that the ovary would normally occupy. One of pregnancy followed which was terminated by early abortion. but the several successful pregnancies that have been obtained in rabbits by other experimenters indicate that fruit ful pregnancy in women as a result of ovarian grafting may yet be hoped for. E. T. Morris (Med. Record, Jan. 19, 1901).