This method of securing the pedicle is in my opinion inferior to that about to be described, first because it is difficult to tie a sufficiently tight ligature en masse with catgut, which is now almost universally employed, so that there is distinct danger of the ligature slipping after the catgut has been softened by the peritoneal fluid; and, secondly, because such a stump can scarcely be covered in with peritoneum so as to avoid leaving a raw surface. Both these drawbacks are avoided by securing the severed pedicle with a continuous suture applied as follows: A curved needle threaded with catgut takes up the ovarian artery in the first stitch, which is tied around the artery and suspensory ligament. The pedicle is then cut through with successive snips close to the tumour, and the needle takes up each successive portion of the broad ligament as it is severed, the final stitch being tied around the Fallopian tube and utero-ovarian arterial anastomosis. The stitches cannot slip off, and practically no raw surface is left; even the line of suture can be buried for the most part by bringing the suspensory ligament and the stump of the tube together with a single stitch. In suturing the abdominal wall the peritoneum should first be united with a continuous catgut suture, then interrupted silkworm gut sutures should be inserted through all the remaining tissues of the abdom inal wall at intervals of an inch, and before these are tied the anterior wall of the rectal sheath should be brought together with a continuous catgut suture. A much neater scar will be obtained if a continuous catgut suture either subcuticular or through the skin edges is added.
The after-treatment of an ovariotomy differs in no respect from that of any other operation, and will be found in detail in the article on Operations, Treatment of (q.v.). It may be mentioned here that the inability of patients to pass water after operations such as ovariotomy is often due to want of training in the use of a bedpan; it is well to sec that such training is given in the days during which the patient is being prepared for opera tion. If any real difficulty exists, no harm will be done by allowing the patient to go on for IS to 24 hours before the bladder is relieved; failing the well-known expedients of warm water in the bedpan and the application of a warm sponge to the vulva, the catheter must be passed with proper aseptic precaution and under the guidance of the eye.
Ovarian Tumour with Complications.—Ovarian tumours are liable to certain complications. Of these, the most common is superficial inflam m.ation, which shows itself by pain and tenderness in the area affected; there is often some interference with the function of the bowels, and some rise of temperature and pulse-rate. Such a condition is best treated by rest in bed with hot applications to the affected area. If the pain is severe Lin. Belladonnas and Lin. Chloroformi in equal parts may be sprinkled on cotton-wool and applied to the skin. It is very seldom that morphia is required, and if it be given the dose should be very small for fear of still further encouraging constipation. The bowels should be carefully
regulated by the daily use of an aperient. As the inflammation almost invariably causes the formation of peritoneal adhesions, which arc soft and fragile at first and become firmer and more ligamentous with time, operation should be undertaken as soon as the temperature and pulse rate have come down to normal and the acute symptoms have subsided.
Another fairly common complication is axial rotation or torsion of the pedicle, which is accompanied by obstruction to the venous return, causing rapid increase in the size of the cyst, with partial necrosis of its walls; this is followed by adhesive peritonitis, causing adhesions to develop between the cyst and its surroundings. The accident is accompanied by pain, which is more acute the more tightly the pedicle is twisted, and may cause collapse and vomiting. The sudden increase in size of the tumour often leads to its detection for the first time, and as the symptoms in an acute case are those of an " abdominal catastrophe," these cases are often operated on at once under the mistaken diagnosis of acute appendicitis, rupture of a viscus or the like. Cases so treated as a rule do very well, but if the true diagnosis is arrived at it is as well to tide over the initial shock and collapse by giving small doses of Morphia with rectal injections of saline solution (Oj. with brandy 5j.), repeated every 3 or 4 hours, and to operate at leisure on the following day. If operation be postponed for some weeks or months the tumour will be found surrounded with dense adhesions.
Rupture of the Cyst may occur with disappearance of the tumour and escape of its contents into the abdominal cavity. Any shock or collapse caused by the accident should be treated and the cyst removed as soon as this has passed off.
Suppuration of the cyst is a dangerous and troublesome complication, but fortunately not common. A suppurating cyst is always densely adherent to its surroundings, and in many cases its cavity communicates with the bowel, bladder or exterior. It is hopeless to attempt to cure such a case unless the cyst is excised, but it is permissible to make an endeavour to improve the genera] condition before operating if the patient is much worn out and emaciated. For this purpose general hygienic measures, fresh air and sunlight, good feeding and rest may be tried. It is possible that vaccine treatment might assist, but in view of the difficulty of deciding what particular microbe is causing the suppuration such treatment had best be handed over to a specialist, as the injection of a vaccine in the dark is likely to do harm rather than good. The attempt to improve the patient should not be too prolonged, and if after a week or two no strength has been gained it is well not to delay operation lest her condition should become so low as to put it out of the question. In desperate cases where a prolonged operation would evidently be fatal an attempt might be made to drain the suppurating cavity through an abdominal incision, and so to relieve the patient to some extent from septic absorption.