1847.] On the Treatment of Ovarian Dropsy. 505 .the tumour, and a continuation of such decrease, or by a positive non-increase for some weeks, then the cyst should be tapped and all its fluid evacuated." "3. Treatment after tapping consists of accurate padding and tight bandaging over the cyst and body generally for two or three weeks; and the medicines and position ought to be continued for at least six weeks. I would particularly wish to enforce the importance of the after-treatment, as on that depends very much the success or failure of the case."-P. 161. Certainly, the system of tight bandaging and padding, after a patient has been salivated is very formidable, and the recital of the sufferings and dangers to which patients have been exposed is sufficient to make any judicious practitioner seriously pause before he sanctions it. Mr. Lee seems to question the successful issue of Mr. Brown's cases, and on the authority of a physician, whose name however does not appear, he mentions two of the successful" cases-one of which has again been tapped; and, after the death of the other, the cyst was found as large as ever. Then, again, much doubt seems to hang on the genuineness of the cases, as to whether they have all been ovarian cysts, or some other abdominal enlargement, so that altogether, Mr. Brown's success appears to have been sometimes temporary only and altogether very equivocal. Of the surgical means for the cure of ovarian dropsy, there are two particularly described, viz. tapping and the excision of the cyst. As a palliative means tapping is sometimes very successful; and cases are recorded where patients have lived many years, the fluid of the cyst being frequently drawn off by the trocar. In Mr. Martineau's case, 13 hogsheads of fluid were taken away from an ovarian cyst in eighty different tappings. But tapping is not without its danger-syncope, and speedy exhaustion may sometimes follow the evacuation of the fluid-a large vessel may be punctured, the cyst may inflame, and peritonitis may ensue. It sometimes is only partially successful, when the tumour is multilocular. Mr. Lee is favourable to an early recourse to paracentesis; and he thinks that, when the tumour can be felt from the posterior wall of the vagina, and fluctuation is distinct, it ought to be tapped. We could have wished Mr. Lee to have collected more facts, to show the results of this early tapping, on the value of which he speaks authoritatively and without doubt. In order to clear the way for a correct appreciation of the operation of ovariotomy, Mr. Lee has collected a number of cases in which tapping was performed, and he has noted the duration of life after it has been had recourse to. Putting together 57 cases of this kind, taken from Mr. Lee's own table and Mr. Southam's, in which death occurred, it appears "that 24 of the 57 died after the first tapping-that they all died in eight months-that 20 of the 24 died within one month-and 12 of the 20 within seven days." Mr. Lee thinks it possible that many of the cases from which his table has been framed, may have been published as peculiar cases, which would of course vitiate the truth of the conclusions. Many eminent men whom he spoke to about it, thought the mortality after the first tapping was too great; but he is himself disposed to think it correct. We must own that the numbers appear very startling, and do not accord with our general impression; but we think that it discloses a far larger mortality, admitting even the possible errors in it, than is generally supposed. Our author concludes that, "taken at its best, tapping is a very dangerous means of palliating ovarian dropsy; that, when it is had recourse to, it will have to be frequently repeated; that the relief afforded between each operation will become gradually less, and the dangers consequently greater. This, then, is a valuable argument in favour of some other means of treating ovarian dropsy." We must now advert to the other operation-namely, the removal of the disease by excision. Mr. Lee's views on this subject are founded on one hundred and eighteen cases in which gastrotomy has been performed, which he has collected with much diligence, and carefully tabulated. Of these 78 have recovered, and 40 have died; in ninety-two the tumour has been removed: in nineteen it was not extracted; and in six there was no tumour to be found. But we meet at once with a source of error in the fact, that (according to Mr. Phillips, Dr. Bird, and Mr. Lee) there are several unsuccessful operations which are not recorded-augmenting, of course, the mortality of the operation, without, we fear, being paired by a corresponding omission of the more fortunate cases. Of these 118 cases of gastrotomy, sixty-nine were for the removal of encysted tumours of the ovary; sixteen for solid tumours of the ovary; six for uterine tumours (fibrous growths); one for an omental tumour; one for the cyst of an ovarian abscess; in six no tumour was found; and the particular disease is not mentioned in 19. Of the 69 cases of encysted dropsy, 48 recovered and 21 died. Of the 16 cases of solid tumours, nine recovered and seven died; and of the six cases of fibrous tumour of the uterus, two recovered and four died. There are two or three important and obvious points on which Mr. Lee makes some observations. One of them is on the mortality after ovariotomy, another, on the difficulties in the diagnosis of ovarian dropsy, and particularly on the means of ascertaining the presence of adhesions, which have proved the principal hindrance in the uncompleted cases. Mr. Lee estimates the average mortality in ovariotomy as one in three; and, comparing this with the mortality in other capital operations, it appears to be rather under than above the mark. Malgaigne has computed the deaths after amputations, of all kinds, in the Parisian hospitals, as four in every ten cases; and it is much the same in the Glasgow and Edinburgh Infirmaries. In the tying of arteries, the deaths have been 3 in 10; and in cases of hernia, 5 in 10. The tendency which ovarian tumours have to contract adhesions to the structures and viscera adjacent to them, is a formidable impediment to their extraction. In the cases which have been recorded, they were found to exist in more than one-half of the number. They may be numerous and firm, without any previous known inflammatory attack; and it is a mistake to suppose that tapping causes adhesion. In the latter case, the collapsed and empty cyst sinks down into the pelvis, away from the opening which has been made by the trocar. There have been several supposed signs of adhesion, on which, however, as single signs, no absolute reliance can be placed. An ovarian sac may be moveable, and yet adhesions, probably long and firm, may be present. Dr. Bright's sign of the new-leather creaking or crepitation as demonstrating adhesions, may not be heard; first, because it is principally to be heard if the adhesions are recent, or, according to Mr. Southam, only when 1847.] On the Diagnosis of Adhesions in Ovarian Dropsy. 507 fluid is present; and then, again, it may be present, but so deeply placed behind the sac, that it cannot be perceived by the ear. A valuable sign of the presence of adhesions in front was communicated to Mr. Lee by Dr. Bird. "When an ovarian sac has attained a size which is productive of great inconvenience and distress to the neighbouring organs, the parietes of the abdomen become greatly attenuated, and the space between the two recti abdominalis is much enlarged; this is well seen if the patient be told, while lying on her back, to raise herself into the sitting posture without the assistance of her arms; and if the sac within be free in its motions it will immediately be protruded through the space between the two recti muscles, and produce an oval enlargement; but supposing the cyst to be intimately adherent in front, no such bulging will take place."-P. 189. The action of the diaphragm on the tumour will help to determine the existence of adhesions. "Another symptom of this sort is valuable, and that is the action of the diaphragm upon the tumour. If the measurement of the abdomen be obtained after the patient has taken a deep inspiration, and again after a full expiration, you will find, when the cyst is free, that the two measurements frequently vary an inch, sometimes more; showing that the diaphragm in the inspiratory movement had driven down the unattached cyst, while it being free, the expiratory effort allowed it to repossess its original position in the abdomen."-P. 189. Tapping the cyst is a practical means of learning the presence of adhesions. "On the withdrawal of the fluid, the walls of the abdomen are observed to follow closely the contracting cyst, when adhesions are present, and have externally a drawn-in and puckered appearance, while the cyst does not descend into the pelvis ; whereas, when the cyst is free from adhesions, it may be found after its evacuation low in the pelvis, forming a hard tumour at the lower part of the abdomen, while the walls of the abdomen may remain free."-P. 190. It is, however, in a careful collection of several of these signs that the complication is to be made out. "But, although the dependence on these symptoms singly may lead us into error, the combination of many of them will generally be conclusive, supposing the patient, when rising by her own exertions, protrudes the cyst as an oval bulging tumour through the space left by the separation of the recti. That on a deep inspiration the tumour is pressed downwards more into the cavity of the abdomen, and then recedes on an expiration; that the bladder is free, and can ascend into the anterior part of the abdomen when filled with air; that all crepitation is absent, and the tumour tolerably moveable; then we may with satisfaction say that adhesions do not exist. Another additional evidence would be, if the patient had been previously tapped, and the sac had entirely disappeared after the operation."-P. 194. Leaving the question as to whether ovariotomy is expedient or not until the conclusion of the chapter, our author describes the two different modes of operating, which are respectively called the major and minor operations. When the incision has exceeded six inches in length Mr. Lee has classed the case as belonging to the former, whilst an incision under six inches in length is ranked as a minor operation. Eighty-five cases have been operated on by the large opening, and the mortality has been one in three. Twenty-three cases have been relieved by the minor operation, and the deaths have been one in six. It is still a disputed point which of the two is the most feasible operation. Dr. Clay, Mr. Walne, and others preferring the major, Mr. Jefferson, Dr. F. Bird, and others holding to the minor. Mr. Lee argues for the latter, and the obvious fact that the latter may, in case of need, be converted into the former is a strong general argument in its favour. Mr. Lee has learned, by private communications from Mr. Lane, Dr. Clay and Dr. Bird, that the women on whom they operated successfully continue to enjoy good health. We conceive this to be a most important addition, and we think that these and other operators should concisely publish the after history of their cases. Mr. Lee thinks that, in the majority of cases, " ovariotomy is most decidedly unjustifiable," and he arrives at this conclusion from the difficulty of the diagnosis in the disease, and from the frequent existence of adhesions. He thinks the increased mortality, when adhesions have been present, disqualifies such cases for this means of relief, and when the diagnosis is obscure he would of course avoid so frightful an operation. He talks in very contradictory terms of the value of the uterine sound in clearing the diagnosis in these cases, for in the text he says that "no tumour of the uterus ought to be mistaken for ovarian disease since the introduction of the uterine sound by Professor Simpson ;" and then, in a foot-note, it appears that "he and several others, men in the constant habit of using the sound, were deceived in a case of ovarian dropsy." We think he has overstrained the value which this really useful obstetric instrument affords in these cases. Mr. Lee, however, is "decidedly of opinion that in some cases the operation is very justifiable." It is particularly so where the "cyst is single and uncomplicated with hard matter, and the powers of life active." The treatment which Dr. F. Bird adopts after extirpation consists principally in being able pretty quickly so to raise the temperature of the room as to cause profuse sweating, for which purpose also he gives the patient plentifully of ice. Should febrile symptoms arise, he brings on the free action of the skin, and watches his patient unremittingly for some days. We have thus brought before our readers the principal results which flow from Mr. Lee's compilation on this interesting subject, and with it our observations on his Dissertation. We congratulate him on the honourable prize which he has won, and we cordially wish him success in the department of medicine which he appears to have chosen. But we seriously advise him, while he yet has time, to cultivate a knowledge of general literature, not only for the alluring purposes of disciplining, storing and enlarging the mind, but for the lower and indispensable object of writing correctly. 1847.] Matteucci's Lectures and Researches. 509 I. LECONS SUR LES PHENOMENES PHYSIQUES DES CORPS VIVANTS. By Signor Carlo Matteucci, Professor in the University of Pisa, &c. Paris, 1847. 12mo. pp. 406, 18 woodcuts. Lectures on the Physical Phenomena of Human Beings. II. ELECTRO-PHYSIOLOGICAL RESEARCHES. First Memoir. THE III. ELECTRO-PHYSIOLOGICAL RESEARCHES. Second Memoir. ON THE PROPER CURRENT OF THE FROG. By the same. IV. ELECTRO-PHYSIOLOGICAL RESEARCHES. Third Memoir. ON [From the PHILOSOPHICAL TRANSACTIONS for 1845. Part II. Communicated by Michael Faraday, Esq. F.R.S.] In the Medico-Chirurgical Review for April 1845, we published a somewhat lengthened article on the interesting and important investigations of Professor Matteucci, contained in his Traité des Phenomenes Electro-physiologiques des Animaux, as well as in the Rapport entre le Sens du Courant Electrique et les Contractions Musculaires dues a se Courant, published jointly by MM. Longet and Matteucci, and noticed in the Comptes Rendus for September, 1844. In that article we announced that the Council of the Royal Society had, on the recommendation of its Committee of Physics, adjudged to Professor Matteucci the Copley Medal, on account of the novelty and importance of his researches. To show his gratitude to the Society for the distinction thus accorded to him, Matteucci communicated, in the three Memoirs whose titles stand at the head of this article, some fresh researches on electro-physiological phenomena. In 1844, the Government of Tuscany appointed Matteucci to deliver, in the University of Pisa, a course of lectures on the physical phenomena of living beings; an interesting subject, for the elucidation of which Matteucci's studies and investigations peculiarly fitted him. These lectures were published in Italy, and have passed through two editions; but they have only recently become known to the English public by the French edition published in the present year, under the direction of the author, who has in it made considerable additions to the matter contained in the second Italian edition. In these Leçons, Matteucci discusses the subjects of the three Memoirs. published in the Transactions of the Royal Society, and in the edition now before us he has introduced a notice of all his most recent investigations on Electro-physiology. This of course renders the French edition greatly superior to the editions previously published in Italy. Professor Matteucci's course consists of twenty lectures, and embraces the following subjects: Molecular Attraction; Capillarity; Imbibition; Endosmose; Absorption No. 108 33 |