tion that may be considered desirable in these cases is the complete dilatation of the mouth of the womb. The dilatation should be so great as to admit a free use of any instrument we should desire to employ. This may be accomplished in two ways; by slitting it up with scissors or a knife, and allowing its edges to cicatrize before proceeding further, or by introducing prepared sponge. If we dilate with a sponge we must introduce a piece every day large enough to fill up the os. When the parts are sufficiently dilated we may proceed to operate. There are several modes of operating for these polypi. The object should be to remove the whole mass when practicable. If the tumor is small, this may be done by torsion, or evulsion, both of which are safe modes; but if the neck is large and strong we cannot remove it in this way without very greatly endangering the integrity of the uterus. In that case, if we can get the chain of the ecrasseur around the neck we should remove it in that way. But, as I have sometimes experienced, this cannot always be done. When this is impossible, there are three other modes of proceeding. The first is to crush the growth as completely as may be done with strong forceps; a large lithotomy forceps will do very well for some cases, or we may have a forceps made for the purpose. When crushed entirely up to the point of attachment, inflammation and sloughing are soon followed by the expulsion of the mass, either piecemeal or wholly, and the patient recovers. Mr. I. Baker Brown recommends his operation of coring, that is, gouging out as much of the centre and as high up as possible, and then leaving the remainder to the powers of nature. The oldfashioned mode of operating by ligature is the most effectual in some specimens; but as it is the most tedious, and probably also the most dangerous method, unless there are special reasons in its favor, I prefer one of the above as being easier performed, more expeditious, and as effective. We perform evulsion and torsion with strong vulsel forceps, twisting and drawing alternately. The operation of ligating the neck of the tumor can be performed with a double canula, described by Gooch, and is so familiar to every student that I need not describe it. When any of the tedious processes are adopted, it will be best to wash out the vagina and uterus with a good syringe several times during the twenty-four hours, to prevent as nearly as possible-by dislodging them-the absorption of any of the noxious products of decomposition. We should be aware of this danger, and guard against it by every available means. The fibrous polypi springing from the cervix, and occupying more or less completely the vagina, should never be ligated, crushed, or dealt with in any other than in a summary way. They should be immediately and completely removed. The preferable plan of removal, when small, is to seize them with a vulsel forceps, and twist them off. This mode, by torsion, almost always proves entirely successful when the polypus is not large. When the neck is so large that it cannot be twisted off, we should draw the tumor down with the forceps, until the attachment appears at the vulva, when the chain of the ecrasseur should be thrown around it, and the connection severed with this instrument. This operation is simple, safe, and practicable. Nobody need fail in it, or fear any subsequent bad effects. But another equally simple and practicable, and almost as safe a method, is to divide the neck of the polypus close to the attachment with the scissors or knife. To do this handily, the polypus should be drawn down as before. In about two and a half per cent., hemorrhage is troublesome after cutting off with the knife, but it may be easily controlled by the tampon; or what is the pleasanter way, to expose the part with a speculum, and apply the persulphate of iron to it. Sometimes we find instances where a polypus has an attachment to the cervix by an ordinary neck, and on account of inflammation, contracts adhesions to the vaginal walls besides. These adhesions, so far as I am aware, are not very firm, and judging from a limited. experience, may be overcome by the finger. Whether this be the case or not, the neck of the growth may be exposed by traction, and severed as before, and these adhesions be overcome by the finger, the handle or blade of the scalpel, as may seem necessary. The soft variety of the polypus may be destroyed by torsion and evulsion always, so far as I am aware. The operation consists in seizing it with flat-bladed forceps and twisting it off. I have, on some occasions, taken it off with curved scissors, without any bad results, and with perfect success, so far as the ultimate cure was concerned. The removal of the fungous polypus is a more serious and diffi cult operation. It is also much more uncertain in its results, in two respects. It is often reproduced in spite of all the care we can summon, and again produces malignant degeneration in the uterus and surrounding organs. In removing the other forms of growth, we are pretty sure of success if we remove nearly all the tumor, a small part of the neck disappearing spontaneously when left to itself. In the fungous or epitheliomatous growth, on the contrary, it is not only necessary to remove all the fungus, but to remove the tissue whence it springs. And we should be so liberal in the removal of the seat of growth, as to include all the cervix that may be amputated without damage to other organs. There are two ways of doing this. In the first place, the cervix should be drawn down by means of strong-hooked forceps, so as to show at the vulva as much as we desire to remove. After this exposure, we may surround the cervix with the ecrasseur, or we may fairly cut through the sound tissue entirely above the disease. This is a serious and not always safe operation in its general results, although simple, and may be easily performed. It is apt to be followed by inflammation of the uterus, and thereby endanger the life of the patient. Any bleeding that may occur, may be stopped, peradventure, with the persulphate of iron and the tampon. CHAPTER XXVI. OVARIAN TUMORS. OVARIAN TUMORS-ANATOMY, NATURE, AND PATHOLOGY-DIFFERENT TISSUES SHAPE-MONOCYSTIC, POLYCYSTIC, OR UNILOCULAR AND MULTILOCULAR CHARACTER OF CONTENTS-MODE OF ORIGIN-PROGRESS-COM ADHESIONS-TREAT PLICATIONS-TERMINATIONS-CAUSES-DIAGNOSIS-RATIONALE-PHYSI- PERFORMANCE-KIWISCH OPERATION-OVARIOTOMY-PARTIAL AND COMPLETE-DANGERS, CAUSES OF CAUSES OF DEATH IN OR AFTER OPERATIONS-MODE OF OPERATINGOBSTACLES MET WITH, AND MODES OF OVERCOMING THEM-AFTER-TREATMENT-CASES. OVARIAN tumors spring from and are for the most part formed of the hypertrophied tissues of the ovaries. There are tumors very much resembling and often mistaken for them, however, developed in the lateral ligaments. These latter are generally distended and hypertrophied sacs of the parovarium, and contain thin serum, merely; are cured sometimes by tapping, or they spontaneously burst, or are broken by accident in the peritoneal cavity, and disappear, never again to annoy the patient. The Fallopian tubes sometimes are the seat of enlargement. The tubal canal becomes obliterated at each end, and fills up with the hilus usually appropriated to the lubrication of its inner surface, hypertrophies in tissue, and thus constitutes a morbid development. Although rare, these two forms of tumors are observed. Doubtless, other enlargements, of a nature not yet properly understood, are sometimes originated by unknown causes. The anatomical distinctions can be made in most instances by careful dissection, so that in cadaverous investigation they need not be confounded with the ovarian tumors, except it be where all tissual distinctions are obliterated by an intercurrent or supernatant disease. It is not my purpose now to pursue this subject fur ther than the mere mention here made. In the proper ovarian tumors, we may trace three coats or layers of tissue forming their walls. The external is the serous or peritoneal. It is shining and smooth as this membrane is elsewhere, and seldom changed in any way, except it may be thickened and hypertrophied. It can be traced into the peritoneal covering of the viscera and abdominal parietes, and consequently needs no elaborate description. The internal coat or lining membrane, is doubtless the membrana granulosa of the ovisac, very much hypertrophied. When small, something like epithelium seems to be its entire composition. As they grow and develop, the epithelial arrangement is less perfect, until, when very large, we can observe it only in patches. In many cases when thus large, this membrane has a smooth, lustrous appearance, but in others, it is more or less thickly studded with granular projections, varying from almost imperceptible minuteness, to the size of peas, or even larger. Regarding the main sac as an hypertrophied ovisac, I think these little granular sacs (for they prove to be sacs upon examination), are also of the same nature, and are the origin of the numerous endogenous or supplementary growths which constitute one of the polycystic varieties. The middle coat is made up from the stroma of the ovary. Its strength depends upon quite a considerable amount of fibres, which enter into its composition. As the tumor develops, these fibres are enlarged, and apparently, if not really, increase in numbers, until they constitute the most of the thickness of the walls, and in some parts make quite a thickness, density, and toughness of tissue. These qualities are greater in old large sacs than in the smaller and younger ones. At the pedicle and for some distance up the sides, they are greater than in other portions, being in these parts sometimes a quarter of an inch thick, while at the fundus or distal portion, they may be thin and fragile. The whole of this coat may be very tough and thick, so as to resist great force, or it may be thin throughout, so as to be easily ruptured at almost any point. Entangled in the meshes of these fibres may be discovered, in many cases, the minute microscopic points so numerously scattered through the substance of the ovaria. These points are believed to be the origin of the germinal spot in the ovum by some physiologists, and around which are developed the ovum and progressively the whole ovisacs and their contents; and |