and Rigg, of Wilkinsburg; aged 35 years, married; the mother of two children, the younger 9 months old. At the time of her last confinement she was attended by Dr. Pershing, and nothing abnormal was developed. Two months. later she discovered an immovable growth in her right ovarian region, about the size of a small egg. This increased but little during the next four months. A few days before operation it was seen for the first time, and was found to be about the size of an adult head. During the two weeks previous it had doubled in size. Her temperature was 103°, she was confined to bed, suffering considerably. Her attendants used the hypodermic needle for purposes of diagnosis and secured a yellow puriform liquid, which subsequently congealed. Microscopical

examination

showed it to be made up largely of fat globules with a few leucocytes. The cervix was crowded forward in the pelvis and perfectly immovable. A diagnosis of adherent dermoid ovarian cyst was based on the rapid increase in size, the inflammatory symptoms and the nature of the fluid withdrawn. An immediate operation was decided on and performed with the assistance of Drs. Werder, Pershing and Rigg. Identification of tissues was very difficult. The great omentum was much hypertrophied and infiltrated and attached below to the fundus of the bladder; it was tightly adherent in front to the abdominal wall and behind to the cyst. The cyst was universally adherent; not one square inch of free surface could be found; the adhesions were of the firmest character. The great omentum loosened from the cyst, secured with clamp forceps above and an elastic ligature below, and cut transversely be

was

between. A sound was now passed into the bladder and it was found that the elastic ligature embraced not only the great omentum, but also a portion of the fundus of the bladder. The ligature was at once loosened and the cut omental surfaces seared with the Paquelin cautery. The cyst was forcibly loosened over a considerable surface on either side and ruptured in the effort. The fluid evacuated was of the same nature as that withdrawn by the needle, and there was also secured a small bunch of long black hair, thus verifying the diagnosis. As soon as the rupture occurred the cyst was freely opened in front. There were two distinct cavities, the larger below. It was impossible to prevent the fluid from entering the peritoneal cavity. Five or six gallons of boiled water was used to wash out the peritoneal and cyst cavities. What was evidently a tooth could be felt in the bottom of the cyst wall. After every justifiable effort had apparently been made to overcome the intestinal adhesions, a plait was taken in the cyst wall on either side and the margins of the opening in the cyst stitched to the lower part of the abdominal incision, a glass drain being left in the peritoneal cavity and one in the cyst.

The peritoneal tube was removed at the end of 24 hours, and the tube in the sac was replaced by a rubber one on the third day. Suppuration occurred in and about the cyst, but the highest temperature during the first ten days was 100 2-5°. Some obstruction to the discharge of pus from the cavity between the bladder and the cyst occurred during the third week and caused an elevation of temperature. In other respects her recovery was uneventful. The sac collapsed and sloughed. It was washed out

three times a day with boiled water, and occasionally with sublimate solution. During the first two weeks there was some discharge of oily matter with the pus, but none since. She is now up and about the house, and the discharge from the sinus is diminishing.

In connection with the history of these two cases, the question arises Could these cysts have been removed? Mr. Lawson Tait at the close of last year said: "I am now in a position to say that no cystic tumor of the abdomen exists which cannot be removed. In my second series I have only to plead guilty to 6 uncompleted operations in 1,000, whereas, in my first series, the number was 30, with the same mortality in each-50 per cent. Even in these six I know now, for post mortem examination revealed the fact, that I could have finished the operations in at least two, perhaps in three, if I had screwed my courage up to a still harder strain, and I blame myself accordingly."

Mr. Tait, in his work on "Diseases of the Ovaries," says: "Whenever, in an exploratory incision, the bladder is found pulled up and spread over the front of the tumor for a considerable distance, the proceeding may at once be brought to a conclusiou, for it may be regarded as perfectly certain that the tumor cannot be removed.”

Olshausen says: "At the present time it may be claimed that adhesions never make the operation impossible.

But, when the connection of the tumor with adjacent organs, especially the rectum, is unusually firm, and when the papillary formations of the tumor have grown into the wall of the organs, complete extirpation will be impossible. How rare this is in reality is shown by Schroeder's dictum that nearly every ovarian tumor may be extirpated. Tumors which he could not remove two years ago, he now extirpated completely in a second laparotomy."

Kaltenbach says: "And despite all our progress in technique, cases remain in which the operation cannot be completed, because the connections of the tumor with surrounding parts are too firm and extensive, or are imperfectly defined.

In cystic tumors we

may confine ourselves to partial extirpation, and stitch the pelvic segment of the tumor into the lower angle of the wound."

Fritsch says: "Should the adhesions in the lesser pelvis be firm, it would be exceedingly dangerous to loosen them.

Schroder obtained the best results by cutting off the upper part of the cyst and sewing the rest into the abdominal wound. The sac, thus separated from the peritoneum, rapidly diminished." My friend, Dr. Howard A. Kelly, of J'hiladelphia, who passed through the city this morning, tells me that he has never yet encountered an ovarian cyst which he could not remove.

On the other hand, Dr. Skene Keith, in his second series of .50 ovariotomies had 2 incomplete operations, with one

Series of One Thousand Consecutive Cases of Abdominal Section.-British Medical Journal, Nov. 17, 1888.

+ The Pathology and Treatment of Diseases of the Ovaries, New York: Wm. Wood & Co.

#Diseases of the Ovaries. By R. Olshausen. New York: Wm. Wood & Co.

ovariotomies stitched the cyst to the

* A Handbook of General and Operative Gynecology. By Dr. A. Hegar and Dr. R. Kaltenbach. New York: Wm. Wood & Co.

+ The Diseases of Women. By Heinrich Fritsch. New York: Wm. Wood & Co.

C. Cameron, in 28 cases had 2 incomplete operations, with one death. Terrier, in 25 cases recently reported, had 5 incomplete operations, with two deaths. It is evident from these quotations and statements, that incomplete operations occasionally happen in the practice of the best operators, but as their experience grows, such cases get less frequent, even to the point of disappearance; but when they do happen the mortality approximates 50 per cent. My own impression is, that if a cyst, firmly and extensively adherent to intestines, bladder and pelvic floor, is encountered by an operator who has not a most extensive experience and extraordinary skill, and if he feels that persistence in attempts at removal will result in the rupture of intestines, bladder or iliac vessels, his patient is much safer with the incomplete operation.

its cause, is always followed by a series of consecutive pathological changes, which, independently of the partial or complete interruption of the passage of the urine, tend to destroy life. A dilatation of the bladder and ureters by retention of urine may give rise to such a degree of distention as to destroy life from suspension of important functions by mechanical pressure. During the stage of inflammation a paretic condition may occur, the blood-vessels in the vesical wall lose their support, and transudation and exudation take place into the paravascular tissue, which, combined with capillary stasis attending this stage of the disease, results in sloughing, infiltration, pyæmia, peritonitis and death. The daming up of the urine may, and does often, cause surgical-kidney, epididymitis and tetanus.

The treatment of chronic vesical catarrh resolves itself into a consider

ation of the causes producing the disease, many of which, the presence in excess of certain inorganic constituents of the urine, stone, stricture and hypertrophy, are capable of correction; whilst others such as malignant tumors and certain conditions of the prostatemay only admit of a palliation of the symptoms to which they give rise and the removal of which must be the first object in treatment. But when a paretic condition of the bladder exists provision must be made for the complete continuous emptying of the viscus; its thorough cleansing by frequent irrigation with hot sterilized water; and the promotion of a healthy tone in the mucous membrane and muscular structure of the bladder. The frequent introduction of catheters for drawing off residual urine and washing out the

bladder has been productive of much harm, and, instead of giving relief, proved to be, by reason of their frequent introduction into the inflamed bladder to draw off the urine two or three times a day, a source of immediate and alarming symptoms. These facts are cogent reasons for adopting surgical means in all cases of intra-vesical troubles as soon as a diagnosis can be made, and often when it cannot otherwise be made, for the complete emptying of the bladder, thorough cleansing, diagnosis, and intravesical treatment.

The epicystic surgical fistula is designed for drainage, introvesical treatment and, cystoscopic exploration, and may be divided for consideration under the following heads:

I. Definition of epicystic surgical fistula.

II. Surgical resources in the formation of the epicystic surgical fistula.

1. Preparation for the operation.
2. Anæsthesia.

3. Position.

4. Incision and opening bladder. 5. Intra-vesical exploration and

treatment.

6. Toilet and after-treatment.

III. Advantages of the epicystic surgical fistula.

1. Cystoscopic exploration.
2. Intra-vesical treatment.
3. Drainage.

I. DEFINITION OF EPICYSTIC SURGICAL

FISTULA.

Epicystic Surgical Fistula is the title here given to a supra-pubic fistula into the bladder created by the surgeon for exploration, intra-vesical treatment and drainage. A fistula, which, acting as an artificial urethra, is capable of giving

free access to the inside of the bladder for cystoscopic exploration, to provide a ready, convenient and comfortable means of emptying the bladder at will, and gives the surgeon a competent opening into the viscus for intra-vesical applications.

It constitutes an essential element in the speedy and complete evacuation of the contents of the bladder in all epicystic operations, and imitates nature in the restoration of its own continuity and repair as the pathological changes within the bladder subside.

II. SURGICAL RESOURCES IN THE FORMATION OF THE EPICYSTIC SURGICAL

FISTULA.

(1). Preparation for the Operation. The of presence two assistants, though not necessary, may be of valuable aid. A temperature of 80° or 85° Far. should be maintained in the operating room from the beginning to the end of the operation. All hair is to be shaved from the pubis and all the details of antiseptic surgery are to be carried out so far as cleaning the pubis and abdomen. The bladder is emptied and thoroughly washed with warm water. When the water returns clean

the bladder is slowly distended with

warm sterilized water thrown into the bladder by means of a fountain syringe, with nozzle in urethra-a degree of pressure sufficient to distend the bladder to its utmost capacity-which can never be too great for the resistance of the bladder. It is better to fail in filling the bladder than to distend the bladder beyond the limit of competency. Indeed it is not necessary to fill the bladder to any degree of resistance. I have operated when the bladder was in an irritable condition and would not

tolerate distention greater than the capacity of two ounces and had no difficulty in avoiding the pre-vesical fold of peritonæum or finding the bladder. The water is secured in the bladder by tying the penis at the base with a rubber tube. A colpeurynter is next to be well oiled and inserted into the rectum-the rectum having been previously emptied by enema-and filled with warm water. This distention brings the bladder into view above the pubis.

(2). Anesthesia.-My preference for chloroform is the result of my own personal experience with it. It is not free from objections as its depressing effect on the heart is well known. The operation usually occupies fifteen minutes; and, hence, its prolonged use would be unnecessary and uncalled for. The objection to ether is the suppression of the excretions and the frequency with which bronchitis is produced when administered to persons advanced in years. The best course to pursue, when the operaation is prolonged, is to follow the use of chloroform by ether. The patient must be kept profoundly under the influence of the anaesthetic from the first incision until the superficial wound is closed.

(3.) Position. The patient is placed on the back on an ordinary operating table with the legs extended as if in a position for perfect comfort and rest. Many surgeons claim advantages in the position recommended by Trendelenburg. Eigenbrodt emphasizes the fact* that the elevation of the pelvis in Trendelenburg's position † helps the surgeon

* L. c., p. 72. Ct. Lang, Med. News, Dec. 4, 1886. + In Trendelenburg's position the patient's legs are held over the shoulders of an assistant with the body resting on an incline table, much in the position which hogs are swung for spaying.

to avoid the prevesical peritoneal fold at the time of the incision of the bladder.

I have employed this posture for introvesical operation by means of the supra-pubic incision with no advantage over the ordinary flat-back position. With two openings in the bladder for a continuous stream of clear water I have no trouble in illuminating every part of the bladder with the electric surgical light and thus enabled to examine the entire intravesical wall. Undoubtedly the position recommended by Trendelenburg, possesses advantages which to the author more than myself, makes it highly ideal. As for myself I prefer and recommend the flat-back position.

(4).-Incision and Opening Bladder. A perpendicular incision three or four inches long is made in the median line above the symphysis pubis. The recti muscles are separated to symphysis. If the pyramidalis are in the way, the fibres should be cut. The transversalis facia is divided on a grooved director from symphysis to within one inch of upper margin of superficial wound. Instead of following Guyon's manœuvre, I catch the bladder with a tenaculum on a line with the symphysis, through the prevesical fat, and cut through with a bladder knife into the bladder with one smooth, clean incision, to prevent undue disturbance of the cellulo-adipose tissue between the bladder and pubis and avoid infiltration. I have never seen a case where it was necessary to put up the prevesical fat, and with it the periIf the bladder is tonaal cul-de-sac. caught on a line with symphysis and cut downwards, no fears need be had for the peritonæum. Cutting this prevesical fat prevents its after dropping down over the opening into the bladder and