prolonged more than usual. A short time ago the abdomen began to swell. She was tapped three weeks ago and a gallon and a half of straw-colored fluid removed.

She has been brought to us by her physician. The abdomen contains a little fluid and there is a movable tumor-apparently two tumors—but there is so much tenderness that she will not permit a careful examination without ether. I shall now examine her under ether. The diagnosis lies between a fibroid tumor of the uterus and a fibroid of the ovary. I find that the womb can be readily moved, and movement of the womb does not communicate any motion to the tumor, and, on the other hand, when the tumor is moved, it has no effect upon the uterus. This is in favor of the idea that the tumor is connected with the ovary; still it may be a uterine fibroid with a long pedicle. The tumor is quite irregular in shape.

I shall now proceed to operation, and as I was not quite certain what would be found, I have come prepared to remove the womb if that should prove necessary. The patient had the bowels opened by a dose of castor oil given yesterday. Last night she had a thorough bath and all hair on the abdomen removed. The abdomen has just been washed with a bichloride solution 1-1000. The instruments have been placed in these trays and boiling water has been poured over them. To this is now added a 5 p. c. solution of carbolie

acid.

I make a free incision through the skin of the abdomen between the umbilicus and pubes, taking care to keep in the median line. I deepen the incision until the sub-peritoneal fat is reached, and then uncover the peritoneum. Before opening the abdomen all hemorrhage is controlled by the catch forceps. I now hook up the peritoneum with a tenaculum and make a nick in it. This opening is then enlarged with scissors, the finger being inserted to prevent injury to the intestines. The tumor is at once seen, and it proves to be a fibroid tumor of the right ovary. There is also a small cyst connected with it which gave the impression of two tumors. The incision must be enlarged in order to permit the removal of the growth. I turn it out of the abdomen, and, after applying pressure forceps to the pedicle, remove the mass. The pedicle is next transfixed and each part tied separately, and then the ends of one of the ligatures are passed around the whole pedicle and secured. I apply

a catch forceps to the pedicle in order that I may examine it before closing the incision and let it go.

I find that the left ovary also shows evidences of change, probably of the same character as that found in the right, and I shall therefore remove it in the same way.

Having satisfied myself that there is no bleeding, I proceed to the next step, which is an important one, that is the toilet of the abdomen. I pour into the peritoneal cavity water that has been boiled and thoroughly irrigate it. The water is then removed with sponges and a sponge is placed in Douglass' cul de sac, to absorb any fluid that may collect there. Two flat sponges are placed over the intestines to protect them, and the edges of the incision brought together. The instruments and sponges are now counted in order to be sure that none have been left in the abdomen.

We are now ready to insert the stitches. The needle is passed from within outwards, and includes the peritoneum and the edge of the tendon on each side. Having placed all the sutures, their ends are grasped with forceps on each side. The edges of the wound are then separated and the sponges left in the abdomen are removed. The stitches are then tied. The incision is then dressed with gauze containing 50 p. c. of iodoform. Over this is placed a pad of cotton which has been rendered aseptic by being baked in an oven. This is held in place by broad strips of adhesive plaster, and over all is secured a flannel binder.

Nothing will be given by the mouth for the first thirty-six or forty-eight hours. This rule is absolute unless there is collapse. Under the latter circumstances whiskey may be given by the mouth. If, during this time, nourishment is thought necessary, it may be given by the rectum in the form of enemata containing milk and beef tea. The reason for not giving food by the mouth is to lessen the tendency to vomiting and to diminish the peristaltic action of the bowels. We wish everything to remain quiescent so that every bleeding point may heal. At the end of a week every alternate suture may be removed, and in a few days the remaining stitches can be taken away.

ABSCESS OF BOTH OVARIES.

Our second patient is Mrs.

-, aged 27 years. She has been married three years and was perfectly well until seven months

ago, when she began to suffer with abdominal pain. Her physician, on examining her, found a pelvic tumor and brought her to me. This tumor is apparently as large as a fœtal head. Menstruation has been regular but profuse. The growth seems to resemble a fibroid tumor of the uterus. The facts, however, of the youth of the patient, the suffering which has been experienced and the presence of nodules posterior in Douglass' cul de sac are opposed to the supposition of a fibroid tumor and point in the direction of

sarcoma.

The patient has been prepared for operation as in the previous case, and I shall at once proceed. I first make an incision three inches long in the linea alba, and, opening the peritoneum, I reach the omentum which covers, and is adherent to, the tumor. I carefully separate this and the growth is exposed. It is now quite clear that it is not a solid mass, but contains fluid. Inserting the aspirator needle, there is at once an escape of a quart of oderless pus. This cyst is evidently formed of the left ovary. The Fallopian tube lies behind it. The abscess wall is firmly adherent to the omentum, the colon and the womb. I have separated all the adhesions but those to the uterus. These are so dense that I think it wiser to allow them to remain, enucleating the inner wall of the cyst and tying the remainder with the Staffordshire knot. There is a portion of the omentum which shows some bleeding. I shall therefore ligate and remove it.

I find that the left ovary has also undergone suppuration and is closely adherent to the omentum, the uterus and the womb. We shall treat this ovary in the same way as that of the other side. It is also necessary to remove a portion of the omentum on this side.

We are now ready to irrigate the abdominal cavity, and in a case of this kind this must be thorough. I shall use a Davidson's syringe, introducing the nozzle and forcing the boiled water into all parts of the peritoneal cavity. I have used some six quarts of water and it now returns clear. It will be advisable in this case to use a drainagetube. This is introduced between the two lower stitches. A wire suture is inserted between these two silk sutures, but left untwisted. The object of this is to close the opening left by the withdrawal of the tube. The iodoform dressing is applied closely around the tube and a piece of thin rubber sheeting eighteen inches square is then taken and a hole cut in its centre. This is sprung over the drainage

tube and serves to protect the dressings. A small sponge is placed over the orifice of the tube and the rubber folded over it. Several times a day the sponge is to be removed, cleansed in a 5 p. c. solution of carbolic acid and reapplied. The tube can probably be removed in the course of twenty-four hours.

The after treatment will be the same as that indicated for the previous case.

SELECTED PAPERS.

ABSCESS OF THE LIVER-TREATMENT.

By VAUGHAN HARLEY, M.D.

Read in the Section of Medicine at the Annual Meeting of the British Medical Association, held in Leeds, August, 1889.

Having enjoyed the advantage of seeing abscesses of the liver treated both in the tropical East and the temperate West, it may not be unacceptable to the profession if I describe what, I think, may with some degree of truth be designated, "A rapid mode of curing hepatic suppurations."

All having had much experience in the treatment of liver abscesses are aware how exceedingly troublesome it is to get them to close up after they have been evacuated; and that, not only does the emptied suppurating cavity occasionally refill more than once, but after a free counter-opening has been made, pus will continue to ooze away for weeks, aye, even months, equally to the discomfort of the patient and discontent of the doctor.

Several methods of treating liver abscess are at present before the profession, each professing to possess special advantages; but not one of these appears to me to be either so simple, or so successful, as that which I am now about to detail, as well as to illustrate the advantages of, by narrating the results which attended its adoption in two most unfavorable cases for treatment.

Before relating them, however, in order that the subject may be perfectly plain to those who have not paid special attention to it, I

will tabulate some of the general principles in connection with liver abscesses, which teaching, reading and experience have taught me to regard in the light of pathological aphorisms.

1. That the hepatic abscesses of the tropics differ in no essential feature, whatever from the same forms of suppurations occurring in temperate zones, except in one single particular, that of relative frequency.

2. Men are far more liable than women to liver suppurations.

3. Although an abscess of the liver may occur at any period of life, it is much more common between the ages of 20 and 50 than at any other.

4. Suppurations of the hepatic tissues are most frequently met with in strumous subjects; and the most unsatisfactory cases of all to treat are those in which a syphilitic taint is superadded to a constitutional struma.

5. The most noted predisposing causes to liver abscesses are struma and alcohol-even when alcohol is indulged in within what is usually regarded as the limits of moderation.

6. The commonest of all the exciting causes is a sudden chill, as pointed out by Sir William Moore.

7. All abscesses of the liver tend to evacuate themselves by burrowing their way to the surface of the organ, and seeking an outlet for their contents either directly through the abdominal walls, or indirectly (in general) through the pulmonary or digestive systems.

8. It is futile to evacuate a liver abscess either by knife or trocar so long as a free opening is not left to give escape to the subsequently formed pus.

9. When an accumulation of pus has taken place in the liver not only tends to do serious mischief by causing disintegration of the hepatic tissues, but, from its becoming putrid, to kill the patient by blood-poisoning. This likewise occasionally happens when dyatids of the liver suppurate, which they frequently do when they contain. daughter cysts.

10. Cancerous and tubercular deposits in the liver, by disintegration, sometimes lead to the formation of purulent formations.

11. As a natural corollary to these facts, I think all will admit that so soon as the existence of purulent matter is detected it should be evacuated, and the speedier this is done the better will be the patient's chances of recovery.