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the uterus, and had expressed an opinion that in the cases he(Dr. Lee) had related in the paper, the sudden cessation of theuterine contractions after its use could not be referred to it. Itwas impossible to reconcile such contradictions, but they ad-mitted of a ready explanation. He lately perused a letterwritten by a fashionable lady soon after her confinement, to aphysician, which contained the following passage:-" Chloro-forme a la reine, just a few drops on a handkerchief from time.to time for the last hour; I found it a most indescribable alle-viation, and that though never insensible. This was a correctaccount, he believed, of the way in which chloroform was ad-ministered by Dr. Snow in natural labour, and it would accountvery satisfactorily for his assertion that the uterine contractionswere little, if at all, impaired by it. Fifteen drops sprinkledupon a handkerchief, and the lady now and then permitted tosniff a little of the vapour from the corner in the last hour oflabour. If he (Dr. Lee) might be allowed in plain language tocharacterize this proceeding, he would say that the whole wasa mere pretence, and calculated only to deceive the weak,ignorant, and credulous. The anesthesia from chloroform, ofwhich Mr. Fergusson had spoken, and which was usually, ashe understood, the result in midwifery, was quite another affairfrom the " chloroforme a la reine" of Dr. Snow. Last week hesaw a surgical operation performed upon a yourg woman, towhom six drachms had been administered. Her pupils werewidely dilated, the breathing stertorous; there was foaming atthe mouth; the pulse was rapid and feeble, and there wereconvulsive twitchings of the muscles of the extremities. Noman in his senses would venture to reduce a woman to such afrightful condition in natural labour. In surgery it might beconsidered justifiable, but in midwifery it was wholly unjustifi-able. Dr. Gream had stated that two ounces of chloroform mightbe given with safety in cases of natural labour, and though headmitted that it decidedly had the effect of diminishing thestrength and regularity of the uterine contractions, yet still itsinfluence might be so managed as to’prevent the progress oflabour being interfered with. If Dr. Gream would stand upin the face of the Society and state how chloroform could be somanaged, he (Dr. Lee) would immediately sit down. (Dr.Gream here expressed his dissent, but Dr. Lee amrmed thatthis statement had been published by Dr. Gream in his lastpamphlet.) In forceps cases, (continued Dr. Lee,) and in allthe great operations of midwifery, chloroform could producenothing but mischief, for in all these cases consciousness wasthe great safeguard of the patient. No forceps cases and he hadhad as many as any person in that Society-were so unmanage-able as those in which the consciousness was lost from puerperalconvulsions, where the patient could not be held in the sameposition for any length of time. In uterine haemorrhage, andin all cases of protracted labour, from whatever cause, nothingbut mischief could result from the use of that narcotic

poison. The exhibition of chloroform in labour he heldto be contrary to the sound principles of physiology andmorality. " In sorrow shalt thou bring forth children," wasan established law of nature-an ordinance of the Almighty,as stated in the Bible, and it was in vain to attempt to

abrogate that law. There could not be a doubt that it wasa most unnatural practice to destroy the consciousness ofwomen during labour, the pains and sorrows of which exerteda most powerful and salutary influence upon their religiousand moral character, and upon all their future relationsin life. But he might put aside all these physiological andmoral considerations, and rest his objection to the use of chloro-form in labour upon the danger of introducing a subtle narcoticpoison into the system at such a time. When only one drachmwas given, who could be certain that it should not instanta-neously be followed by the death of the person to whom it wasadministered? Upon this point the whole questions might beallowed to hinge.The next meeting of the Society will be held on Tuesday,

January 10, 1854.

NORTH LONDON MEDICAL SOCIETY.

WEDNESDAY, DEC. 14.—CHARLES TUNALEY, F.R.C.S., VICE-PRESIDENT, in the Chair.

Mr. ERICHSEN related a case of hip disease, in which he hadrecently excised the upper part of the femur and a small por-tion of the acetabulum. Drawings of the case and the excisedportions of the bone were exhibited. The case promised a veryfavourable issue. He then read a paper

ON THE EXCISION OF OVARIAN TUMOURS.

After some introductory remarks, he related the case of a lady,

aged sixty-five, and the methods employed to form thediagnosis, and determine the selection of the mode of opera-tion. The room having been warmed to a temperature of 80°,the patient was laid on a table of convenient height, coveredwith doubled blankets, so that the legs hung over the end ofit, chloroform administered, and the bladder emptied. (Thebowels had been cleansed out by a purge on the preceding day.)The operation was commenced by an incision about five inchesin length, made in the linea alba from the umbilicus down-wards, the tissues carefully incised, and the peritoneum opened,when the tumour presented itself. Into the part on the leftside, that was soft and fluctuating, a large trocar was intro-duced, and about a gallon of very thick, pasty, dark-coloured.

fluid drawn off. The hand was now introduced into the cavityof the abdomen, and the more solid part of the tumour (whichextended high up on the right side, lying against the liver)was drawn down and brought out through the wound. Indoing this, a few adhesions, that passed between the anteriorwall of the abdomen and the tumour, were broken through.The mass, which was of considerable magnitude; was now liftedout of the abdomen (the intestines, being protruded, werepassed back with soft warm cloths), and was found to beconnected by a broad attachment to the right broad liga-ment. This pedicle was short, wide, and composed prin-cipally of large bloodvessels, with some connecting cellulartissue; it was drawn well forwards. A nasvus-needle, armedwith strong whip-cord, was passed across it, care beingtaken to avoid any of the bloodvessels. The peritoneal invest-ment of the pedicle was then dissected off to the extent ofabout a quarter of an inch in breadth all round, and the whip-cord ligature firmly tied on either side along the line. Thetumour was then detached by cutting across the pedicle, halfan inch above the ligature. The wound was closed by a seriesof interrupted sutures, closely applied, and at the lower partby two hare-lip pins, with figure of 8 sutures; round these theligatures of the pedicle were firmly twisted, so that the cutstump projected out of the abdomen between the lowest pinand the inferior angle of the wound. The abdomen wasthen supported with cross strips of plaster and a bandage.Mr. Erichsen then detailed the after treatment adopted. The

patient left her bed on the sixteenth day. He considered thatthe case illustrated well the surgical management to be adopted.The principal points in the operative procedure, that in hisopinion required attention, are to regulate the length of theincision to the size and character of the tumour. The morefluid the tumour, the less extended need the incision be. Asthe solid part of the mass must necessarily be extracted entire,an incision for its ablation must be proportioned to its magni-tude and shape, and the surgeon should not advocate eitherthe small or large incision exclusively. The ligature of thepedicle is an important point, as unless this be properlypractised there will be no inconsiderable risk of the superven-tion of secondary haemorrhage. It is best done by trans-fixing with a naevus-needle, carrying a whip-cord ligature,.and tying on each side as tightly as possible. The dissectingdownwards of that portion of peritonseal investment of thepedicle, across which the ligature is tied, appears to be ofmuch importance in preventing the constriction and sloughingof the otherwise included line of serous membrane, and thuslessening the dangers of peritonitis. It is a part of the opera-tion, however, attended by some risk, by the chance of wound-ing the bloodvessels, which are here thin, walled, and large,that they may be avoided by careful manipulation. After

tying the pedicle, it is of considerable moment that the liga-tures should not lie in the peritoneal cavity, and that thestump should not slough off within the cavity of this mem-brane, as under each circumstance peritonitis of a severe orfatal character would probably ensue. All this is best avoidedby drawing the pedicle well forward, so as to project abovethe wound, and attaching the ligature to the harelip-pins, withwhich the lower line of the incision is closed. The after treat-ment consists in keeping the patient in a warm room, giving aliberal supply of ice, with opiates to tranquillize the system,and arrest peristaltic action, to draw off the urine, and not toattempt to relieve the bowels, which may be left confined formany days without inconvenience to the patient. In consider-ing the subject of ovariotomy, two questions present them-selves-first, as to whether the operation is a sound one, andought to be retained in practice ; and secondly, if retained, inwhat class of cases it should be had recourse to. In answerto the first question, the course taken by ovarian tumoursvaries greatly. In some instances these growths do notappear to be incompatible with prolonged existence and a fairshare of health; in other instances, again, after remainingquiescent for some length of time, they assume considerable

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activity of development, and interfere so seriously with theother abdominal organs, and with the general operations of theeconomy, that life is attended by great misery and discomfort;and in a third class of cases they rapidly and steadily runtheir course to an unfavourable termination. After a time, inthe majority of instances, the tumour may be materiallylessened in bulk by tapping; but when once this operation hasbeen performed, it will require to be repeated with increasedfrequency, the intervals between each succeeding tappingbeing diminished, and then a fatal termination at a compara-tively early date may be looked for. Mr. S. Lee states thatof 46 patients who were tapped, 37 died, and only 9 recovered,and that of the 37 who died, more than one-half did so in fourmonths from the first tapping; 27 out of the 37 in the firsttwelve months, and of these 18 were only tapped once. Theobjection had been raised against ovariotomy that the mortalityfrom it was so high as not to justify a surgeon in performing it.Undoubtedly a very high rate of mortality after an operationwould constitute a very serious bar to its performance, and themore so if it could be shown that the disease for which it waspractised was not necessarily fatal, or even a very serious one.Thus Mr. Phillips had collected the particulars of 61 cases inwhich ovarian tumours were extracted; of these 35 were suc-cessful, and 26 died. Mr. Lee gave 90 cases; of these 57recovered, and 33 died: and Dr. Robert Lee, the most recentwriter on the subject, had collected 102 cases of ovarian ex-traction, of which 60 did well, and 42 terminated fatally.From these statistics it would appear that the mortality afterthe removal of ovarian tumours amounted to rather more thanone in every three cases. This appeared to Mr. Erichsen not tobe excessive, when compared with the result of operations,various severe surgical injuries, or scrofulous diseases. In thenext place, ought ovariotomy to be performed in all cases, oreven in the majority of instances of ovarian disease? or oughtit to be limited to a few and exceptional cases, and practisedas a last resource? The most ardent advocate for this opera-tion would scarcely, he thought, advise that an attempt shouldbe made to extract the ovarium from every woman labouringunder tumour of this structure, but would rather recommendthe employment of palliative treatment until the growth hadbegun to interfere seriously with the comfort of existence, orwith the healthy action of the abdominal organs, the patientwasting, suffering much discomfort from her size, with difficultyin breathing, repeated vomiting, gastric irritation, &c. Heconfessed he saw no chance of giving relief or of prolongingher existence except by the removal of the tumour; medicaltreatment was of no avail in those cases, and tapping only gavetemporary relief; therefore one must either leave the patientto her fate, or have recourse to the ablation of the tumour,which, it had already been shown, might be done with theprospect of success in nearly two cases out of every three. Thequestion of diagnosis had to be considered in two of its bearings :first, as to the existence of such adhesions between the enlargedovarium and the other abdominal organs as to render the ex-traction impossible; and, secondly, the diagnosis betweenovarian and other abdominal tumours. Such adhesions as

would prevent extraction having been met with in rather morethan one-third of the whole number of cases operated on,-according to Dr. Lee, in 60 out of 162 cases,-the diagnosis ofthis complication was of extreme importance. Its existencemight in general be suspected when it was ascertained that thepatient had been the subject of attacks of peritonitis; whenthe abdominal tumour did not appear to change its position onthe patient taking a deep inspiration and then expiring freely;and when, on the patient raising herself into a sitting posture,the sac did not tend to move forwards into the space betweenthe recti muscles. So also much light might be thrown uponthis important point by ascertaining the existence of a crepitantor crackling sensation between the anterior abdominal walland the tumour, and more particularly when the tumour, wastapped, drew down with it the abdominal parietes, or sunkinto the pelvis without exercising any traction on those parts.The conditions also of the pelvic viscera,-viz., the bladderand uterus, as ascertained by examination with the sound,might tend to show whether connexion existed in this quarteror not. But in other instances, and more particularly whenthe mass is bound down posteriorly, there was no probabilityof determining this point, and then the surgeon might, to hisgreat annoyance, find that after laying open the abdomen theoperation could not be completed, and the tumour require tobe left. In those cases in which there was any reason tosuspect the presence of adhesions, it was a wise precaution tomake a small exploratory incision into the abdomen, through

which the fingers or hand might be introduced, and the con-nexions of the tumour examined. If these were too extensive

to admit of removal, the aperture might be closed, and possiblythe patient might escape without any very serious consequencesensuing, as in these cases the peritoneum had in a greatmeasure lost its character as a serous membrane, and was notso susceptible of the diffuse and destructive forms of inflamma-.tion that would otherwise be likely to occur in it.

Mr. GREENHALGH detailed the case of a young woman who,after being struck by a chair over the region of the left ovary,wasseizedwithsymptoms of ovaritis, which yielded totreatment.Some time afterwards, a swelling, about the size of an orange,was detected in the iliac fossa, which increased in spite oftreatment, until it greatly distended the abdominal cavity.She lost during seven years three children at the full period,each progressively smaller; this he attributed to arrest of de-velopment from the pressure of the tumour; this was alwayspressed above the gravid uterus. Gentlemen skilled in thediagnosis of abdominal enlargements pronounced it to beovarian and fit for removal. However, three weeks after thelast confinement, she sank from exhaustion in her twenty-ninthyear, when, upon post-mortem examination, the tumour turnedout to be cerebriform disease of the kidney, weighing twenty-seven pounds.

Mr. TUNALEY related the case of a lady, mother of twochildren, the last born in September, 1851, the labour easy,and recovery good. In April, 1852, he was consulted re-

specting a swelling in the right iliac region. The patientconsidering herself pregnant, no treatment was adopted,although the nature of the disease was explained to thepatient’s friends. Mr. Tunaley was again consulted in Sep-tember, 1853. No sign of pregnancy was found. Many con-sultations were held, and all opinions agreed. At the end ofOctober in this year another gentleman was consulted, and thelady pronounced seven months and a half advanced in preg-nancy. A month later this opinion was still maintained, andon the 4th of December, Mr. Tunaley was summoned to thelabour; he found a foetus in the vagina some two months old.For three days after this miscarriage she continued as well asusual, no difference existing in the size of the abdomen. Onthe fourth day peritonitis arose, and the patient sank on the7th; a forty pounds weight of multilocular ovary was foundon the examination of the body. The fcetus and ovary were

presented to the Society, together with a microscopical andchemical analysis of the contents by Mr. Adams. Mr. Tunaleyremarked on the singularity of the occurrence of pregnancyunder so great a pressure on the uterus.

Dr. BALLARD read an elaborate analysis of cases of ovario-tomy, from which he deduced an opinion favourable to theoperation.Mr. PART thought that in denuding the stump of its peri-

toneal covering, Mr. Erichsen had avoided a very frequentsource of fatal termination. He related a case in which thesac after twice tapping had filled with featid gas, which, byits distention, interrupted the functions of the viscera.

Correspondence.

SMALL SIZE OF THE SPLEEN IN LUNATICS.

JOHN ROSE, M.D.

"Audi alteram partem."

To the Editor of THE LANCET.SiE,—Numerous opinions have been advanced regarding the

functions of the spleen, and perhaps we may never attain tocertainty on the subject. Its small size in the fcetus appearsto favour the idea that it is in some way connected with theprocess of digestion, and that it acts as a sort of ce’CMMK,or reservoir. This, we think, is the most generally receivedtheory of its operation.

In connexion with this subject, a curious fact has been latelyobserved in this hospital. At the post-mortem examinationsof patients who have died in the lunatic asylum, Drs. Wilsonand Stuart have remarked that the spleen has been almost in-variably of an unusually small size.

I am not aware that this fact has been previously noticed.It is possible that its small size in the cases alluded to maybe a mere coincidence; still we think it worth recording,although we do not pretend to affirm that it is of much prac-tical importance, or that it will throw any new light on thefunction of the spleen.

It will be interesting, however, to know if any of your readershave made similar observations, and it is on this account thatI trouble you with this note.

I am Sir, your most obedient servant,Haslar Hospital, December, 1853. JOHN ROSE, JB1.D.