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TABLE OF CASES OF OVARIOTOMY PERFORMED BY MR. SPENCER WELLS.

SERIES 1.--In which ovariotomy was completed-50 cases : 33 recoveries; 17 deaths." II. " " was commenced, but not-completed-3 cases. No death from the operation." III. "an exploratory incision was made in aid of diagnosis-3 cases. 1 death.

SERIES 1.—FIFTY CASES IN WHICH OVARIOTOMY WA.S COMPLETED.

SERIES II.THREE CASES IN WHICH OVARIOTOMY WAS COMMENCED, BUT NOT COMPLETED.

SERIES III,-THREE CASES IN WHICH AN EXPLORATORY INCISION WAS MADE.

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that operation, what have you to substitute for it?" But Mr. the operation, and sometimes causing great difficulties in sepa-Wells had pointedly put it to this Society to state whether rating the tumour from neighbouring organs. It was in thisovariotomy was a justitiable operation or not, and this question way that the intestine had been ruptured, portions of the liverought to be answere,l here. Now how were we to judge whe- torn away, the peritoneum stripped up from the abdominal wall,ther an operation is justifiable or not ? By these tests-by the and other serious and fatal mischief induced. But adhesions were

consequences of the disease bong left to itself, by the mortality dangerous in other ways. They ofen contained bloodvesselsattending it, and by the result following its successful perform- which could not retract in the dense substance of the adhesion,ance. They had just heard he lamentable consequences of and though they did not bleed much at the time of their divi-leaving ovarian disease to run its own course, and it was known sion, did so afterwards, slowly oozing into the abdominal cavity,that medicine was inoperative in checking it. Now as to the and giving rise to dangerous and fatal haemorrhage. But adhe-

mortality after ovariotomy. Several years ago, before ovario- sions were not an unmixed evil. When extensive they seemedtomy had attained that degree of perfection and of comparative to obliterate the peritoneal cavity; to destroy the serous mem-safety which improved methods of diagnosis and of operative brane as such, and to reuder it less liable to take on in flam-manipula,:iun have now given to it, Dr. Lyman, of New York, matory action than when it was in its normal state. In this

published a most able essay containing an analysis of 300 ope respect the peritoneum resembled the synovial membrane ofrations performed up to that time ; of these the mortality was joints. Just as we often see that when the knee has beenabout -12 per cent. Since that period ovariotomy had greatly chronically inflamed, its synovial membrane destroyed and re-imprdvpd in safety, as was evidenced by the results of the placed by fibroid tissues, a great amount of mechanical violenceoperations of Mr. Wells, Dr. Tyier Smith, and others. The in the way of forcible extension and flexion may be inflictedmortality now was probably not 30 per cent. Let this for a upon it without exciting inflammation in it, so in the peri-moment be compared with what occurred in other operations, toneum, when that has been coated with old adhesions andwhich no surgeon hesitated for an instance to undertake. It organized plastic matter, inflammation is little liable to occur.was old and trodden ground to compare it with the result of Adhesions, therefore, were very dangerous and troublesome atthe operations for hernia, ligature o! arteries, &c.; and in these the time of the operation itself, but rendered the patient lesscases also the comparison was scarcely fair, as these were ope- liable to the after-danger of peritonitis. Another importantrations of necessity, whilst ovariotomy was an operation of element in the success of the operation was the age of the patient.expediency, and not of immediate and imperative necessity. So far as his experience wrnt, it was entirely in accordance withBut compare it with " amputations of expediency" of the lower the deductions made by Dr. Lyman from his table of cases, thatextremity. He (Mr. Erichsen) wortl 1 terke for this purpose the the operation was much more dangerous in young than in elderlystatistics of a most able paper published two years ago in the women. Although not contraindicated by early age, it must"Transactions" of this Society, giving the results ofamputa- be looked upon with more anxiety in young women fromtions performed in one of the largest, hospitals in London- eighteen to twenty five than in women beyond the middle age.Guy’s- here it was known not only that the patients had the The most successful age for its performance was after the cessa-benefit of the most eminent professional skill, but all the appli- tion of the menstrual function, and every surgeon who had hadances that wealth could afford for their recovery. In that very experience in tho operation must have been struck by the greatable paper Mr. Bryant stated that the morrtality after amputation success often occurring in apparently most unpromising cases,of the lower extremity for tumours was 36 per cent., and the in women between fifty and sixty years of age. There were manymortality after "amputations of expediency" of the leg was other questions of the highest importance in connexion with66 per cent. Compare this result of amputations performed this operation into which time would not allow him to enter;under the most favourable circumstances, by men of the greatest but on reviewing the whole subject, he (Mr. Erichsen) thoughtskill and judgment, with those of ovariotomy, and the advan that the Society must reverse the decision to which it came tentageous position of the latter operation would be at once seen. or twelve years ago, and instead of condemning ovariotomy,Then take the next point-the result of ovariotomy as com- give that operation its hearty approval and justification.pared with other operations for tumours, say of the breast. No Mr. HuTCHiNSON stated that he thought Mr. Wells deservedsurgeon hesitated to operate in cases of cancer of the breast, much creditfor prominently bringing forward his facts respectingbut he knew that the result was most unsatisfactory-certain ovariotomy. He hoped that one great point would be gainedand probably speedy recurrence ; and he watched his patient by the recent progress in professional favour which this opera-with anxiety for the earliest signs of that return of the disease tion had made. In the future we might expect that patientswhich he knew must inevitably occur. But how was it with would be operated on at much earlier periods than had hithertoovariotomy ? Why truly- been the case. To this, more than to any other change, he

Aut cita mors veuit aut victaria lreta." looked for an improvement in ovariotomy statistics. He

agreed most fully with Mr. Erichsen in considering that theIf the patient survived the operation her recovery was com- operation was a perfectly legitimate one. He had himself per-plete and permanent. There were doubtless a few exceptional formed it in seven cases, with a result of four recoveries andcases, in which the disease might r:turn in the other ovary, three deaths. In an eighth case he had operated only on thebut these were so few as scarcely to deserve being taken into afternoon of the day of meeting, and, therefore, could not in.account. In the great majority of cases the patient was at elude it. Now, as he htd included several very bad cases inonce and permanently cured. without fear of recurrence. Con- those operated on-one, especially, in which Mr. Erichsen

sidering. therefore, ovariotomy from all these points of view, assisted him, which was at one time almost beyond hope-heit must be pronounced as a proper and a justifiable operation considered four recoveries a very fair result. He could fullyThere were’ some very important considerations connected with confirm the statement of Mr. Wells, that when patients re-the diagnosis of ovarian tumours, and their conditions as affect covered they usually regained very excellent health, and wereing the probable result of operation, which deserved to be permanently restored to full enjoyment of life. As he did notcarefully studied. These were, the effect of concomitant drop- believe that adhesions were of the slightest possible advantage,sical effusions, of adhesions, and the influence exercised by the hut, on the contrary, considered that their influence on theage of the patient on the operation. Errors had no doubt been hopefulness of a case was entirely on the other side, he heldmade in the diagnosis of ovarian as in that of all other tumours, it to be very desirable that cases should be operated on early,external or internal, but these were much less likely to occur, before they had time to form. In thanking Mr. Wells for theand did actually occur with much less frequency.. at the present support which his facts gave to ovariotomists, he begged alsoday, when the question of operation had perfectecl the dia to thank, not less warmly, Dr. Robert Lee, since he consideredgnosis, than happened formerly, when so accurate a knowledge that the paper recently read by him, in which, for the first time,of the nature and conditions of these rumours was not neees- statistics were ignored by an opponent of the operation, wassary. With regard to concomitant constitutional mischief, as the greatest triumph which its advocates had yet achieved.influencing the propriety of an operation, the surgeon would of Mr. SPENCER WELLS said that the importance of the pointcourse be guided by those considerations that influenced him raised by Dr. Graily Hewitt could hardly be exaggerated. Noin all cases. But there were two special complications which slirgeot, could be justified in performing any operation neces-were of peculiar importance: one was ascites, and the other sarily attended by serious risk to life, unless life was seriouslyanasarca of the general cellular tissue. Ascites appeared to threatened by the disease. If an ovarian tumour was not veryhim (Mr. Erichsen) always to be a serious complications, and lar.e. or was not growing fast, no one would think of advisinghe did not much like to operate in such cases. Anasarca. had ovariotomy. It could only be justifiable when other treatmentbeen shown by Dr. Clay to be a condition unfavourable to opera- was useless, and life was threatened at no very distant period.tion, and in this he fully agreed. Then. as to adhesion?. These But all experience showed that-putting aside some rare ex-undoubtedly were a serious obstacle to the success of an opera- ceptional cases of women who lived for very many years withtion. They were an evil in two ways : first, by prolonging or without occasional tapping-it was rare for a patient to live

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for two years after an ovarian tumour had attained such a size as Ito raise the question of ovariotomy. He had stated his grounds forthis belief in a paper read before the British Medical Associa- Btion at Canterbury, and it was very interesting to find that IDr. Hewitt’s analysis of Dr. Lee’s own cases more than con-firmed the accuracy of his estimate of the duration of life underpalliative treatment. He did not aree with Dr. Hewitt inregarding fluctuation as being necessarily found in progressiveovarian tumours. He had seen many cases of such tumours,which grew very rapidly, and yet fluctuation could not be de-tected ; especially if there was much fat in the abdominal wall.Nor did he think that it could be called a mistake if a surgeonremoved a tumour, although he did not frel certain whether itwould prove to be uterine or ovarian. The great questionswere-" Is it movable, and can it be removed ?" In two ofhis cases great doubt had been felt before the operation. Oneof them had been alluded to in the paper. The other patienthad been examined by at least twenty gentlemen of great ex-perience, and about half thought the tumour was uterine, andthe other half ovarian. He himself felr great doubt, after re-peated examinations; and though, at the time of the operatic!),he was iuchned to think it was ovarian, he would not have ebeen surprised if it had proved to be a peritoneal fibrous out-growth from the uterus. Had it proved to be so, it would havebeen removed quite as easily, and probably quite as safely asit was, though the patient made an excellent recovery. Pro-vided the uterus and the tumour could be moved independentlyof each other, he thought the surgeon need not be deterredfrom operating by any doubt as to whether the tumour wereuterine or ovarian ; and he certainly could not be accused ofa mistake if, before his operation, he felt the impossibility ofbeing positively certain as to his diagnosis. Mr. Erichsen’ssupport of the principle of the operation by comparing the mor-tality with that of orher recognised operations was most valu-able. With regard to anasarca, he had bjen led to regard itas an unfavourable sign, and had noticed that many of thepatients in whom it had been present had done badly ; buthe thought we were arriving at a sort of law that, when it

merely depended upon the pressure of the tumour retardingthe return of blood from the lower limbs, it was of no more im-portance than in pregnancy. But when it depended on diseaseof liver, or spleen, or kidneys, or heart, or on leukaemia, thenit should lead the surgeon to consider the case as unfit for ope-ration. So with ascites. If it depended on disease of the liver,kidneys, or spleen, or on chronic disease of the peritoneum, thecase was very unfit for operation. But if no such disease couldbe detected, and the dropsy seemed to be caused by the merepressure of the tumour, or by its movements mechanicallyirritating the peritoneum, the effusion ceased as soon as th<tumour was removed. He had seen several such cases do verywell. In one there were fifty-seven pints of ascitic fluid, ancin another forty pints. He could quite confirm Mr. Erischen’:statement that persons above fifty years of age recovered remarkably well. He had operated on seven patients betweerthe ages of fifty and sixty, and only one died. But he dienot think young women unfavourable subjects for the operation. He had twice operated successfully on girls of seventeenand of fifteen cases between twenty and thirty, twelve had re-covered. Between forty and fifty, of eleven cases, seven hadrecovered. But, between thirty and forty, of fifteen cases, onlysix had recovered. They seemed to do better before thirtyor after forty, than between those ages. Wliether this wasaccidental, and would be corrected by a larger number of cases,he could not say. He quite agreed with Mr. Hutchinson’sremarks as to adhesions, although in many cases very extensiveadhesions had not appeared to have any retarding influenceupon recovery ; and he concluded by thanking the Society forthe attention which had been paid to the paper.

Correspondence.

WALTERS AND ANOTHER VERSUS LUSH.

" Audi alteram partem."

Tu the Editor of THE LANCET.

SiR,&mdash;In your last week’s impression, I observe that Mr.B. W. Lara, apparently stung by your comment upon theabove trial in THE LANCET of November 29th, has emergedfrom the self-obscuration he indulged in during its progress,and I consequently am compelled to publish a plain statement

of the facts and reasons that induced me, in the interests ofthe profession, to resist a demand which 1 deemed extor-tionate. Why inir. Lara, having brought the action in hispartner’s name, to the exclusion of his mcn, now discloses hiscomplicity therein, I cannot say : possibly unexpected successhas made him envious of his late associate’s fame, and weknow that in the balance against envy, discretion often kicksthe beam.Warned by my example, I trust that medical men will nar-

rowly scrutinize the tenor of a printed circular, the postaldelivery of which, in answer to an application for terms, isheld to be an implied authority to Messrs. Lara and Waltersto make a charge as commission utterly disproportionate to thework done, and where absolutely no information that could beacted upon was afforded by them to the persons BBho sought it.Though the case came twice before the Court, and was

nominally tried before a jury, the real facts never came out. Thejudge (Baron Martin) at the conclusion of the plaintiff’s case,without, permitting the defendant to offer rebutting evidence,directed the jury to return a verdict in o-a certain form, to beargued in the full Court, where, of course, the judges clecidedonly upon the facts already deposed to in the Conrt below-dry law, and not the merits of the whole case, clearly aloneinfluencing their judgment.

In August, 1S61, I applied to Lara and Walters, of 6, Pump-court, Temple, to find me a successor in a general practice Ihad carried on at Salisbury during twenty years, but fromwhich private circumstances rendered it necessary that I shouldretire in March, 1862. After two or three letters had been

exchanged, I authorized them to offer the introduction for salein the usual way, stipulating, however, for obvious reasons,that "I relied upon their llot disclosing the name of the

vendor, nor his place of residence, except to a bo.,,(i j’ttle appli-cant. "

It appears from Mr. Walters’ evidence, that in reply to myinquiry for their terms, they sent me a printed paper containingthe subjoined clause, though I certainly never read it untilit was again sent to me underlined, when Lara and Walterseventually applied f r commission. Though in some way Igathered that their charge was five per cent., I did not readthe following crafty and fatal paragraph :-

" Disputes often arise as to the right to commission whenprincipals employ other agencies ; therefore, to avoid allquestion upon this, it is distinctly understood that the com-

; mission becomes payable upon the adjustment of terms be-Ltween the contracting parties in every instance in which; any information has been derived at, or any particulars,r whether in writing or otherwise, have been given by, or anyi communication whatsoever has been made from, this office,7however and by whomsoever the negotiation may have been1 conducted, and notwithstanding the business may have beens subsequently taken off the books, or the negotiation may have. been concluded in consequence of communications previously

made from other agencies, or on information otherwise derived,1 or the principals may have made themselves liable to pay com-. mission to other agents."

With the paper came a letter trom Lara and Walters, wellcalculated to put anyone off his guard in such a matter, inwhich they wrote, " you will see that you need be at zio expenseuntil we find you a purchaser.’’ As I never intended, inapplying for the aid of Lara and Walters, to bind myself andmy affairs irrevocably to their behests, I took other steps, andmade various efforts, by replying to advertisements in themedical journals, to obtain my object, the more especially asthere was little time to spare, and no good result appeared tofollow my application to them.To one of my private letters, Mr. Needes, of Belgrave -street,

Euston-road, replied, and I eventually sent to him also theparticulars previously furnished to Lara and Walters, who, Imay observe in passing, gave me the addresses of only two-gentlemen during the whole transaction (five months)--one ofthem not sufficiently qualified, and the other, who desired aninconvenient concession, did not apply until after I had madearrangements with Dr. Young.That gentleman, being on a voyage for the benefit of his

health, was expected to return in November, and Mrs. Youngon his behalf wrote to Lara and Walters for particulars of somepractices for disposal. ’1 his was in October, and their replywas that " they trusted all the practices then on their bookswould be cleared off before the end of November," and there-fore that it was needless to sead her any particulars of them.On November 16th she wrote to them a second time, and they

then sent to her wiitten particulars of two practices, neither ofthem true as to mine in several important elements, and either