268 intra-mural and sub-peritoneal hysterectomy. Pedicle made of cervix and dropped. Incision closed, no drainage. Convalescence uninterrupted. Dismissed twenty-first day. One large intra-mural growth and ten smaller sub-peritoneal fibroids. Both ovaries pure fibroids, no vestige of ovarian tissue left. Section made April 13th, 1893. Called when passing the house April 15th, 1894, and found her at work ironing, looking and feeling well. Private house. Case XXXVI. Mrs. J., aet. 34, married, two children, youngest nine years old. Had complete laceration of perineum. Operated on twice with failure both times. These operations were made in a distant city. Did flap splitting operation in October, successfully. She also had a retroflexed and fixed uterus. The left ovary was in the Douglas' cul-de-sac. Found it impossible to break up adhesions or replace organs. Nervous phenomena exceedingly marked, amounting almost to mental aberration at times. Section made January, 1894. Considerable force required to break up adhesions. Ovaries and tubes removed. Uterus brought forward and ventro-fixation made with silk worm gut. Patient recovered from the operation very nicely, and at the present time is doing her own work, excepting the washing. I should have said earlier that she complained of continuous pain in the left ovary, which at menstrual periods was intense. She still complains of pain in that region, probably in the stump. Also of various nervous phenomena belonging to climacteric period. Hospital case. Case XXXVII. Mrs. X., aet. 30, married, no children. Very fleshy. Has had an umbilical hernia for several years. It has never given her much trouble till recently. Hernia the size of an unhulled walnut. Cutaneous covering thin and dark. On section found the hernia to be entirely omental, and when released from the pressure, expanded into quite a large mass. About one half of it was so badly damaged that I did not dare to return it to the abdominal cavity, so ligated it and cut it away. Returned the balance and closed the incision by three layers. Abdominal wall over four inches thick. Patient recovered. Bowels obstinately constipated before operation, moved naturally and regularly afterwards. Hospital case. Case XXXVIII. This case should have come in the first half of the series as it occurred in 1887 and 1888, but could not find my notes until the balance of the paper was written up. In the recapitulation it will be commented upon in its regular place. Mrs. M., aet. 29. Came under my care in her second confinement. This labor, like the first, was difficult and slow, but different from the first in that forceps were not used. She had a fairly comfortable but not rapid convalescence. I examined her some two months later in order to discover the cause of some very uncomfortable sensations in the pelvis. Found the pelvis full of a mass of what seemed to be an exudate that fixed and immobilized the uterus. Under proper treatment in the course of a few months the larger portion of the hardness laterally disappeared and along with it the tenderness and pain. There still remained in the cul-de-sac a firm globular body the size of an osage orange ball and not very tender. The uterus lay above it or in front of it, the uterus being found high behind the symphysis pubis. The attachments 269 of the tumor to the uterus did not seem to be very close. I diagnosed a tumor probably of the ovary and advised an operation, The husband asked for counsel and it was obtained. Just what it was the eminent gentleman in counsel did not decide. Of two things, however, he was positive, The first was that it was not a tumor; the second was, of course, that no operation was called for. The husband states that the consultant later volunteered the information that an operation should never be done with his consent. As I still remained obstinate in my opinion, further counsel was had. The second gentleman, after three examinations, decided that it was a fibroid tumor in the posterior uterine wall, and advised against an operation in very strong terms. As her health was now fairly good, I saw her but seldom for the next six months. She being on a visit to St. Louis during the fair, consulted Dr. Engleman, who diagnosed a pelvic tumor beginning to break down, and strongly advised an operation at the earliest possible moment. On her return she consulted me again, and on examination, I found the old solid tumor had disappeared and in its place was a soft, baggy, thin walled sac evidently containing fluid, and as she had been in a febrile condition for some weeks, probably pus. A few days later, after due preparation, I pushed a small trocar into the most prominent portion of the cyst, and as stinking pus ran out freely, opened the puncture with the knife and dressing forceps. Nearly a quart (estimated) of fluid escaped, and besides the pus was quite a quantity of a buttery or cheesy substance and quite a quantity of hair, but nothing like bone. This settled the diagnosis. The firm tumor I had discovered many months before was a dermoid cyst. To make the sad story as short as possible, in spite of drainage tubes, and irrigation and every thing else I could think of, abdominal section excepted, the case went on, better when the sac was almost empty, worse with the access of a new attack of inflammation when the sac filled up again. Never well, always hopeful and even cheerful. Frequently when irrigating the sac, if the pressure was a little too great, she complained of severe pain. About six months after the opening was made the pain while washing out the sac, became very severe. Severe inflammatory symptoms with high temperature and a rapid filling up and hardening in the right side of the pelvic cavity developed in the three following days. While making some movement a day or two later, the abcess walls gave way and the pus was poured into the abdominal cavity. Section was made as soon as possible; the abdominal cavity thoroughly flushed out and closed, excepting for drainage. The patient died a few minutes after being put to bed. Private house. Case XXXIX. Mrs. A. H., colored, married, aet. 34. Has one child 14 years old. No other pregnancies. Something over 31⁄2 years ago she noticed that her abdomen was increasing in size. This was at first supposed to be pregnancy, although her menses still continued. She, in time, became very large, but until quite recently kept at work. In October, 1892, she was tapped twice with a five days interval between tappings. The first about two gailons were drawn off, the second time two and onehalf gallons. This very much diminished the size cf her abdomen. The lower portion of it much less than the upper. I made a diagnosis of multi 270 locular ovarine cyst and made a section before the class December, 1893. But little trouble with adhesions in front and but little anywhere of a serious character excepting in the posterior inferior wall of the tumor. The tumor proved to be a proliferating papilomatous ovarian cyst beginning in the hilum of the ovary and at first growing downward between the folds of the broad ligament from the left cornua of the uterus to the lateral pelvic wall. It had to be tied off in sections. The weight of the fluid contents was twenty-one pounds; of the cyst walls, four pounds. Within the mother cyst arising from its thick walls were numerous daughter cysts, also numerous papilomatous spots, also lower down a dermoid cyst containing hair, a cheesy substance, and tissue resembling skin and a bony tooth-like plate. The right ovary had undergone cystic degeneration. It was the size of a large hen egg, and with its tube was tied off and removed. She began menstruating on the morning of the operation. She promptly recovered from the operation, and at the present time is in the best of health and working in a hospital laundry. The other case, making the forty called for, was a multilocular ovarian cyst in a woman nearly 70 years old, who recovered. But as several other professional gentlemen were in the case, I omitted it from the list. Attempting to classify my cases, I find as follows. First as to diseases or condition for which operation was made: Ovarian tumors (not fibroid), 6 cases, I died; ovarian fibroids, 2 cases, 2 died; cystic ovaries (small), 10 cases, 2 died; uterine fibroids (cirrhosed), 6 cases; pyosalpynx, 4 cases, 2 died; purulent ovaritis (double), I case; extra-uterine pregnancy (abdominal), I case, I died; purulent degeneration of dermoid cyst, I case, I died; umbilical hernia, I case; ventral hernia, 2 cases; menstrual insanity, 2 cases; intestinal or abdominal tuberculosis, I case; sarcoma of kidney, I case, I died; multipli fibroid of uterus and both ovaries, I case; total, 39 cases, 10 died. Results: Cured, 24; not benefited, 3; unknown and lost sight of, 2; total, 29. Comparing results between hospital cases and the same kind of work done at the house of patients, we get the following: Cases in hospital, 16 deaths, 6 recovered; cases at the home of the patient, 23 deaths, 4 recovered. That is, the percentage of deaths was more than twice as great in the hospitals as at the home of the patient. The deaths in private houses were: Case VI. Solid growth of ovary weighing 40 lbs.; patient practically moribund at the time of the operation. Case X. Exploratory. Tumor proved to be a malignant tumor of the left kidney, weighing 45 lbs. Incision closed. The patient died a few days. later from exhaustion. Character and weight of the tumor determined by autopsy. Case XXIV. Abdominal pregnancy of eleven months standing; child dead six weeks. Mother pyemic and operation made to give her a chance for her life. Case XXXVIII. In this case had my advice been followed and an operation made early before suppuration had occurred, the woman might 271 have been alive and well today. Two men who stood well in the profession made a mistake in diagnosis, and this mistake cost the patient her life. No operation being made until her abdomen was full of stinking pus from the rupture of an abcess. Excluding these four cases, in none of which would any surgeon operate who had greater care for his reputation than for his patient's life, and in all of which the only ground that would justify an operation was that they were entitled to a chance for their lives. My work in private houses since 1880 gives a recovery rate of one hundred per cent. In my hospital work you will notice two recoveries and two deaths in double salpingitis. Both deaths occurred in old chronic cases, one of five and the other more than five years standing. The tubes were absolutely rotten, and in both cases broke down while being removed. Both cases were long and completely saturated with pus, and only consented to an operation when it became the last resort. The lesson is, in these two cases, that in suppurative inflammation of one or both tubes, don't wait till the last moment. Operate early or your patient's chances for recovery are poor indeed. Two hospital cases, Nos. 3 and 4 were operated upon on account of hystero-epilepsy and lost their lives from faulty technique and bad surroundings. Under present conditions if I operated in such a case at all, I would almost be willing to absolutely guarantee recovery from the operation. Case XVI was one of the cleanest and easiest operations I ever made and should have recovered, and had her bowels been moved in time she would have gotten well beyond a doubt. I might go on and moralize indefinitely, but this wouid only tire your patience still further. Case V at the hospital, was practically moribund from peritonitis at the time of the operation, and comes under the same category as the fatal cases in private practice. This, gentlemen, ends the story truthfully stated of an experience dating back to 1880, when asepsis, as understood today, was entirely unknown up to January, 1894. Will Meet. The Austin Flint Medical Society, a large district society. in North Central lowa, will meet at Mason City, July 9th, 1895. Therapeutic Value of Gold.-Professor J, S. Wight, of the Long Island College Hospital, has used arsenauro with advantage in cases of suppuration, and more recently has given the solution of the bromide of gold and arsenic (arsenauro) to patients suffering from cancer and sarcoma. He has not yet had experience enough to speak with certainty as to the value of these remedies, yet is convinced that they will turn out to be remedial in the true sense of the word. In some cases of adenosarcoma the absorption of the neoplasm has been brought about in a few weeks. It seems certain that the solution of gold and arsenic (arsenauro) will prove to be a most valuable remedy in the treatment of sarcoma and the less virulent forms of cancer.-Medical Bulletin. 272 Neurology of the Female Reproductive Organs. BY M. R. MITCHELL, M. D., TOPEKA, KANSAS. WESTERN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS, OMAHA, NEBRASKA UR theme, considered etymologically, would apply to the anatomy, physiology, and pathology of the nerve structures of the female reproductive organs. It is necessary to make only an allusion to the anatomy and physiology of these structures. We may call to mind that the nerve supply of the uterus and its appendages is derived from the two great systems, viz, the nerves of animal life, through the internal sacral nerves, and the great sympathetic through the inferior hypogastric plexuses. The spinal nerves mainly supply the sphincter fibres of the cervix, and the sympathetic mainly supply the uterine body, the Fallopian tubes, and the ovaries. Hence is accounted for the reflex nervous influence existing between these structures. So that when one suffers, all of the others may suffer with it. The ovary becomes congested during ovulation and has its sympathizers in the tubes and uterus. The chief physiological determining cause of labor is traceable to the direct pressure of the uterine contents upon the sphincter fibres of the mouth of the womb, which irritation is reflected to the uterine walls, causing contraction and expulsive efforts. This same reflex influence put forth by the sympathetic nerve system clearly accounts for a striking physiological intimacy, and a pathological affinity between the utero-ovarian and other structures of the body, Morning-sickness, anorexia, and other forms of morbid appetite, can be explained better, perhaps, by the reflex action of a copious net-work of the sympathetic innervation of the utero-ovarian apparatus and that of the stomach. Guerriot, in speaking of the vomiting in pregnancy, says: "That a morbid or abnormal state, the nervous system as the carrier of reflex-action, and the stomach are three prime factors in this malady." He urges, "that any abnormal state of the uterus and appendages, whether they be ulcers, excoriations, flexures, or of a specific nature, should be corrected, the nervous system, particularly the spinal nervous centres, should receive attention." The pathological aspect of the subject must assume an attitude of startling importance when we call to mind how frequently we are foiled in the ready attainment of a satisfactory etiological explanation of the existence of some new affection in a distal organ. Or, perhaps, the sudden development of some latent malady. Pozzi says: "There is no function upon which uterine disease reflects more constantly than on the digestive, and ignorance of this fact may cause grave errors in diagnosis. Dilatation of the stomach is very common in |