wall for sewing, thus giving coaptation more readily. It is not of any advantage when the object of operation is to establish permanent drainage.

DR. A. H. MEISENBACH, of St. Louis, regarded such devices as wholly unnecessary when Trendelenberg's position is employed. Besides there is too much danger of rupture of the bladder from even this amount of distention, uniform as it may be, in some cases of unusually fragile bladder wall. The catheter is enough of a guide. The transverse incision of

Hahn is one that gives much more space for work and is to be advised in old patients especially. In a case recently operated upon by himself the patient was a man 70 years of age; he removed a stone which weighed two ounces and two drams. There was no bruising of the tissues by making this transverse cut and no subsequent trouble of any kind.

DR. A. H. MEISENBACH presented two specimens showing "Traumatic Separation of the Lower Epiphysis of the Femur." One was an acute trauma-the end of the bone being wrenched from the shaft by being caught in a rapidly revolving wheel of a wagon, the patient being a boy nearly grown. The fracture was easily replaced and maintained in position, but the boy developed "secondary shock" and died, without any other discoverable lesion. The second case was one of spoutaneous separation from tuberculous disease. A typical resection was made Oct. 13, 1894. The patient (a girl 13 years of age) did well and was discharged in three weeks, healing by primary union having been secured. Three weeks ago three sinuses began discharging, so she ceased walking on the leg and returned for treatment, the attending physician thinking there was a return of the tuberculosis. But investigation showed the trouble to be nothing but the silver wire causing an irritation. Removal of the three wires was followed by immediate cessation of the discharge and rapid healing of the sinuses. She is now entirely well.

DR. A. L. FULTON, of Kansas City, claimed that no suppuration would have occurred if catgut instead) of wire had been used to hold the'

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bones in place and that it would have been just as effective.

DR. FRANCIS REDER believed that a steel nail would have been better-removed at the end of the second week.

DR. EMORY LANPHEAR suggested that in many instances it would be better not to drill the bones at all, as the drill hole for the wire or catgut might become another locus minoris resistentiae if the bone be not absolutely healthy. So in doubtful cases it might be best to trust to plaster of paris alone to hold the ends together.

DR. MEISENBACH replied that the whole matter must be decided by the state of the patient and the local condition. Silver wire, in an aseptic wound, in healthy tissues, ought never to cause suppuration or other trouble, but sometimes-as in this casethere is no encysting, and this is particularly apt to be the case in resec-; tions for tuberculous disease. Exactly the best means of handling these cases have not yet been determined.

DR. C. C. MORRIS, of St. Louis, read a paper entitled: "When is Removal of the Uterine Appendages Justifiable?" He said there are two classes of doctors-one takes one extreme in answer to this question and another the other extreme; one says all ovaries should be removed for pain-the other that they should never be excised except for pus tubes. His experience has demonstrated that some cases would have been better off if not operated on. He related the history of two cases to illustrate the difference in results. The first case was a

woman of 38, the mother of five children, pale, anaemic, an invalid for 14 years-since the birth of her last child. She suffered much pain and was subject to menorrhagia of extreme degree, so much as to nearly die of acute anaemia at times. The most careful examination failed to show an uterine disease or marked tubal or ovarian trouble. Abdominal section was made and the tubes and ovaries removed to check the menstrual flow alone; the ovaries were only slightly cystic. She made a slow recovery, but improved gradually af

ter the second week and for some months has been in perfect health, having gained 40 pounds in weight. The second case was an unmarried lady of 32 who first menstruated at 14, suffering from dysmenorrhoea for 3 to 5 days at each period. Ten years ago she became neurasthenic and was subjected to all kinds of treatment, but received no benefit from either gynaecologist or neurologist. As the nervous symptoms were prominent only at the menstrual period, and there was much pain and tenderness in the ovarian organ, Battey's operation was performed.. The ovaries were abnormally small and cirrhotic. She made a speedy and satisfactory recovery from the operation, but now after more than six months she is more nervous than before the operation and has more pain in the ovarian region than ever before. He thought the chief and all-important point in such cases is to make a correct diagnosis and operate only when the presence of some gross lesion promises good results from removal. In some cases heretofore deemed possible to cure only by operation non-operative treatment has proven perfectly satisfactory. Notably was this true of a case of hydrosalpinx recently under his care. Catheterization of the Fallopian tube removed the dropsical effusion and cured the patient-evidently a much better treatment than the mutilating operation of extirpation. Another conservative measure to be applauded is visection of a diseased ovary, leaving the healthy portion of the organ so as to permit continuance of ovulation and menstruation, thus not totally unsexing the woman.

DR. J. H. MCINTYRE, of St. Louis, was requested to read his paper at this time so that a joint discussion could be carried on. It was entitled: "Some Propositions in Abdominal Surgery," as follows:

1. Operations in the abdominal cavity should be very speedy and absolutely clean.

2. A short abdominal incision should be made and no bruising of internal organs practiced.

3. As little anaesthetic should used as possible. Much of the

be

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called "shock" is water-logging with chloroform.

4. Every physician who attempts to do abdominal work should have had long instruction by one of the masters and have had practical experience under their guidance with some experimental work.

5. In abdominal and pelvic work the unexpected is always to be expected-hence every emergency is to be provided for.

6. No man should operate unless he is capable of making a true diagnosis.

7. Exploratory laparotomy is never justifiable in the work of amateurs.

8. Exploratory operation is sometimes excusable with the expert who knows exactly what the trouble is but cannot otherwise determine as to possibility of a cure.

9. So-called conservatism is not advisable in fatal cases. Operation should be made at the earliest possible moment.

10. The earlier operation can be done for abdominal and pelvic disease the better for the patient.

11. Antiseptics can never be used in the abdominai cavity excepting dioxide of hydrogen in pus cases.

12. "Chronic Surgery"-(i. e. slow, tegious operations) is often followed by bad results.

13. Drainage is advisable in most cases if properly done.

14. No antiseptic pad should be applied over the belly for 24 hours before operation, as is frequently practiced.

15. Silkworm gut sutures are to be preferred for the abdomina! wound. 16. The general surgeon cannot expect to get as good results as the man who limits his practice to operative gynaecology.

17. Secondary operations are bad; therefore the operator should seek to complete his work at the first operation.

18. No stitch-hole abscess can form if the operator is sufficiently clean in his work.

19. There are too many men trying to do abdominal surgery. Many lives are being sacrificed to amateurs.

20. There has been too much faulty teaching as to the simplicity of operations upon the abdomen and pelvis and

too great faith put upon the prospects of success.

21. There are too many surgeons ambitious to have their maiden trial in abdominal work. Many lives will yet be lost before such men realize the necessity of referring such cases to the skilled operator.

22. We cannot always do an ideal operation-notably in appendicitis. We must often do only what is good for the patient, not what is ideal surgery; hence the abdominal surgeon must have good judgment.

DR. A. H. MEISENBACH protested against proposition 16, as statistics will now show that the general surgeon who thoroughly understands his business gets just as good results as the "adominal surgeon." The mistake most frequently made is the attempt of inexperienced operators to do such work, especially outside of the hospital.

DR. I. N. LOVE, of St. Louis, also objected to this statement of Dr. McIntyre. He especially deprecated operation by general practitioners except in emergency cases. All abdominal and pelvic operations should be referred to the specialist instead of being subjected to the additional danger of operation by an inexperienced hand. There are certainly too many ambitious to do a laparotomy.

DR. EMORY LANPHEAR, of St. Louis, declared Dr. Morris's position correct so far as Battey's operation is concerned. No surgeon of any experience would now remove healthy ovaries and tubes for the relief of pain alone, or as treatment for one of the neuroses. Of course pus tubes, or other marked tubal or ovarian disease, demand removal from the neurotic as well as other patients; and operation will assist in curing. He most emphatically condemned catheterization of the Fallopian tubes for hydrosalpinx for two reasons: (1) the danger of pushing the instrument through a fragile tubal wall and producing fatal peritonitis and (2) because the hydrosalpinx generally depends upon such local disease of the tube that simply evacuation will not cure-removal of the diseased Ovary and tube being the only true method of treatment. He favored ex

ploratory laparotomy in cases of doubt as to the diagnosis, full preparation being made to meet every possible condition which may be found and remove it upon the spot. Of course anyone will condemn opening the abdomen just to see what the condition is and then closing it up without any attempt at remedying a curable disease. Strictly speaking this is the true exploratory laparotomy; but from the general standpoint almost every abdominal section is in a measure exploratory, for there are few abdominal surgeons who can be absolutely positive of the real condition of affairs until the fingers are inserted in the abdominal incision. So far as the general practitioner is concerned, every physician ought to be thoroughly prepared by proper study and instruction and experiment to be able to operate intelligently in every emergency case-volvulus, strangulated hernia, acute appendicitis, etc.. though there is no question but what it would be better to send chronic cases like complicated ovarian tumors, large uterine fibromata, diseased gallbladder and the like to an experienced surgeon who has good hospital facilities, as such patients would certainly have better chances than in the hands of men who have done only a few sections, especially if there be many complications. There is another important aspect of this question: in emergency work if a death results after an operation by a general practitioner there is little or no criticism; but if a case which might just as well have been sent to an experienced surgeon is operated on at home and dies from some unexpected complication it is very apt to nearly if not quite ruin the practice of the operator; and as it is the unexpected that is always being met the average doctor cannot afford to assume the risk to himself, leaving the question of the life of the patient entirely out of the question. Dr. McIntyre might well have added another proposition: Too many cases that ought to be operated upon are going about in more or less danger because the family physician hesitates to advise operation.

(To be continued in our next issue.)

AND

Paper read by DR. I. C. BARNES, Topeka, Kas. Subject, "Treatment of Abortions, with Report of Cases." (See page 323.)

Discussed by DR. CHASE: I want to congratulate the author of the paper on the success in which her patients are reported, but I do not believe in the use of corrosive sublimate. If you are bound to us an antiseptic, the best of anything I ever used is creoline, which is soft to the hands. I do not see what good the corrosive sublimate will do in that temperature.

DR. JONAS: I would recommend the use of hydrogen peroxide as an antiseptic in irrigation in these cases. I have used it and have been well satisfied with it.

DR. MITCHELL: In regard to the use of the uterine douches of bichloride I do not use it in these cases; 1 think it is not as efficient as some other remedies, and if at all, would not use it as strong as the author of the paper. If I understood correctly, she used 1 to 3,000 in the last case.

Now in regard to the tampon in this threatened abortion, I have my doubts whether it would be the best treatment unless abortion is inevitable, then the tampon would certainly be the proper treatment. I generally use opium, one-half grain as often as may be necessary, to allay pain; it also acts to a certain extent in restraining the hemorrhage.

This question of criminal abortion, of course it is an old one, but after all, gentlemen and ladies, it is certainly one of the most important questions with which the profession today has to contend, and I almost dread saying anything about this question, for it has been talked about a good deal. And gentlemen, today I know of men standing well in the profession that is as far as outward reports are concerned, who are practicing this criminal procedure every day, or quite frequently, and their

acquirements largely come from that source. Now as I said, the responsibility rests somewhere. I can say that it rests nowhere more heavily than it does upon the profession. Now what can we do? Can we do any thing? It is a difficult question to know what should be done. If there could be some plan of detective bureau to bring to justice those who are guilty of this crime. Some systematic plan ought to be adopted. It is practiced every day before us. Every day almost, patients come to us making application to have this operation per formed. They say, "I know where I can get it done." In our town of Topeka I know men who are at least making their living very largely in that way. It is sometimes difficult to prove this, but as I say, some plan of detection ought to be done.

DR. SCHRADER: Quite a number of points in the paper are well worthy of discussion. It brings up points in regard to the causes already alluded to by Dr. Mitchell, especially the one alluded to by the writer and not fully dwelt upon as it might have been. The results of these abortions. Το take these matters up, I will say that I have given some considerable attention to this matter of abortion, and will say, I do not believe very much of this comes from doctors in good standing. It comes from the class who are trying to make their living outside of legitimate practice of medicine, and I think very few of those would be recognized as physicians in good standing and guilty of this procedure. I agree with Dr. Mitchell that some plan be made to detect these operations.

In regard to the douches alluded to, I am not much in favor of the bichloride of mercury. Boric acid is a very harmless and very good infection. Peroxide of hydrogen is also very good but not very safe if injecting bichloride into the uterus. I think I have known some cases where deaths come

from the use of douches used once or twice a day. Consequently I do not use it very much in those cases. One point that has not been alluded to that is worthy of discussion by this society and that is in regard to douches after a normal labor. Some physicians are in the habit of recommending that once or twice a day the patient should have a thorough douch. Now normal labor in all its stages, after we have given one good thorough douch, half an hour or an hour after the labor is completed and have made our examination to ascertain whether there are any lacerations that need our attention, is all that is necessary.

I wish to thank the doctor for the care she has taken in reporting these

cases.

DR. BARNES, Creston, Ia: I quite agree with Dr. Schrader in regard to his speaking of the use of bichloride of mercury; it does harden the hands and it is impossible for you to detect what you want to find out. I have used a preparation called Iatrol. I use it where there is a raise of temperature following abnormal labor.

What are you going to do with these professional abortionists? They are everywhere.

DR. WARD: I want to say that I am also opposed to the use of the douche. I do not think that it ought to be used very strong. I have used creoline a great deal and like it ever so well. I think that clear water is the thing that we can use. You cannot make a mistake and can use as much as you please. In regard to the use of hydrogen I would not care to put it into the cavity I think. It might work all right, but it must have lots of room, and I am afraid it might do harm.

DR. ADAMS: I am very much pleased with the paper of Dr. Barnes and shall endeavor to convince myself that her treatment is correct. Now abortions must be clased under three different heads: The spontaneous, the criminal and the justifiable. The doctor has taken four points. I would add one more, the hemorrhage. I have met cases where it was a doubt in my mind as to whether I was justifiable in producing an abortion. A case came to me where the woman, if the truth was told, was so that life was in danger. Now judging that

she was in a pregnant conaftion, what should I do? Would it be safe in the first two months? It was a question of course under those circumstances. Now the question of prevention depends if the woman wishes to go to term and you wish to prevent abortion. I do not think the doctor touched upon one case which touches father and mother, and that is that disease which is the great and almost all in all case of spontaneous abortion, depending upon the father and the mother and the ovum. Now in regard to the treatment as I said the other day, I will reiterate that the individual that takes a curet and because the patient gets along well, has no justifiable reason to say that the curet did the work. It is simply a question, and they do not know what they cut and what they did not cut, and I defy any one to disprove that question, because you simply say you curetted. Now the question comes up as to what month is safe, and what months unsafe. hold that on the second month it is safe if I wish to perform an abortion. Between the third and fourth month you have all the difficulties where the curet must come into play. Therefore

I

your curet comes in between the third and fourth months. If you curet, you curet nothing but the membrane. You have an instrument that you use that has slots on the side, and if you never think about whether the uterus is dragged down, you will find as a rule in an abortion before the fourth month the cervix is tipped back a little. With this slot instrument you simply pare this off. I will show you some instruments which can be used safely if you care to look at them.

DR. HALL: I wish to say something in regard to the use of the bichloride of mercury. I do not believe that there is any essential danger in it; it is the way we use it. I do not believe that it is the use of it, but the improper use of it that gives the trouble. I use it and never have trouble. I dry the uterus out and be sure that I do not leave any pockets within the uterine cavity. After that I go over it with carbolic acid.

DR. SCHOOLER: I think our friend Adams roars too strongly against the use of the curet. The curet may be an instrument of incision. In the use of the curet, it depends on