that they are necessary at a church communion service for the purpose of passing upon the quality and character of the wine before it is used in that service.

Differences of opinion are likely to arise in many questions. Honest differences of opinions have lead to the truth in many instances. David Harum said: "Difference of opinion makes a horse-race." That variety of difference of opinion to which David Harum alludes is the variety which the medical expert is censured for expressing, and no criticism or condemnation for such reprehensible conduct can be too severe.

But honest differences of opinion arise among the most intelligent and best informed. They exist in the highest courts of the land; and so it will be as long as we are confined to the surface of the earth by gravity, and are dependent upon the atmosphere which surrounds it for our existence. The honest differences of opinion among medical expert witnesses will be received by an ever indulgent public with that same charity which characterizes its treatment of those people in other capacities of life whose conduct merits the same.

Treatment. I have nothing startling, revolutionary, or specific to recommend. Like that of many diseases with which we come in contact, some home remedies are quite as likely to produce good results as any which I have heard, or seen recommended. And those which I shall suggest are in the line of general principles, and quite as necessary for the success of any other system as for the one in use at the present time. My suggestions and recommendations

are:

First. Let us be fair and honest with ourselves.

Second. Having arrived at that position and condition, let us insist that all others shall be fair and honest with us. Gentlemen: Are we equal to the emergency?

A GYNAECOLOGICAL REPORT.

HENRY LADD STICKNEY, M. D., MANCHESTER, N. H. Resident Superintendent Hillcrest Hospital, Manchester, N. H.

Four rather obscure cases are respectfully submitted and the author has purposely refrained from entering into the technic of operations, familiar to most of you, or from any analysis or discussion more than is necessary to give you a clear clinical picture of same, preferring rather to present the report unvarnished to your intelligent consideration.

Then, too, by so doing the writer has possibly a selfish interest, viz.: to himself profit by the discussions which if honestly entered into will be of infinite good in their results.

Case I. Blanche P-, thirty-two, the wife of a dentist, gives a history of dysmenorrhoea from early menstruation. Constipation, or rather obstipation, has also been a most troublesome symptom all her life. Coupled with this last, and undoubtedly an influential factor in its cause, has been an intestinal indigestion with all of its accompanying symp

toms.

One year prior to marriage she consulted me, complaining of such subjective symptoms as are characteristic of dysmenorrhoea, obstipation and intestinal indigestion, laying special emphasis on pain in both right and left pelvic regions, seldom absent even for a day. From time to time palliative measures were advised and faithfully followed, with no marked improvement.

Following her marriage, in due course of time and in the

natural order of events, she gave birth to a large, healthy boy, but not without a protracted labor of many hours, necessitating finally instrumental interference.

Two years later the writer saw her again, and added to the former complaints, narrated above, was the unpleasant symptom of feeling that the floor of the pelvis had no support. This was accounted for by a lacerated cervix and perineum. Married life and subsequent motherhood failed to give amelioration to her condition, but on the contrary seemed to augment it.

February 10, last, she was admitted to my private hospital, Hillcrest, in a very anæmic and chlorotic state of health, intensely neurotic, melancholic and desperate to the last degree, completely indifferent as to what the future had in store for her. Such a case did not admit of any very extensive operative procedure. It was deemed inadvisable to do anything more than a plastic operation at first and the laparotomy was deferred for a time. Trachelorrhaphy and perineorrhaphy were performed February 11. Patient returned to her room in what seemed at the time to be a very satisfactory condition.

At 11:30, the following forenoon, she vomited about eight ounces of a greenish fluid with a decided ether odor. This, notwithstanding the fact that she had been given the customary stomach lavage before leaving the table. Lancinating pains in bowels, temperature 99, pulse 110. Up to February 14 she continued to vomit; the vomitus gradually growing darker and of a projectile nature, until finally it became very dark, indeed nearly black, semi-solid in consistency, and of a distinct fecal odor. Pulse rate increased to 140, temperature still remained at 99.

The third day following the operation she suddenly went into a state of collapse. Dr. Wilkins, who had previously seen the case with me, was asked to come in and concurred with me that the cause of the obstruction must be immediately sought after and remedied if found. At five o'clock

the same afternoon she was again placed on the table, when a median abdominal incision was made. Not until we had carefully inspected the intestines, which were much distended with gas, from the pylorus to the rectum, were we willing to acknowledge that not a single cause for this unhappy condition presented itself. Adhesions, volvulus and intussusception were all absent. The appendix, tubes and ovaries, much to our surprise, appeared normal under the hasty inspection we were able to make. However, we punctured the ileum and large quantities of foul smelling flatus escaped. Within the puncture four ounces of a sterilized saturated solution of sulphate of magnesium was injected and the intestinal puncture closed with Lembert sutures,

The patient was returned to her room, pulse having dropped to 124, and temperature in the meanwhile having gone up .8 of a degree. She still vomited greenish fluid and mentioned that she tasted epsom salts in the vomitus. Mind wandering at times and still complained of severe pains in bowels but thought the position of the pain had changed somewhat. The following morning again vomited fecal fluid.

Dr. S. J. Mixter, of Boston, was called. Before his arrival the patient had both voluntary and involuntary stools, mostly involuntary. This afforded instant relief and she said she was better.

The doctor reviewed the case with me. He recommended large quantities of water per mouth and the head-rest. elevating the body to nearly an erect posture. She made a very satisfactory recovery and without further complication. Has since taken on considerably more flesh than was her accustomed weight. Bowels now move regularly and without artificial means. Menstrual periods more regular and attended with less pain.

Case II resembles the former in some respects, yet differs in one or two particulars and for the purpose of comparison is reported in this connection.

Mrs. C, married, thirty-one years of age, mother of six children, three miscarriages. Saw her for the first time in February, 1904. The pulse was rapid; temperature 101.2; two severe chills; an anxious expression and upon making a digital examination per vaginam, a very sensitive fluctuating mass was found to the left and posterior to the body of the uterus. Her case was undoubtedly a pyosalpinx.

She was removed to the Elliot Hospital, where a large adherent pus tube and diseased ovary of the left side, also a small cyst of the broad ligament of the same side were excised. The post-operative picture of this case up to the fourteenth day was normal and without incident. Was allowed the chair and blanket for a few hours each day. But on the fourteenth day, two hours after her dinner, she complained of intense pain in her bowels and began to vomit violently. The writer saw her shortly after. The vomiting continued all night. Hiccoughs became so frequent that with the hiccoughs and vomiting she soon became exhausted. The late Dr. Adams, of Manchester, saw her with me and an immediate operation was agreed upon.

Strips of adhesions had resulted in a complete strangulation of the ileum, and following these adhesions for about forty-eight inches the bowel was collapsed. The constrictive bands were severed. With the fore-finger and thumb gas was gently forced through the collapsed gut. No resection seemed necessary. A few inches, only, of the intestine was darkened or looked at all suspicious and this was wisely left alone. She was returned to her bed in a much better condition than when she went to the table and made a good recovery, leaving the hospital two weeks later.

Several weeks after her discharge from the hospital, while traveling in an open street car on a suburban line a little way out of Boston, the car by some means became derailed and smashed into a near-by tree, throwing her on to the seat in front. She was confined to her bed for