New York TO MEMBERSHIP BY STATES. 1 death to 1706 members. 1 death to 1264 members. in other life companies, since their medical examiners TABLE SHOWING THE PROPORTION OF TUBERCULAR DEATHS are probably as anxious to shield themselves from a suspicion of having admitted impaired risks into their ranks as those of the Knights of Honor. Furthermore, if we add in each column the percentage of tubercular and respiratory diseases it will still appear that the comparison is favorable to the Knights. The results of diseases of the digestive organs are a little better than those of the other reports; those of the urinary and generative organs. not quite as good; whilst the percentage from casualties and suicides is unusually large. I have made special note of the cases of cancer, because in some similar organizations great importance has been attached to this as a cause of death, by refusing admission to persons whose near relatives have had any form of it. It appears that even including one or two doubtful cases, such as stricture of the oesophagus, which may or may not have been cancerous, there are but twenty-five in all the thousand and thirteen cases, which would tend to show that this disease is not a very important factor in life insurance; and I find it reported in the Medical Record of 1874 that of the twenty-three cases occurring in twenty-four years' experience of a life insurance company only one seemed to have been of hereditary origin, and that in this case it had existed only in one other member of the family, a sister. The two and a half per cent. which cancer shows in the Knights of Honor columns is a trifle more than in the Massachusetts report, or that of the New York Company, these being the only ones where it can be traced out. Let us scrutinize more strictly now the cases of tubercular disease, one hundred and seventeen in all, which number, it will be remembered, was not unduly large. It will be observed, too, that though there were Some who died within a comparatively short time after joining the association (four died within six months) there were but twenty-six who died within a year. The shortest time was that of a member from Missouri, who lived but four months after admission, and one each from Kansas, New Jersey, and Wisconsin, who died in five months; the longest that of one who lived over five years from the date of his entrance. The average time was a little over a year and eleven months, which would indicate that a reasonable amount of skill was used in the preliminary examinations. The following table shows the number of deaths in each State from tubercular disease; Maine, Vermont, Connecticut, Maryland, Texas, Colorado, Minnesota. and Nebraska having had none :— Virginia... Pennsylvania. 21 New York .... 12 South Carolina.. 11 Rhode Island... 11 Michigan.. 6 Kansas. 6 Alabama 5 Iowa. 3 Mississippi.. 3 North Carolina 3 West Virginia..... 22222. Michigan Iowa Massachusetts Ohio South Carolina. Rhode Island 1 death to 849 members. 793 members. 792 members. 758 members. 740 members. 691 members. 598 members. 549 members. 541 members. 517 members. 414 members. 392 members. 355 members. 1 death to 1 death to 1 death to 1 death to 1 death to 1 death to 1 death to I death to 1 death to 1 death to 1 death to 1 death to I death to 1 death to 1 death to 317 members. 296 members. 271 members. 221 members. 218 members. Michigan, Kansas, Pennsylvania, Iowa, and Massachusetts, as Northern States, show records which need not fear reproach, whilst New Jersey, New Hampshire, Indiana, Ohio, and other Western States have been less As it will be remembered that the number of mem- fortunate, and the States of South Carolina, Virginia, bers in these different States varies greatly, our next and Kentucky excite our surprise at the large numtable shows the proportion of these deaths to the member of consumptives in their favored climates. bership. The apparently good results in Tennessee and Mis sissippi are evidently owing more to the large number of deaths from yellow fever than the small number from phthisis. Leaving here this subject of tubercular disease, of which much more might be said, let us conclude by a brief investigation of the deaths by casualties and suicides. These two are thus associated because there is no doubt in fact a connection between them, some deaths being attributed to accident which may have been suicidal, whilst there is, of course, a possibility that some may have been purely accidental which were considered self-inflicted. Many of the former are reported in such a way as to lead one involuntarily to at least think of suicide: thus the one caused by "strangulation," those by "poison," those by "drowning," and by being "shot." The following table gives a list of the casualties which are certified to as the causes of the deaths of ninety-three members of the order: Railroad accidents.. Falls (from buildings, etc.). : 20 15 As regards suicides, the large number of them has led to the apprehension that some persons may have joined the order for the purpose of committing suicide, so as to leave the insurance to their families; and an interesting question of casuistry has been raised on this point, whether such an action should be applauded as a sacrifice of life and a heroic deed for the benefit of those dependent on them, or be denounced as a fraud upon the insuring company. It is, however, evident in most of the thirty cases reported in our list that these persons did not join the order with that intention in view, as they continued their membership and paid their dues and assessments for a considerable length of time before the fatal act, this time averaging over a year and a half, — only one killing himself in fourteen days after joining, one other in less than two months, and but six in less than a year. The total time of the thirty members sums up to forty-five years and two months. - This concludes our inquiry into the results of 1013 deaths in cooperative life insurance, in an association where the medical examinations have been conducted by average men, chosen by a popular vote, probably in some instances more for their social qualities than their scientific attainments. I think the result of the inquiry speaks well for the ordinary medical practitioner of our country. -The Connecticut legislature has recently passed an act authorizing the State Board of Health to prepare rules and regulations for the examination of railroad employees in regard to color-blindness. Every company in the State is obliged to hold such exami nations on or before the 1st of October. CASES OF OVARIOTOMY. BY HENRY CLARKE, M. D., WORCESTER. THE operation of ovariotomy has become of late so safe in the hands of a few skillful surgeons that it behooves every one who undertakes it to study well his failures, and see if they have not resulted from some fault of his own. It would almost seem that such must be the case if we take the recent results of Dr. Keith and Mr. Wells for our standard. Yet many speak lightly of the operation, as one to be undertaken by any surgeon. Sometimes, indeed, it is a simple operation, but at other times quite the reverse. Certain it is that no surgeon has as yet had any great success either in simple or in difficult cases, except through thorough preparation, painstaking care, and unwearied devotion. I cannot boast of any large experience, but I have had enough to suggest these introductory remarks, and I believe they will command the approbation of all operators of greater experience than my own. After having had six successive recoveries from ovariotomy, I have had one case which resulted fatally. I will note only a few facts of interest in connection with the successful ones before passing to a fuller report of the last one, which is the chief object of this paper. Of these six cases three were treated without the use of antiseptics, one with partial antiseptic treatment, and in two the operation was done under the carbolic spray. All were operated upon in private houses, but two of them were in localities with poor sanitary surroundings. In five of the cases the pedicle was tied with silk or linen ligatures and dropped into the abdomen, and the abdominal opening was closed by sutures throughout its whole extent. In one only was the pedicle brought out and fastened in the lower angle of the wound, but this caused so much discomfort by dragging upon the pelvic organs that it was allowed to drop into the pelvis at the beginning of the second day. In the first case the woman was delivered of her first child within a twelvemonth from the date of the operation. In the fourth case there was general peritonitis at the time of the operation, resulting from a rupture of one of the cysts. The sixth case was a girl of fourteen, who weighed only sixty-five pounds. The uterus was undeveloped, and there were no indications of approaching puberty. The tumor was a dermoid cyst, which contained flat pieces of bone, resembling frag ments of the skull, teeth, and hair. The girl made a rapid recovery, and was taken to drive within three weeks from the time of the operation by Dr. Leonard Wheeler, who had had the principal care of her. In the other cases there was nothing worthy of special mention. This brings me to my last case, which terminated fatally, and I shall report it at greater length. The two special points of interest in it which will be par ticularly considered are the size of the tumor and the sloughing of the stump. tion in the latter part of November, 1879. The tuMiss C., aged forty-two, came under my observamor was judged to be a monocyst, and was very large. She had been advised by a distinguished ovariotomist, two years before, to submit to an operation, but for several reasons she had postponed it. According to her statement, the tumor had enlarged more rapidly during the two preceding months than at any other corresponding period of time since its discovery, about seven years previous. A comfortable apartment was procured, the patient antiseptically prepared, and the operation was performed December 1, 1879. I was assisted by Drs. Wood, Marble, Wheeler, Rich, Hammond, and Bull. A Codman and Shurtleff spray producer and a smaller steam atomizer were intrusted to an experienced assistant. Ether was administered, an incision three inches long made through the linea alba, and the cyst tapped with a curved trocar. The large sac, together with a mass of small cysts attached to it, was drawn out through the opening, no fluid escaping into the abdominal cavity. The pedicle, which was unusually short and thick, was tied in halves with carbolized silk, and then one half of the ligature was made to encircle the whole, and firmly tied. After cutting away the walls of the cyst there was some oozing of blood from the stump, in consequence of which it was lightly cauterized by Paquelin's thermo-cautery. There was very little bleeding from any source, and there was but a small quantity of bloody serum to be sponged from the pelvis. In fact, I never saw so dry an operation. As the pedicle was drawn up for a final examination before tying the abdominal sutures a little bleeding occurred, and while I held it between my thumb and fingers an assistant passed another ligature around it and tied it as tightly as possible, and, as I now fear, too tightly. The intestines and omentum did not descend to fill up the pelvic cavity as much as is usual, although they were pulled down for that purpose. This was shown by a quantity of air issuing with a gurgling sound from the lower part of the wound when pressure was made laterally upon the abdomen before tying the last suture. I have omitted to state that there was an interruption of the spray, which occurred before the sutures were applied. The interruption was complete for two or three minutes, the tube of the smaller atomizer becoming obstructed while the larger machine was being put in order. The wound was, however, immediately covered by flannel wrung out in hot carbolized water. The antiseptic dressing, after the method of Keith, was applied, and the patient put to bed at one o'clock in a satisfactory condition. A careful record of the condition of the patient was made at each subsequent visit, but I will not give unnecessary details. The first four days were passed very comfortably. The highest temperature was 101.5° F., and the pulse varied from 100 to 115. No vomiting. Flatus passed by rectum on the second day. No distention or tenderness of bowels. Took a little nourishment by the mouth, but more by the use of nutritive enemas. Vomited for the first time on the fifth day, and temperature rose to 102° F., and pulse to 120. Vomiting ceased, and on the sixth day temperature fell to 100° F., and pulse to 110. Sutures removed on this day. Wound apparently united, except at one point between the two upper stitches, where some pus escaped. The bowels were moved by an enema of spearmint tea on the seventh day. Some nausea, but no vomiting, and temperature and pulse as on previous day. Took a little nourishment by the mouth. Nutritive and stimulating injections continued. Eighth day. Countenance good; temperature 99° F.; pulse 98; skin moist, as it has been from the first day; no pain and little tenderness of bowels; wound discharged more pus. Ninth day. Temperature rose to 1020 F., pulse to 125; vomited frequently and distressingly; stomach distended by gas. Tenth day. Vomiting continues; transverse and descending colon much swollen and hard; stomach less so; bowels flat; pulse feeble at 125. Eleventh day. As upon previous day; a large injection of spearmint tea was followed by a copious dejection, and accompanied by a disappearance of the distention of colon, which was so hard as to suggest an accumulation of hardened fæces. But this was not the case. The patient sank rapidly from this, time and died in the early part of the twelfth day. It will be observed that there was very little pain, no marked tenderness, and no tympanitis of abdomen at any time. Autopsy twenty hours after death, in which I was assisted by Dr. Wheeler. Abdomen but little swollen. The wound was found united upon its peritoneal surface, except at one small point near the lower angle. The pelvis contained about half a pint of thin purulent matter with a slightly pinkish tinge. Pedicle had sloughed up to the point of the ligature. The peritoneal membrane was granular and reddened, and adhesions were quite extensive. Some strong, firm bands crossed and tied down portions of the transverse and descending colon. It was evident that these strong bands across the colon were what caused the accumulation already noted. No other morbid changes were observed. Here we have a case of peritonitis of an asthenic type following ovariotomy performed under the spray. What was the cause of this unfortunate result? Had the size of the tumor any causal relation to it? The weight was fifty-five pounds, and the intestines were pushed upwards, as were also the thoracic organs. Schroeder, in his report of his second series of fifty ovariotomies, speaks of the increased danger in cases of ovarian cysts of unusual size. Upon the removal of a very large tumor, there is a redundancy of tissues forming the abdominal walls. The greater displacement of the intestines causes a cavity to be left in the pelvis, in which air may become inclosed. To avoid this danger, he packs the pelvis by drawing down the intestines and the omentum over them, and then pressing the abdominal parieties well in, before closing the wound. In this way the air is expelled. It will be observed that the very condition of things spoken of by Schroeder existed in this case. Might not some air containing septic germs have remained in the abdominal cavity, and have caused the inflammation and suppuration? It should be remembered in this connection that a slight interruption in the carbolic spray occurred while dressing the wound, and before the sutures were tied. Another question which has suggested itself to me is whether the pedicle could have been so tightly tied as to cause it to slough. As previously stated, it was tied twice, and the last time the ligature, which was of carbolized silk, was drawn very firmly by the strong hands of one of my assistants. Could it have been drawn too tightly, and is this one of the dangers to be guarded against? No such warning is given in any of the systematic treatises on ovariotomy. The reasons that the stump does not slough are said to be the following: First, an exudation of lymph forms over and around the ligature, which organizes and carries blood to the distal end. Secondly, the peritoneal membrane on either side of the ligature may bulge over the deep, narrow gutter made by the constriction, and unite, and thus give life to the part from which the circulation of blood has been cut off. Now, if these are the only means by which nature preserves the life of the stump, there can be no danger of drawing a small ligature too tightly, because the deeper it sinks the more certainly will the little gutter be bridged over by the bulging of the parts on either side. portion than in further manipulation. Four days later she died from septicemia. In another case he should remove the fœtus if possible, using the finger as a curette, and, if not successful in this, plug. DR. INGALLS spoke of his great good fortune in never having had a case of puerperal septicæmia in a long obstetric practice. In cases of abortion he has sometimes left the placenta to nature, but has often removed the ovum with the finger, which he considers the very best instrument for the purpose. Within a few years he has in several instances introduced the whole hand into the vagina, thus having the thumb That these processes do occur cannot be disputed; and forefinger with which to work. In one case, even but do they always occur soon enough to prevent after the introduction of the hand, he could not remove sloughing when the constriction is so great as to cut the placenta, and the woman had a foul, fluid, slateoff all circulation from the distal end? I find one au- colored discharge for six or seven weeks after this; thority who answers this inquiry in the negative. I but it then ceased, and she has been in perfect health refer to an article by Dr. Alban Doran, published in ever since. This is the longest period which has come the twelfth volume of Saint Bartholomew's Hospital under his observation, the time generally varying be Reports. Dr. Doran describes the post-mortem appear- tween a day or so and two or three weeks. The treatances of ten cases which had been operated on by ment of these cases is certainly a very important and different surgeons in the Samaritan's Hospital. In embarrassing point in obstetric practice, and it is often only a small minority of these cases could death be difficult to make the patient realize the importance of attributed to the intra-peritoneal treatment of the ped-rest and quiet, she being very apt to think herself beticle. The presence of a firm coagulum upon the end of the pedicle he considers a good indication, as showing that it had not been tied so tightly as to cause sloughing, and yet tight enough to prevent hæmorrhage. He says the pedicle sometimes partially sloughs in consequence of being too tightly tied, and warns surgeons against this danger, which he considers a greater one than the possibility of hæmorrhage from being tied too loosely. It seems to me that here is a source of danger which is not duly appreciated by most operators, and I cannot help feeling that in the case here reported the second ligature was the principal cause of the extensive sloughing of the stump. It is of course impossible to know certainly whether one of the above-mentioned conditions, or all of them combined, produced the peritonitis which was found to exist, but the points which I have raised in this case will not, I hope, be considered unworthy of the prominence I have given to them. Heports of Societies. ter than she is. DR. C. E. INCHES said that in his experience plugging is the best treatment, and that he has become convinced of the truth of Dr. Meigs's statement that the blood dissects away the membranes. He always plugs with ordinary cotton, and after eighteen hours or so finds the membranes behind the plug. SUBNORMAL TEMPERATURE. DR. BRADFORD reported the case of a child who, after excision of the elbow by Dr. Ingalls some time before, was eating and sleeping well, and had no unfavorable symptom, but whose temperature was found to be 95° F. It being thought that there must be some mistake, other thermometers were used, one of them tested and vouched for at Kew not long ago, but all registered alike 950 F. The next day the temperature was 96° F., the next 97° F., and since then it has been normal, there being no other indication of change in the condition of the child. DR. INGALLS remarked that it is very possible subnormal temperatures would be oftener met with if it were made an invariable rule to shake the index well below the lowest markings before using the instrument. DR. STONE related the case of a child recovering PROCEEDINGS OF THE BOSTON SOCIETY FOR from bronchitis whose father had bought a clinical ther MEDICAL OBSERVATION. FREDERICK C. SHATTUCK, M. D., SECRETARY. JANUARY 5, 1880. DR. BUSH read a paper on A CASE OF ABORTION, WITH INSTRUMENTAL DELIV- A woman thirty years of age miscarried during the fourth month, after prolonged use of the sewing-machine and accidental violence. The foetus was delivered with instruments, on account of the exhausted condition of the woman, who had a feeble pulse and irregular pains, causing great agony. The vagina was hot and tender, abdominal tenderness was marked, and as her condition was growing more alarming it was thought best to empty the uterus. The placenta was adherent and only partially removed, the reporter thinking there would be less risk in leaving the small mometer, and, finding the temperature 96° F., went to Dr. Stone in alarm. He found the child asleep, bathed in perspiration, and verified the thermometric observation; the next morning the temperature was normal. DIPHTHERIA, WITH LONG PERIOD OF INCUBATION. JANUARY 19, 1880. DR. WELLS reported the case. A governess living in the family of a late New York surgeon had nursed, several weeks previously, two of her young charges through attacks of diphtheria. Two weeks after they were well enough to go out-ofdoors they were taken to a summer resort on the coast of Maine. A few days after their arrival, and two and a half weeks after they had begun to go out, the gov erness, who had not been well in the mean time, was attacked with what the family supposed to be an ordinary sore throat. It proved, however, to be a well-marked case of diphtheria, from which she event ually recovered. Dr. Wells was led to connect her CASES OF EMPYEMA was read by DR. A. T. CABOT. He reported three cases, one of which was treated antiseptically, with rapid recovery, and invited discussion, particularly on the following points: (1.) How useful is aspiration in empyema, when should it be done, and how often should it be repeated before resorting to the more radical operation? (2.) How important is the strict observance of antiseptic precautions in making a free opening? (3.) What are the relative advantages of the different methods of treating the opening? DR. MINOT strongly advocated a free opening whenever the consent of the friends can be obtained. Its necessity is unquestioned in adults, and in children, though aspiration alone is not infrequently successful, recovery is more sure and rapid after incision. He has often tied a condom to the end of the drainage tube in children to receive the discharge. DR. PORTER said that empyema should be treated like any other abscess, and opened. As yet he has never used the antiseptic method in this operation, but means to do so in future. Lister says that when his method is rigidly carried out there never is any secretion of pus, but only an abundant serous discharge, requiring thorough drainage and a change of the dressing once during the first twenty-four hours, and then daily in an adult. In antiseptic surgery in general it is important to make sure that the spray does not give out before the operation and dressing are completed. DR. TARBELL also expressed his intention to employ Lister's method in future in these cases. In some of his cases, in which objection was made by the patient or the friends to the knife, he had used a very large trocar, and introduced the drainage tube through the canula, then withdrawing the latter. The reader inquired whether Dr. Tarbell had ever seen any trouble arise in these cases from the fibrinous clots which were retained in the chest. DR. TARBELL answered in the negative, and then alluded to the unwillingness of some physicians to etherize a patient in operating for empyema. He always uses the anesthetic, seeing no reason why we should not seek to avoid the pain of that as well as of any other operation. The treatment by frequent aspiration cannot be regarded as justifiable nowadays. fluid from the chest. The patient was a woman, sick three weeks with a large effusion and terrible orthopnoea. Dr. Wyman called the late Dr. Homans in consultation, and proposed tapping with an exploring trocar and canula and a suction pump. Dr. Homans thought it better not to interfere, but Dr. Wyman advocated the experiment so strongly that Dr. Homans said he would talk with his professional friends in Boston and return in the morning. When they met again he said, "Wyman, everybody is opposed to the operation, but, as the woman will die unless relieved of her dyspnoea, perhaps it is allowable to operate." Dr. Wyman immediately tapped, with prompt and entire relief, and in three weeks the woman was well. Gerhard, of Philadelphia, after the operation had been done in Boston, said, in reply to a question from Dr. Bowditch, that he would as soon put a bullet through the chest. Dr. Bowditch first operated in Boston because no one else would do so, but, owing to his want of surgical skill and experience, was in great fear and trembling before his first operation, and enjoined upon his friend, a young surgeon who accompanied him by special request, to take the instruments from his hand and complete the operation should he (Dr. Bowditch) be unable to do so. A wonderful advance has been made in the treatment of these cases during the last twenty years, but the tendency now is to make an opening under almost any circumstances, without regard to the age of the patient or the duration of the disease, factors which should not be left out of account. It is often very difficult to decide whether to aspirate or to make a free opening, and he has seen cases run down under either method when the disease was of long standing. DR. ELLIS expressed the opinion that aspiration, if resorted to, should be repeated as often as pus could be found, so as to leave as small a cavity and keep the lung as much expanded as possible. DR. T. B. CURTIS said that with Lister success is apparently the rule, and neither in spinal abscess nor empyema is any pus secreted after the opening is made. He applies gauze from the axilla to the pelvis to insure against the entrance of air, and he never gets carbolic-acid poisoning, because he never washes out the pleural cavity; indeed, he seems to disapprove strongly of such a procedure. DR. KNIGHT remarked that it is evident that little pus can be absorbed; if it were possible to get our trocar into the lowest part of the chest and remove the whole accumulation, we should probably succeed oftener in curing by aspiration. The annals of the Charité Hospital in Berlin during the last eight years illustrate well the change which has come about in the treatment of pleuritic effusions. In 1871 Traube and Fraentzel were beginning to take an interest in aspiration. The former inquired of the speaker, who was at that time at Berlin, as to Dr. Bowditch's results, DR. ROTCH inquired as to the danger of carbolic- got a pump, and convinced himself that there is no acid poisoning from washing out the pleural cavity danger in the procedure. Their apparatus is now firstwith a solution of that substance. Several gentlemen rate, and they have of late opened empyemnata successstated that they had neither seen nor read of such fully, according to Lister's method. The point sean occurrence, and the reader said that his idea in lected by most Americans for puncture is low in the washing out the cavity was simply to remove the coag-back, but the speaker thinks it better to tap in the fifth ulated fibrin, not to render the cavity aseptic, which it is already if the proper precautions have been observed. DR. BOWDITCH expressed himself as deeply interested in the discussion, and said that it is now almost exactly thirty years since Dr. Wyman first drew off interspace between the axillary and the mammillary lines, as is done in Germany, for the reason that the fibrin naturally gravitates to the lower and posterior portion of the chest, and a "dry tap." is thus more likely to occur if the needle is plunged into that part. DR. ELLIS said that he has now for a number of |