In by the knife it is well to use the electric cautery upon any suspicious places, and thus prevent the return of the disease. treating the tumors with electricity, if they yield to the treatment from time to time, we may safely conclude that they are not malignant. In our experience glandular and adipose tissues yield very slowly to the action of electricity, and we must expect nothing more than to remove the troublesome symptoms. UNSOLVED PROBLEMS. 1. Under what conditions are operations justifiable during pregnancy? 2. The best method of treating displacement of the ovaries? 3. The most successful method of curing vaginismus ? 4. The causes of amenorrhoea? 5. The causes of sterility? 6. The best method of treatment of rectocele ? 7. Gonorrhoeal infection? DISCUSSION. SHELDON LEAVITT, M.D.: Some one else was to have opened the discussion on this paper, and in his absence I have been requested to do so. I have had the privilege of reading the paper, but have not had time to give it merited consideration. There were two or three observations which attracted my especial attention. First, with regard to the statement concerning the advisability of eventually operating in all cases of tumor of the ovary, or tumors involving the broad ligament and Fallopian tube, and in cases also where pus is present in the tube or ovary. The question which was raised in the paper concerning these was chiefly: Ought we not to operate at once, or as soon as the patient can be put in proper condition? We are all desirous of choosing the golden moment for operating, but just when that moment arrives is a matter upon which we are not altogether agreed. It is always desirable in these cases to take them at the earliest practicable moment. In the case of enlarging tumors we find it advisable, of course, to operate before the constitution has been materially affected-before the system has been much reduced. I believe that we should all right there exercise our best judgment to determine in a given case the proper moment for operative interference. In the beginning, when the tumor appears to be so situated as to give the woman no trouble or discomfort, we may allow it to go undisturbed for a time, but if it be a case which, owing to environment, is likely to pass out from under surgical sur veillance, then in its incipiency surgical treatment is wise. With regard to pus in the Fallopian tube and ovary the same rule should be followed which applies to pus in other parts of the body. That is to say, when pus is present in any part of the body it is advisable to liberate it as soon as possible. But in the matter of pus in the Fallopian tube, when we have, in other words, pyosalpinx, we should not forget that other measures than radical ones have been resorted to in some instances with considerable success. You all know, of course, that a few years ago Dr. Pope, of New York, recommended the thorough curettement of the uterine cavity and the packing of it with iodoform gauze. Others also have seen cases of this nature markedly improved and some of them apparently cured by the Pope method. Whether this is true or not it appears to be advisable in some cases of pyosalpinx to resort to this expedient because, even though it does not cure the patient, it puts her into a better condition for the more radical operation. Before leaving this subject let me say that there is a question in my mind concerning the advisability in the average case to approach pus in the ovary or in the tube through the abdomen. I believe there is a growing disposition on the part of operators to get at purulent accumulations through the vagina, performing, if necessary, vaginal hysterectomy, and thereby providing thorough drainage. Such a course enables the operator at the same time to make a complete removal of the offending parts. I have found from my limited experience in this direction that in some instances where I approached the diseased structures through the abdominal walls it was exceedingly difficult to get to them in a satisfactory manner, the entire pelvis being completely roofed over by the adhesions. The structures which we seek to exsect are sometimes torn away in our efforts to remove them. When the pus sac is approached from the vagina, and especially if vaginal hysterectomy be performed, we can more thoroughly provide for drainage, while the necessary after attention can be given more satisfactorily than when the operation is done through the abdomen. Dr. Higbee has something to say with regard to the use of massage after laparotomies for the purpose of breaking up or preventing adhesions. He tells us that this should be begun very soon after the abdominal wound is healed. There is a question in my mind whether the desired effect can be produced by such a performance. I believe it to be wise as a preventive of adhesions to watch as carefully as we may the peristaltic action of the intestines. We can determine not alone by the movements of the bowels, but by the frequent passage of gas, as well as by auscultation over the abdomen, whether this function is being properly performed or not. By apply ing the stethoscope we can determine whether the bowels are quiet, or whether they are going through their usual peristaltic motions. In the absence of a normal amount of the latter we should, by the administration of certain remedies and the adoption of certain measures, influence the intestines to the performance of their proper function. He has something to say also with regard to mammary tumors and their removal. We are led to believe by many that it is wise to have recourse to electricity in these cases. The fact is that none of us can say positively on the first appearance of a growth in the mamma, whether that growth is malignant or not. But we may learn something as to the probability of malignancy from the age of the patient herself. When a lump develops in the mamma of a young woman, our suspicions of malignancy are not as strong as when a growth is found in the breast of a woman who is at the age of 40 or 45 years. I believe it to be wise, however, when we find a nodule within the breast of a woman who is advanced in years, to take very little chance of its development into a malignant growth. I believe it far better for us to assume that it is malignant and institute a complete removal of it. In the case of the younger woman I believe that we should have a little more latitude, and if we think best, for a time keep the case under surveillance. We may apply electricity, and if it be nothing more than an adenoma very likely it will disappear or be dispersed. I have a case now in mind where such a growth developed in a woman about 35 years of age. There was not only the growth present, but there were the severe and even burning and lancinating pains. I felt that a radical operation ought to be performed, and so advised the husband; but he would not listen to the suggestion for a moment. I was under the necessity in that case of using electricity, and after the woman had been under this kind of treatment for a period of some three months, the growth had entirely disappeared and has not since recurred; that was some three or four years ago. Occasionally she has the same sort of pain in that region, but nothing abnormal whatever is to be found about the breast. S. B. PARSONS, M.D.: There is one point, and that is in relation to the use of carbolic acid in the peritoneal cavity, and advising caution against using it too strong; that is an important point. Ĭ want to tell you just what my experience was; it may be a lesson to you, and my friend, Dr. Comstock will remember the case. We had a case in the Good Samaritan hospital in St. Louis that was ripe for a laparotomy; it was a case of ovarian tumor. About that time a German friend of mine had been to Europe and on his return brought me the latest instrument for using the spray in laparotomy. It was used by the first German surgeon at that time; carbolic acid was the solution that was used. They were using the 10 per centsolution. The method of using this spray was when you had begun your operation the spray was to be thrown directly along the wound. so that you would kill every bug within two feet of the wound so that none should get into the peritoneal cavity. I had a good assistant and made every preparation to throw the spray on the wound and on my hands and instruments, and he did throughout the entire time until the wound was closed. I thought we were going to have a good result and we did, so far as the spray was concerned; the air that went in there was loaded with the carbolic acid. Our patient went on through the night fairly well, but in two days the urine was as black as ink and she died in sixty hours from carbolic acid poisoning. I have never used it or anything else in the way of an antiseptic in the abdomen since. I don't use anything at all except sterilized water, sometimes a weak solution of salt water, but usually it is nothing but sterilized water, and we can get just as good results and better than from the antiseptic irrigations. We can get corrosive sublimate poisoning from a weak solution thrown into the peritoneal cavity. It is unsafe to throw anything in there. The peritonæum is a very quick absorbent. All patients are not equally susceptible. Some can stand a considerable washing with medicated solutions, but others cannot. Dr. Higbee closed the discussion by saying that Dr. Parsons evidently misunderstood his paper, as he (Higbee), condemns the use of carbolic acid and of bichloride, and said distinctly that he thought the use of the sterilized water was the best. HYSTERECTOMY: IS IT EVER ADVISABLE? IF SO, IN WHAT CASES AND BY WHAT METHOD IS IT BEST ACCOMPLISHED. BY E. H. PRATT, M.D., LL.D., CHICAGO, ILL. First. Is it ever advisable? Preventive medicine outranks in importance all curative measures. Every honest man in the practice of medicine seeks to save rather than to destroy. But the life and health of the body in general is superior to that of any of its parts, and, unfortunately for humanity, important sacrifices are frequently demanded in order to secure health, happiness and sometimes a continuation of existence itself. Operative surgery is necessarily destructive in its nature, and is invariably an apology for better work. If voiced it would say to the object of its consideration, be it tumor, abscess, gangrene or other deserving pathology, "You are not only in a diseased condition yourself, but you are interfering with the bodily harmonies and endangering life itself; I am unable to cure you, I must therefore kill you. I know that my processes are painful, my measures are destructive, and I am perfectly well aware that I mutilate, maim and deface; but you are so sick that you cannot recover, and you are endangering the community of bodily organs of which you are a part, and for the sake of the rest I must destroy you. I hurt that I may help, I ruin that I may rebuild, I kill that I may cure. You are sick and diseased beyond repair by drugs and other milder remedial measures, and you must sacrifice your existence that the rest of the body may live." This is the universal language of operative surgery. Its history is written in blood, and its memories recall a long panorama of ghastly sights and one continual echo of agonizing sounds. It is prolific of deformity and pain, and sometimes even death. It is disgusting in practice, horrible in contemplation, and its necessity is invariably disaster. It plucks out eyes and cuts off limbs. It resects joints, trephines skulls and removes |