stances it would be justifiable to give the patient this operation. But there is another risk in an operation of this kind that no man can foretell, and that is hæmorrhage. We get the hæmorrhage from a fibroid, the uterus cannot contract, and the hæmorrhage may be severe or even fatal. No man could say there was only one tumor in this uterus before the operation. The operator could not assure the patient that she would not. have another fibroid within three years and would have to undergo another operation. Therefore, I believe this operation will not come into general use and will be resorted to only on very rare occasions.

Dr. Zinke:-Mr. President: Do you think a uterus from which such a mass has been removed would be a safe uterus for pregnancy?

Answer: If that were the only tumor, I think it would be safe.

Dr. Ricketts: In nearly five out of six of these cases, the ovaries are in a diseased condition and the operator knows nothing of their condition. For that reason I wish to emphasize the advantage of an exploratory incision in diagnosis.

CLOSE OF DISCUSSION.

Dr. Reamy:-Mr. President: I have been really amused at the delicacy with which the gentlemen have introduced their criticisms, saying they meant nothing personal. I do not understand it. If I were a youngster, speaking here for the first time, it might excite me to have my methods opposed, or if I were advocating a method new and to be tried only at the risk of human life.

Dr. Hall: The reason I spoke in that way was because the operation has been defunct so long I thought an apology in order, because it was presented before the society.

Dr. Reamy: Intra-uterine polypi are not under discussion. I think nobody here would remove the uterus for an intra-uterine fibroid polypus. I take it for granted there are few here who would remove the uterus even if the attachment of the polypus were somewhat sessile. You remind me very much of the story of an Irishman employed to trim an orchard. When asked if he could trim apple trees, he said, "Yes, your Honor, I can." The Irishman was employed and in the evening the owner of the orchard returned and asked how he got along. Patrick replied that he got along very well. The man asked, "Did you get them all trimmed?" Patrick replied, "No, I haven't got them all cut down yet." And you, gentlemen, who propose to remove the uterus because it has a fibroma in it, remind me of the Irishman.

I will take up the criticisms in the order in which they were made. First, as to the question of sepsis. The cases to which my friend, Dr. Johnstone, referred, operated on by Goodell, were operated upon in 1883, when antiseptic surgery amounted to nothing.

Dr. Johnstone: As I saw them carried out, it was just as good as at the present day.

Dr. Reamy: Well, then, he was the only man, because at that time Lister had not formulated methods by which a sepsis could be carried on one-fourth as well as now. From what sources must the sepsis come in such an operation? My friend, Dr. Bonnifield, said I had a little sepsis. when I made the preliminary incisions. I expected a little sepsis then, because it was in the vagina, and although the instruments were sterile and the parts were thoroughly sterilized before the operation was commenced, and although antiseptic treatment was continued, necessarily from the location there was a slight amount of sepsis; but I had no fear that sepsis would go to any considerable degree. These preliminary steps are only made in cases in which the lower segment of the uterus is involved in the growth. And what is the objection, suppose this sepsis should continue-an almost impossible thing in a properly selected case, for this was not a soft tumor? I would not subject a soft myoma or vascular tumor to such treatment. If you should find sepsis established itself in an individual and it was grave, what is to hinder a hysterectomy and the removal of all the source of sepsis? But I have never had sepsis in thirty cases, except in a solitary one, that amounted to anything, and in that one the sepsis was from the old practice of making the dilatation with tents. At the time that Dr. Johnstone refers to, Goodell, himself, in a large number of these cases, used tents in addition to a dilatation with instruments. This I have seen him do.

Dr. Johnstone: He did not use tents in the cases I saw.

Dr. Reamy: Goodell also used, in his cases, Goodell's divulsion forceps, and dragged these tumors away, and he recommended that procedure in his lectures. He did not attempt to cut them away.

Dr. Johnstone: Yes, he did, and I have seen him do it.

Dr. Reamy: He dragged them away. I know what I speak of, notwithstanding Dr. Johnstone's remarks to the contrary .Goodell left a large part of the tumor in the uterus. If you attempt to remove the tumor in that way in such a case as this, of course you will destroy the woman's life. A man who is not accustomed to working in the uterus should not attempt this operation. But I beg you to remember that when you say it is a neat thing and easy and safer to remove the uterus than it is to remove only the diseased tissue, it is not the highest surgical science. The fact that a woman is 49 or 59 years of age is not against this. Your objections are purely theoretical. At the time Dr. Johnstone referred to, except by one solitary man, in proportion to the cases of abdominal hysterectomy, at that time more women died than died under Goodell from the removal of tumors by morselmon, as defective as it was. Because abdominal hys

terectomy has been perfected and because advances have been made in vaginal hysterectomy, do you think it is, therefore, reviving a nightmare when we consider an operation that is more conservative, which leaves the uterus healthy and leaves the woman not mutilated? That is not science. Wait until you find out whether these women live or not; wait until you have tested whether the mortality from morselmon in properly selected cases is any greater than from hysterectomy, before you condemn it. Don't condemn it on theoretical grounds. I have lost only one case, and that was from sepsis induced before the operation. As to danger from hæmorrhage, I would not touch a soft myoma or any case which I could not dilate before the operation. In a large per cent. of these cases the operation can be finished in a single sitting. In conclusion, I would like to say this woman may have a recurrence; another tumor may grow. So may another cancer appear in the other breast after one breast has been removed, and so may a sarcoma in any part of the body after a sarcoma has been removed, and so may a patient die of tuberculosis after he has once recovered from tuberculosis; and should you cut out a woman's uterus because she might have a tumor in it some time in the future? I beg to say, without any personality, as you have said, the time is coming when not only myself but a large percentage of those present will be doing this operation. You will be compelled to do it, for the practicability of this operation will so impress not only you but the women themselves, who will demand it. The women will object to having you take away one of the constituents of their make-up when it is not necessary, and if you do not resort to this operation, gentlemen, you will not be as smart in this as you have been in the past. The blood supply of these tumors is, in almost every case, in the periphery of the tumor; and the reason this woman did not bleed was because it was a hard tumor and the larger vessels were cut off before I incised it. The uterus will contract and you can crowd it with gauze if necessary. But there is practically no danger from that nor from sepsis.

Dr. Johnstone: What is the mortality of this operation?

Dr. Reamy: Well, it depends very largely on the operator. During the last twenty years I have done the operation on at least thirty cases and have lost only one case, which was due to sepsis from the use of tents for dilatation.

Dr. Zinke: What was the nature of the case, which I saw with you, that died from hæmorrhage before we left the room?

Dr. Reamy: That was a case that died from shock, and has been reported by the doctor who had charge of the case.

Dr. Ambrose Johnson read the report of a case of fibroid tumor of the

uterus.

Presentation of Specimen-Dr. Johnstone.

Mr. President: This is simply a large ovarian cyst and there were a great many adhesions, and some difficulties about the operation made it long and tedious. The reason I want to put it on record is because it is the first case of the kind I have come across. The patient is a woman aged 25, who has never menstruated, although she is thoroughly developed in every way. She has never been pregnant. Here is the opposite ovary, with a little dermoid. This is a proof of what Bland Sutton says, that these tumors are never found except in the Graafian follicle. You will observe that both the ovaries are diseased.

Dr. Palmer: It would be interesting to know whether, if this patient had been pregnant, she would have menstruated during the pregnancy. I had one case in which pregnancy has occurred three times, and the patient never menstruates until she is pregnant, and then she continues to menstruate during the period of gestation.

Dr. Reamy: I have two cases in which menstruation occurred only during pregnancy.

Dr. Johnstone: It would have been impossible for pregnancy to have occurred in her, because the Fallopian tubes were plugged.

Dr. Rufus B. Hall.

Case 1.-Hysterectomy for double pyosalpinx. Mrs. K., Troy, O., aged 30, married 12 years, 1 child 11 years old. Gave a history of specific infection. In November, '95, had an attack of inflammation, confining her to bed three weeks. At this time had a discharge of pus per rectum. March 1st, '96, was anæsthetized and the uterus curetted by her physician, Dr. Wright. She entered my private hospital Nov. 18, '96, and was operated upon the 21st. You will observe the specimen consists of both tubes and ovaries, with the uterus. Both tubes contained pus; there was an abscess in the left ovary holding an ounce or more of very offensive pus, and the right ovary contained about a dram. The adhesions in the pelvis were extensive. The fact that the uterus was almost denuded of peritoneum led me to select hysterectomy in connection with the removal of the suppurating tubes and ovaries, as offering the best chance for recovery. I feel convinced that in all cases of suppuration of both sides, the uterus being denuded of peritoneum, the best operation to make is hysterectomy. The patient has made an easy and satisfactory recovery.

Case 2.-Hysterectomy for multiple fibroma. The patient, Mrs. D., Glendale, O., aged 33, 2 children, youngest 9 years old, has been conscious of something wrong in her pelvis for three or four years. She suffered from profuse menstruation and severe pain at times in the abdomen. She entered the Presbyterian Hospital Nov. 26, '96, and was operated on the 30th. Both ovaries and tubes were bound down by adhesions.

The specimen consists of both ovaries and tubes, with the uterus, which is studded with multiple fibroma; the largest,size of a large orange, is in the posterior wall. This patient is also convalescing nicely.

Case Reports-Dr. Edwin Ricketts.

Mr. President and Gentlemen:-I want to report a couple of cases of rural surgery. In these days of antiseptic craze, it is well to go back and remember we can do surgery without these things when it is necessary. Not long ago I saw a case in which a woman had been tapped and relieved of 40 pounds twice and 10 pounds the last time, two weeks previous to when I saw her. I did not have a nurse and nothing but well water. I had a pitcher of this water boiled, and after cleansing my hands the abdomen was opened, and I found a multilocular cyst. The, omentum had to be tied off in three segments. It was impossible to get the tumor out without flooding the cavity with fluid. I heated the water until it was comfortable to my hands and then I had to sponge the cavity, from the pelvis to the diaphragm to get rid of the flakes. I found some flakes present from the previous tappings. Her reactive temperature was 100.4°, her pulse 110. The second day the bowels moved, the temperature was normal, pulse 84, and there was no distention or untoward symptom. She is now eating, and there is no doubt as to the result.

Second Case-Nearly seven weeks ago I saw a patient, æt. 68 years, who had been sick 90 days with abscess of the left lobe of the liver. The operation was done by cutting down into the pus, of which at least three pints was removed. In this case the drainage tube was discarded and iodoform gauze was packed into the wound. It has every indication of being a single abscess. The indications now are that we will have a recovery in this case.