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What the patient most desires is for us to relieve his condition, consequently if we would do this we must bid adieu to the time honored lotions, leeches and insufflations which have been the ear specialist's vade mecum, and resort in the future to the naso-pharynx as the battle ground, and then use surgical weapons only. No amount of medicinal treatment has been successful in my hands. The tissue must be removed if the patient is permanently benefited.

Among surgical methods the galvano cautery seems most cruel, and chemical agents slow and ineffectual.

Most humane and satisfactory is the use of Gottstein's curette, or Cradle's forceps.

I prefer to operate under chloroform anesthesia, but have operated upon many children with only an application of cocaine.

Modes of operating are immaterial. What I wish mostly to emphasize is an earlier recognition of this condition, with immediate attention from the family physician, which will, in my opinion, result in the prevention every year, of thousands of cases of deafness, with concomitant ear disease.

While conversing upon this subject with a teacher in one of our large cities not long ago, she remarked, Now that my attention has been called to this, I know that our school houses and streets are full of children suffering from some abnormal condition of the upper air passages, and nothing is being done for them.

Preventive measures in this matter rests largely with the physician, and we must destroy that insane prejudice against "meddling with the ear because it is such a delicate organ."

Hundreds of people go through life not only with that "melancholic curse of deafness," but with suppurative ear disease, resulting, not infre-. quently, in abscess and death, because some medical man has advised them to let their ears alone.

Case 1.-John E., aged 8. Suppuration in right ear of three months duration; could not attend school on account of increasing deafness in both ears, with fullness in the head.

Hearing distance, R. E. 2-36, H. D. L. E. 4-36: examination revealed depressed drum membrane, with perforation in right ear and deafness and thickening in the left. Examination revealed faucial tonsils with excessive growth of adenoid disease in naso-pharynx. Removed, with only cocaine. anesthesia of faucial tonsils and vegetation, with subsequent treatment of suppurating ear, which was caused by the pathological naso-pharyngeal condition, resulting in a complete restoration of hearing in the left ear and with an improvement in the right ear, when he returned to school and has remained well six years.

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Case II.-Willie G., school boy, aged 9 years. Brought to me by parents, giving history of deafness for two years, with suppurative discharge from both ears, following colds or attacks of indigestion, H. D., right ear, 3-36; left ear, 1-36. Examination of the ear showed the usual pathological changes found in these cases, and post-nasal space filled with adenoids. Patient had been treated by several physicians with instillate of medicine in the ear, and various other methods without relief. I thoroughly convinced the parents that no help could be given the boy without operative procedures, and they allowed me to operate at once. I gave the boy a few treatments for the resulting ear changes, together with treatment for a marked conjunctivatis which resulted in my opinion from the post-nasal condition, and in three months discharged him as cured.

Case III.-Frank B., aged 10; sent me from North Minnesota. Was one of the worst sufferers ever brought to me; mouth open; articulation imperfect; asthmatic attacks upon the slightest change in the weather; fullness in the head, and came with almost total deafness. Could not make any examination of post nasal spaces until I first removed faucial tonsils, which I especially wished to do, to ascertain if they relieved any of the symptoms. The little fellow suffered in the same way for several days, when I operated for removal of so much adenoid tissue that I am sure if Í had made rhinoscopic examination I would not have recognized a landmark in the vault of the pharynx. After keeping the parts in a perfectly aseptic condition for several days, I began inflating the Eustachian tube, which I continued for two weeks, sending him home a perfectly well boy, with every distressing symptom, including deafness, permanently relieved.

Died. Dr. W. A. Morton, of Liberty, Mo., died December 10th. Dr. Fortes, of lowa Falls, Iowa, died December 14th.

Seton Hospital for Consumptives.-The new Seton Hospital at Spuyten Duyvil Parkway, about a mile from the railroad station, which has been completed at a cost of $330,000, was opened Dec. 4, by Archbishop Corrigan with elaborate ceremony. The building, which occupies a commanding position and is surrounded by a lawn of about twenty acres, required two years for completion. It will be devoted to the care of consumptive people who can not get undivided attention in an ordinary hospital. It is 250 feet in front, and in the center, where the chapel expansion is, has a depth of 200 feet. The side wings are 90 feet deep. It comprises a basement and four stories, the top one of which is surmounted by a cupola. The material is brick and terra cotta, and the style is that of the Italian Renaissance. There will be accommodations for 200 ward patients, who are expected to be free patients, and a number of private rooms for pay patients, a source of income which, it is hoped, will contribute materially to the support of the establishment.

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Uterine Fibroids, Hysterectomy; Treatment of the

Pedicle.

BY A. H. CORDIER, M. D., KANSAS CITY, MISSOURI.

Lecturer on Abdominal Surgery, Kansas City Medical College.

READ BY TITLE BEFORE THE MISSOURI VALLEY MEDICAL ASSOCIATION AT HOT SPRINGS, ARK, NOV. 20, 1894.

A

S WE learn more and more of the pathology of uterine fibroids, we limit the application of the removal of the appendages (Tait's operation) to relieving the symptoms produced by their presence, and to checking their further development. The pathologist and clinician have repeatedly demonstrated that it is of not infrequent occurrence for fibroid tumors to undergo sarcomatous degeneration. This is especially true of that form of uterine neoplasm known as a fibro-myoma, or as Mr. Tait terms them, myomata. This form of growth develops like sarcoma, at any age, but is most likely to appear before the age of thirty, and is usually a single growth, soft, semi-fluctuating, rapid in its development, and unattended by the usual hemorrhages so often accompanying the multi-nodular or hard. fibroid. These growths (myomata) do not cease their development at or after the menopause, but may grow with increased rapidity after this period is past. They are liable to undergo mucoid, colloid or sarcomatous degeneration. They are composed principally of muscular tissue. They may grow rapidly for a few months, then remain quiescent for a number of years, start up from their lethargy and develop rapidly. Owing to the rich blood supply of this form of uterine tumor, they are not as likely to suppurate as the hard, compact, fibrous growths, but let this nourishment be cut off by the ligation of the vessels leading to it (Tait's operation), or the ligation of uterine from below (Dorsett-Martin operation) and the danger from necrosis is real, not imaginary, Any small tumor of the uterus may become an enormous growth filling the abdomen, hence all small tumors that show a disposition to become steadily larger should be dealt with surgically. Electricity, ergot, etc., etc., are agents that have been tried and discarded in most instances, for some procedure that is reasonably certain in its results, and that is some form of surgical operation, removal being by far the most exact, and in the aggregate, safest.

Chicago-St. Louis has given us a new procedure (ligation of the uterine arteries per vaginam) that to the unwary and inexperienced seems reasonable, safe and certain, but to one who understands the pathology and

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clinical behavior of these growths, the Dorsett-Martin operation is a most inexact, dangerous and incomplete piece of surgery. The blood supply is not alone the sole supporter of the growth and development of any structure, and this is true of uterine growths, as of any other part of the body. The nerve supply is of much import to the vitality of any structure, and in the uterus, Mr. Tait long since called attention to the necessity of the ligature including a nerve (Johnson's nerve) near the cornu in the broad ligament, in order that the menopause might be completely brought about. Some one up in the northwest, recognizing this fact, ligated both ureters, then opened the abdomen and ligated both ovaries and included this nerve (?) and his case was a success, as the growth ceased its development, as did the woman her earthly existence. Uterus sloughed.

The appendages have been found diseased in my cases, with a frequency to warrant the conclusion that there exists a casual relation between inflammatory diseases of the appendages and the development of uterine fibroids. If this fact is recognized by the surgeon, I am sure he would be neglectful of his duty and unsurgical in his methods should he resort to any procedure that had not for its object the removal of the diseased appendages, breaking up of adhesions, and the liberating of sound imprisoned surrounding organs, and the removal of the growth, if large or of that variety liable to continue its growth after the appendages are removed.

Many growths produce by their presence, pressure on the bladder, rectum and ureter. Such Such a growth should always be removed by the surgeon, and not left for nature to absorb (?) or for its presence to produce irreparable injury to surrounding organs.

I do not desire to be misunderstood in my position as regards the removal of these growths. I would not operate on dying patients, because they will continue to die in spite of the surgery, and not as a result of the surgery. Operations on dying people bring reproach to this class of lifesaving work.

I mention this fact to impress some one, possibly, who may hear this read or see it in print, of the necessity of early surgery in all cases where past experience has demonstrated that at some time in the progress of any given case surgery becomes necessary in order to save the life of the sufferer. Early surgery means completed and satisfactory work. I am no advocate of abandoning a procedure when once begun, for any surgical operation that is done in an imperfect manner must of necessity, in most instances, beget disaster and disappointment.

The operation of Mr. Tait's is applicable to a few cases, to check hemorrhage and cause the growth to cease its development. The growth must

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be small, of the hard variety, and in a patient near the natural menopause, and uncccompanied by any polypoid growths within the uterine cavity. Enucleation is applicable to a very limited degree, to small, single, hard fibroids in the front wall of the uterus. The appendages must be normal, or should be removed at the same time. Any extensive enucleation is attended with more danger than a hysterectomy, and leaves behind a poor piece of surgery and a useless uterus, in most instances. It is possible for some fibroid uteri to become impregnated, and a recognition of this fact should form an operative indication, in these cases, for the mortality to both child and mother is very high.

We have arrived at a period in the history of pelvic surgery where we cannot yield to the plea for ideal surgery, as far as a theory is concerned, but must submit to the more intelligent entreaty for good results and low rates of mortality-really the goal of truly ideal surgery. If a skilled operator has a preference, or is partial to a particular method, he is certainly entitled to do his favorite operation, provided his results are equally as good as those of others doing the same work in another way, If a large series of cases be reported with a mortality of five per cent after a given method by one surgeon, and on comparing this per cent with the work of another doing the operation with some modifications, you find a death rate of twenty per cent, you may rest assured that the fault, in the majority of instances, will not be found in the operator so much as in the faulty principles underlying the procedure of his choice. I find many operators who are constantly changing their technique, trying a new stitch here, and a buried ligature there; or a different instrument is applied, all, possibly, at the expense of the abandoning of an old, faithful and efficient procedure. Usually the old have been abused, hence the seeking of something new to try. All that is necessary, in the majority of instances, for a procedure to receive their unqualified endorsement, is a foreign stamp, or a so-called conservative imprint by some illustrious and superannuated book writer, or professor. Unfortunately, the outlines of much abdominal surgery are mapped out by turning a revolving book-case, while the topography is dictated to the office stenographer.

The surgery of some abdominal operators reminds me very much of the rapid transformation of a piece of butcher's meat, in an average boarding house-roast today, soup tomorrow, and hash the next day, not recognizable at all; a species of surgical omelet, so to speak. While my comparison may seem a little absurd to some of my hearers, I am sure others will agree with me, in the main. I am fully in accord with any surgical advances, but do not believe in abandoning a good procedure, one that is all that could be desired, for an uncertainty.