24 Pean's method being the one of my choice, is one that I shall describe in full. Mr. Tait, Drs. Price, Bautock, Keith and McMurtry all perform the Pean operation. Operation: The preparation of the patient for a supra pubic hysterectomy is one of much import, and too much care and attention cannot be given the details of the same. Cleanliness should be the watchword, and the eyes of the operator the sentinel, that no unclean nurse, sponge, instrument, or assistant, cross the aseptic halo. A larger number of instruments are necessary in doing a supra-vagina hysterectomy than is required in an ordinary "section." The operation. itself demands a variety of instruments, and to be ready to meet unexpected complications requires more to be added to the list-one dozen hemostats, two hysterectomy pins, Koeberle serre-noeud, with delta metal wire, (this wire may be obtained from Krehne & Sessemann, London,) an extra Koeberle, in case of a break should be on hand, a knife for the abdominal wound, a large scalpel to cut away the tumor, four large tissue forceps to clamp the broad ligaments while making the pedicle, strong straight needles to sew the abdmoninal incision; silkworm-gut sutures, silk two sizes, for ligatures-bladder and intestinal injuries require a fine silk suture—a strong, straight needle to sew through the pedicle to reduce its size and keep the peritoneum from retracting; large flat sponges, smaller round sponges; irrigator, drainage tube, piston syringe to empty tubes; dressing material, iodoform gauze, etc. I prefer ether as an anesthetic in all abdominal operations. This is an important item in the performance of a hysterectomy, and the operator who recognizes this and completes his work quickly will, everything else being equal, have the lowest mortality. The abdominal incision should be inside (to begin with) a little nearer to the umbilicus than is usually made in a "section" for the removal of diseased appendages. This precaution is made necessary to avoid wound. ing the bladder in the first incision, as this viscus is frequently pulled up by the growth of the tumor. Having entered the peritoneal cavity and settled the error or correctness of the diagnosis, proceed to sweep the fingers of the whole hand over the growth, going first above, then to either side, finally examining very closely for the location of the bladder; satisfying yourself that the growth can be removed (it is very rarely that one cannot be removed), your incision is carried downward to the full limit of safety, and if need be, upward above the umbilicus. The growth is now brought forward through the abdominal opening. If omental adhesions are present, they are "sponged" off, or double-ligatured, and cut until freed from the 1 25 growth. In delivering the growth, be careful that no undue force is used with the fingers in the region of the broad ligaments, where you will find enormously enlarged and tortuous blood vessels. The same precautions should be exercised posteriorly, for here in many cases you will find large and vascular adhesions, which, if torn across, bleed profusely, and are found and ligated with difficulty. In the globular oedematous myomas you will often find that it is with much difficulty that they can be removed from their snugly-fitting mould. They can be easily dislodged if you can succeed in getting air to the bottom of the pelvis by pressing the finger or a clean catheter alongside of the tumor to the bottom of the pelvis. If you fail in this, then the cork-screw of Mr. Tait will be of much assistance to you. This instrument is screwed into the "fundus" of the growth, and traction made slowly and steadily until the tumor is delivered. Examine again closely for the location of the bladder, which is usually marked by a difference in color and the course of blood-vessels, and a faint line may be seen marking its limit when made out. If still in doubt, have an assistant quickly introduce a catheter, and its limit is then easily made out. If the bladder is pulled up too high to admit of the wire being applied, carefully dissect it from the walls of the tumor, and permit it to drop out of the way. If the pedicle is small, the wire can now be applied, the pins having been placed in position before the wire is tightened. The pins should be placed parallel, and exactly across the abdominal incision, and on a level with the surface of the body. If the pedicle is too large to admit of being constricted by the wire and fastened in the lower angle of the wound, pass a large tissue forceps on either side of broad ligaments, two to each ligament, and cut between them down to the tumor, and from side to side in front and behind, having previously caught the peritoneum with hemostats, in many places around the tumor, just below the proposed line of incision in the capsule and above the bladder attachment. This last precaution guards the bladder and prevents the peritoneum retracting beyond the proposed location of the wire. Having divided the capsule, rapidly dissect it down to just above the location to which the wire is to be placed. You have almost practically enucleated the tumor, and have reduced the pedicle from the size of the thigh to that of the wrist, and that, too, without loss of blood and time. The pins are now pushed through the capsule, and the wire tightened by the noeud and the remains of the tumor and capsule are cut away an inch from the pins, and the wire tightened again until all oozing stops. At that stage of the operation when the tumor is delivered, a large flat sponge should be placed over the intestines, and two or three sutures passed through the parieties and 26 grasped by heavy forceps and crossed over the line of the incision. This protects the intestines and keeps them in place. The hemorrhage being controlled by the wire, the cavity of the cervical canal is cleaned, and a piece of gauze packed in it to prevent infecting the peritoneum during the completion of the operation. The peritoneum is washed or cleaned by sponging, if it needs it, especial care being given the location of the bladder, as here blood-clots are liable to be left behind. Two strong strings are placed around the pins, to be used in pulling the stump into the lower angle of the incision, and to hold it steady while the peritoneum is being stitched to the pedicle below the wire. Fine antiseptic silk is used for this sewing. Union takes place quickly between the parietal and pedicle peritoneum, and soon seals that cavity from any outside source of infection. You now introduce your sutures, then remove the large flat sponge and irrigate or clean out the recesses of the peritoneum, especially the pelvis, and if the tumor removed was a large one, in the "flanks” also. Silk-worm-gut sutures should be used in closing the abdominal incision. You now take a strong straight needle, armed with stout silk, and sew back and forth through the pedicle to reduce its size, to aid in controlling hemorrhages should the wire break in your absence, and to prevent the peritoneum retracting below the wire (not likely to occur) and to reduce the size of the stump. A drainage tube can be used if the usual indications for its use are present, such as oozing from adhesions, free fluid in the peritoneum at the time of operation, escape of pus from a pyosalpinx, (a complication of frequent occurrence in fibroids of the uterus). Care must be exercised in approximating the cut surfaces about the pedicle, for fear too much tension is placed on the integument surrounding the stump, and cause stretching of the skin. Pledgets of iodoform gauze are applied under the edges of the stump, and under the pins to prevent pressure on the skin, and the stump is covered with iodoform to hasten the drying process. The usual dressing should be applied with gauze and the many-tailed bandage, the Koeberle, is permitted to project from the dressings that it may be tightened as often as may be necessary without disturbing the patient or her dressings. If the pedicle is a large one the dressings will soon be soiled by the discharge. There should not be a large one. The nurse is instructed how to tighten the wire if oozing of blood is detected. The wire is tightened by a turn or two of the clamp each day until the stump drops off, which usually occurs from the eighth to the twentieth day. The dressings are changed as often as it is necessary. Every aseptic pre 27 caution should be carried out in its fullest detail in doing the operation and in the treatment of the pedicle afterwards. If suppuration about the stump takes place, it is due to a want of aseptic care on the part of the surgeon or nurse. If this accident has occurred, it is best treated by keeping the groove around the stump lightly packed with iodoform gauze saturated with pure listerine or campho-phenique. After the pedicle drops, there remains a shallow cavity that is soon filled up by healthy aseptic granulation tissue. This description of the technique of a supra-vaginal hysterectomy is one applicable to all uncomplicated cases. The inventive ingenuity of the surgeon will find here a broad field in which to extend in meeting unlookedfor complications. If I have succeeded in making the various steps of this, the choice operation for the removal of uterine myomata, clear and plain to those unacquainted with its technique, the object of writing this paper has been attained, and my desire gratified. I beg to submit to your consideration the following deductions: 2. Procrastination, tinkering and electrical darts convert many a simple case into one of great magnitude, with many complications, making the work of the operator very difficult and hazardous to the patient. 3. Small, stationary, hard fibroids, without dangerous symptoms, may with safety be allowed to remain, especially in women nearing the menopause. 4. Rapidly growing dematous myomas may not present any dangerous symptoms, may occur at any age, may and do continue to grow after the climacteric; removal of the appendages does not check their growth. 5. ŒEdematous myomas should be removed by a hysterectomy, as the entire uterus will usually be found taken up in the body of the neoplasm. 6. Fibroids undergoing mucoid or colloid degeneration should be removed by a hysterectomy. 7. Suppurating fibroids, when not extruded into the vagina, should be removed by a hysterectomy. 8. Pediculated fibroids, if the pedicle is small, may be removed with safety by taking all due precoutions to guard against hemorrhage. 9. All hysterectomies (with Dr. Price's qualification) should get well. 10. Oophorectomy or salpingo-oophorectomy as a means of relief for tumors of the uterus is being more and more limited in its sphere by a more thorough understanding of the nature of these growths. Medicinal agents and electricity may, in many instances, relieve the symptoms for a short time, but the uncertainty and the dangers attending their use more than outweigh their expectations for good. 28 A Case of Hydrophobia. By E. H. BULLOCK, M. D., NODAWAY, Mo. T is not that I expect to offer any thing new, or of special importance upon the subject of hydrophobia, that I write upon this subject, but because I have recently had the misfortune to encounter a case of this horrible disease in man. I speak of it as a misfortune to thus meet with a case of hydrophobia, for after the first symptom of the disease is apparent the physician is as powerless to render aid or relief to the unfortunate sufferer as man is to cope with the wisdom of the Creator. To those who have never encountered a human being writhing in the agonies of this awful malady, I will say, your ideas of it are as far from the reality as the "ridge-pole of heaven is above the mud-sills of pandemonium." I must beg pardon for the use of a vulgar simile in the foregoing paragraph, but language is not strong enough and words are lacking to picture the hideousness of the affection. It seems more like a blast from hell than any earthly thing, and yet it seems impossible for hell to be so terrible. On the morning of October 15th, 1894, Jacob Weber, aet. 54, who was then working as a farm hand, for a prosperous farmer, near town, presented himself at my office with the flesh of both wrists very badly lacerated, discolored and swollen. His statement was, in substance, as follows: On the evening of Otcober 14th, about dark, he was going along the public road, from the barn to the feed-lots a few rods away, to attend to the feeding of stock, when he saw coming toward him a strange dog that had no unusual appearance or action that he noticed. Thinking it some neighbor's or mover's dog he kept on his way till the animal was opposite him, when it sprang furiously at him and buried its teeth in his right wrist. Very much frightened at the ferocity of the dog, the man threw out his left hand to push the brute away, when it loosened its hold on right wrist and set its teeth into his left. It then went on its way. The man hastened to the house and bound up the wounds. That night he suffered very much, and the next morning his wrists were very stiff and painful. On examination fifteen hours after the injury, I found that the animal's tusks had pierced almost through the right wrist, between the radius and ulna, while the left was not so deeply wounded. I immediately opened up the wounds and thoroughly cauterized them with lunar caustic; they were then dressed antiseptically, and healed very quickly, so that in about a week the man was at work. He was to all |