I was laughed at then by some who have now gone to their final account, thus denying me the opportunity of enjoying the best of laughs, the last. I recall a two hours' discussion on the streets of Brooklyn with a busy practitioner, holding the dignified position of professor at the Long Island College Hospital, on this very question of the feasibility of exploratory laparotomies. He seriously doubted that this would ever become a recognized procedure, though I maintained that it would, and that at an early date. He has made many since then, and does so now every year. But I will return to the subject in hand. My own article of January, 1885, related to a peculiar form of pulmonary congestion, ending in sudden death, in which the cavities of the heart were enormously distended, and for the relief of which it seemed to me that there was nothing else feasible than direct aspiration through the heart-wall as suggested by Westbrook. In this article, I remarked as follows, in reply to the adverse criticisms of Drs. Wyman and Cheesman relative to Westbrook's operation that was called cardicentesis: "It is hard to conceive how the cardiac valve might ever be stitched up, but that divulsion of the cardiac orifices is much more plausible can readily be seen. I have long ago deemed divulsion of these openings a practicable operative procedure, and should not hesitate to have it done upon myself in case of stenosis of one of my own cardiac orifices. Lack of thorough anatomical knowledge makes even bold surgeons, timid at times. And this was a fact that was fully appreciated by Professor Billroth, when he exhorted his students to thoroughly master anatomy ['Anatomy, gentlemen, Anatomy! Anatomy! A human life often hangs on the certainty of your knowledge of this branch!']"

It is gratifying to me to be able to look

back to 1881-82 as the time when I made 80 per cent. of the observations upon the cadaver, of many of which I still have the original records, upon which were based the points of election settled upon by Dr. Westbrook for the introduction of the needle. We went over these data together, and agreed at the time upon this point. He is now dead, and the profession of Brooklyn has lost in him one of the most promising men its ranks ever contained. I mention these facts as evidence of the interest that was taken in the possibility of future surgery of the heart at that relatively early day.

This

Now we find, in the March 8, 1902, number of the New York Medical Journal, on pages 419-20, an editorial in reference to an article by Sir T. Lauder Brunton, that appeared in the Lancet for February 8th, under the heading of "Preliminary Note on the Possibility of Treating Mitral Stenosis by Surgical Methods." credits Brunton with having "some time ago" conceived the idea of the feasibility of dividing the cardiac valves in stenosis in lieu of the impossibility of ever successfully treating this condition medicinally. "Some time ago" can hardly be presumed to extend back twenty years or more. He tested his idea by experiments upon animals, thus convincing himself of the comparative harmlessness of cardiac manipulations of almost any kind. The application of his suggestion he leaves to surgeons.

Brunton's proposition is viewed by the editor of the New York Medical Journal with "bated breath." The editor further says of this operation that "a blinder procedure it would be difficult to imagine." To this I cannot agree. There are subcutaneous tenotomies, not necessary to enumerate, in which the danger of damage is even greater than in that of section of the cardiac valves.

One element of danger has not been suggested, and this I deem to be the only one, aside from the possibility of hemorrhage, from the insertion of too large an instrument. I refer to the possibility of cutting the chorda tendina. If enough of these are severed, the sufficiency of the valve segment to which they have been attached would be destroyed, thus permitting a regurgitation that might prove disastrous; but even this objection and danger could be minimized, perhaps even entirely eliminated, by the use of a proper instrument.

Lauder Brunton certainly was not the first man to have suggested the feasability of section of the cardiac valves for stenosis. Since the publication of my paper in January, 1885, in which I incidentally mentioned the feasability of divulsion of the mitral orifice for stenosis, and the reading of which sentence before the Northampton County Medical Society, at Bath, Pa., the year preceding, called forth smiles of derision, there have been numerous cases of suture of the heart from stab wounds, the first of which, however, was not reported until twelve years after the reading of my paper, to wit, in 1896, one by Cappellen, and the other by Farina in the same year. Others followed in rapid succession, until now we have about 30 reported cases, in which about one-third recovered. A most remarkable showing in view of the opinions held concerning cardiac sur gery only twenty years ago.

A tabular statement of 24 of these cases may be found in an article by Geo. Tully Vaughan, M. D., of Washington, D. C., in the Virginia Medical Semi-Monthly of March 7, 1902, page 536. An instructive, though fatal, case of heart-suture is also reported by H. L. Nietert, M. D., of St. Louis, on page 1034 of the Philadel phia Medical Journal, of December 14,

1901. The patient was unconscious from loss of blood and compression of the heart by the surrounding effused blood, so that no anesthetic was required, and he recovered perfect consciousness during the removal of the extravasated blood from the pericardium. No perceptible shock was noticed while the heart was being manipulated. He died thirty-three hours after operation, with total suppression of urine during this entire period. His condition was otherwise quite favorable within an hour of his death, at which time his temperature was 104°, and his pulse very rapid. He remained conscious up to the last moment. He was 22 years of age, and weighed about 180 pounds. It seems to me that this death was attributable to the suppression of urine, and that it was possible for those in charge to have resorted to better means to guard against this fatal end than appears to have been exercised. It seems to me that more strenuous efforts should have been made to encourage the supplementary elimina-` tion of urea by the skin and bowel than seems to have been done. Besides this, active counter-irritation or cupping might have been beneficent, and certainly could not have been harmful, in the lumbar region.

In most of these cases, the knife penetrates the pleura before entering the heart. In that event, if bleeding is free, the patient may rapidly bleed to death into the pleural cavity. It was otherwise in Nietert's case, in which the pleura was not entered, thus limiting the extravasated blood to the pericardium, resulting in compression of the heart, thus interfering with its work in diastole. A whizzing or splashing sound, or both, in stab wound of the heart, indicate penetration of the pleura and lungs, resulting in admixture of air with blood, without which these sounds would not be possi

ble. It seems almost needless to say, that an extra-pleural wound should be approached without entering this sac.

Another interesting fact in this same case is, that the forcible drawing up of the heart to the opening in the chestwall, to be sutured, was not followed by the slightest tearing or shock, though done with forceps. In short, experience In short, experience has shown that the heart is a tough organ that in no way seriously resents mechanic interference. In fact, there is every reason to believe that this very interference stimulates it to renewed and increased effort when it is about to give up.

The only immediate danger in the surgery of the heart is from hemorrhage. The secondary ones are from septic infections of various kinds, involving the blood, endocardium, heart-muscle, pericardium, pleura, lungs, and the tissues of the chest-wall that have been severed, including the bone cartilage. The latter danger is more likely than in most other operations because of the great haste in which it is usually necessary to begin and continue work. Many of these deaths occurring from hemorrhage, it is advisable, at the same time that steps are taken for the operation, that preparation should be made for intravenous injection of decinormal salt solution.

An old adhesive pericarditis would favorably modify the effects of a stab wound upon the heart, provided the wound was extra-pleural, for there would be no opportunity for hemorrhage except into the anterior mediastinum, in which the connective tissue, though loose, would offer some bar to the extravasation of blood. The danger of compression of the heart by effused blood would be nullified; so, also, would that of a pericarditis.

This paper is already longer than I originally intended. It is written simply to call attention to the fact that the pos

sibility of present cardiac surgery was pointed out more than twenty years ago, that the earliest deliberate attempt at it was made by Westbrook in 1881-82; and that I am on record as having publicly expressed my faith in it as early as 1884, sufficient to be willing to have my own cardiac orifices divulsed by mechanic means if they were stenosed. In all these years I would certainly have done considerable cardiac surgery had I had the opportunity, and in some things-as, for instance, section or divulsion of the cardiac valve-also suitable backing.

2353 N. Seventeenth St.

Sterility in the Female, and Its
Curability.

By S. L. KISTLER, M. D.
Los Angeles, Cal.

The slight attention paid to this subject is possibly due to lack of information as to value of treatment, and partly because of disinclination for the burdens of maternity.

In this paper I shall avoid prolixity, as the subject is one which admits of great extension. Therefore, I shall, of necessity, treat it in a casual way only.

The conditions may be either acquired or congenital, and, in taking the matter up, I will consider the term "sterility" or "barrenness" to apply to women who, under favorable circumstances, fail to procreate. I might be more exact, but to do so would only confuse, and my excuse for presenting this paper is to call attention to a subject of much importance to all practitioners, as it is fast becoming more and more widespread, and it behooves the doctor to use his best efforts to remedy the defect when called upon.

The Causes of Sterility
May be enumerated as follows:

1. I believe that many cases of this condition, as well as of uterine disease in general, are the result of loss of sympathetic nerve-force, the effect of disease or injury arising from sexual demands.

When a case applies for treatment for sterility, we must bear in mind the fact that not all cases are imputable to women. Indeed, "Dr. Vedder, who carefully examined 300 married women (and their husbands) who were childless, proved, in effect, that 70 per cent. of his particular cases were due to the man, either directly in consequence of functional impotence or absence of spermatozoa, or indirectly by infection of the woman with gonococci. In 30 per cent. of his cases the cause was due to the woman, and most generally owing to neoplasms or atrophy of the uterus." Regarding this quotaRegarding this quotation, will say, that I believe the reverse holds true in this part of the country.

Therefore, if treatment, either indicated. or tentative, does not yield results within a reasonable time, we should proceed to investigate the husband's condition before we carry treatment further.

It behooves us to search diligently until we find the cause, and, if found incurable, the patient may be so informed, but I would advise all to go slow on this point, as our patient may, on the other hand, become enciente, much to our chagrin and discomfiture. So, as before noted, search diligently for the cause. Get as complete a history of the case as possible, for many factors may enter, and heredity cut a wide swath in helping us arrive at a conclusion. The poet who said "Every man is an omnibus in which ride all his ancestors," may have spoken concerning the very case you have in

hand.

Probably our most beneficial remedies are belladonna, the auric salts, and electricity, combined with such local treatment as is indicated.

Tone up the nervous system and proTone up the hibit frequent coitus. uterine uterine mucosa, for conception may occur, and the result be blighted early if the condition of the mucosa is unfavorable.

For inactive ovaries and atrophy, we have valuable aids in electricity, protonuclein, ovarine, thyroids, sabal serrulata, ignatia, and such other agents as

are indicated, and tend to develop and bring to maturity.

In congenital deficiencies, anomalies of the hymen, and malformation of tract, the help of the surgeon must be had, when he will remedy the condition, if possible. Likewise, we must call the surgeon in cases of laceration, neoplasms, and malignant growths, and, if thought necessary, in cases presenting myomas, though it is supposed that they very seldom cause the condition.

Excessive acid reaction of vaginal secretion may be often corrected by use of suitable alkaline douches. Further treatment will consist in toning up the mucous membrane. Catarrhal conditions of not too severe a type may be treated by applying solutions of arg. cit. or iodized phenol, and in cases presenting marked hurt in the endometrium, the above is profitably used before applying the

curette.

Of course, all malposition must be corrected as soon as possible. "Graily Hewett" reports thirty cases dependent upon flexions and versions cured by remedying the abnormality.

Vaginismus, neurasthenia, exhaustion, physical decadence, nymphomania, and all neuroses appearing, demand careful investigation in order that the source of trouble may be discovered, and, if possible, remedied. Amenorrhea and menorrhagia are other occasional causes of sterility.

Since the days of Marion Sims, we have been taught that the chief reason for sterility, attributable to the woman, is narrowness or flexions of the uterine canal. But when it is remembered that the narrowest pinhole os will admit a sound on careful manipulation, which is many times larger than the self-propelling spermatozoid, it will be seen that this reasoning is scarcely satisfactory, and it is doubtless due to the operative furore that the popularity of the stenosis and atresia theory of sterility continues. Since the time of Sims and Simpson, practically no form of treatment has been employed save some method for opening or enlarging the canal, a procedure which not only has been, as a rule, ineffective,

but has been followed by morbidity and mortality, especially after slitting the cervix.

Being satisfied with the effect of electric currents, and accepting the evidence offered, we believe that we have in it a treatment far and away in advance of any other means known at the present time. Sims' assertion that sterility can only be cured by surgical interference is untenable; rather use medication that raises the nutrition of the entire organism. "And now we are told to feed or starve the woman according as we wish male or female progeny."

Constitutional diseases and conditions call for such measures as their respective types indicate.

In case of very large vagina, recourse may be had to artificial fecundation. Avoid the use of articles containing tannin, also forego the use of antiseptics.

In case of absence of ovaries, Knauer has reported "successful pregnancy fol lowing transplantation of ovarian tissue."

Obesity produces sterility by mechanic pressure, and by excess of fat in the blood, thus causing amenorrhea, and ripening and bursting of the Graffian follicle is thus prevented. The treatment is obvious. Always bear in mind. that such cases may be the result of senile decay.

If gonorrhea has sealed up the ends of the tubes, their restoration ad integrum is scarcely possible. However, as a dernier ressort, an explorative incision will show if the condition be possibly remediable.

A noted American gynecologist has said that he "never knew a woman to bear a child after having had gonorrhea.” This statement none of us believe.

Finally, in the treatment of sterility, we should bear in mind the fact that each case is a law unto itself, and we should study it as though it were the only one, remembering the great number dependent upon slight causes.

Conclusions.

1. The great majority of cases of sterility are dependent upon slight causes.