micized cat-gut, and if the wound be deep use two rows of sutures to close the wound. With the first or deep sutures, for which I use chromicized cat-gut, suture the deep fascia and the muscle clear to the bottom of the wound, while for the skin sutures I use silkworm-gut, and include only the skin and superficial fascia. I then apply antiseptic dressings and bandage well and do not disturb for three to five days, when I am usually rewarded by finding good union.

Then there are a class of injuries come to us from the planing mills, which are always ugly wounds, on account of the ragged condition produced by the saws, which usually cause these wounds. In these cases I trim the edges and make the wound look as much like a smooth free incision as possible and suture, using, of course, as much antiseptic precaution as if I were doing any other operation.

Then there are a class of patients that we all meet, suffering from an injury which, I think, is the most painful of them all-namely, burns. These, I think, are harder to treat and more unsatisfactory than any other class of injuries. The most common remedy is linseed oil and limewater, which is itself very likely to be septic, and it is usually applied freely

before the doctor gets to see the patient. When I find this the case I add carbolic acid to the mixture and let them continue to apply the dressing. But in this connection I wish to say, without advertising anybody's preparation, that the most satisfactory results that I have recently obtained from the treatment of this class of cases was by keeping the parts dressed with gauze saturated with Glyco-Thymoline, an alkaline antiseptic solution, made by the Kress & Owens Company, of New York. This dressing in my hands appears to stimulate healing, and leaves a minimum amount of cicatricial tissue.

You will notice from my paper that there is not so much surgery in handling these cases as there is surgical asepsis and antiseptics. And that, I think, is paramount to everything else in managing and treating every class of minor injuries. The antiseptics that I use are lysol, carbolic acid, bichloride of mercury, creolin, boracic acid, Listerine, Glyco-Thymoline, alcohol and heat. I use, perhaps, more than anything else for dressings in these cases, gauze, saturated with alcohol and glycerine, equal parts. I find that this is germicidal in its effect, and that it stimulates healing by keeping the wound sweet and clean.

That man is generally at fault in divorce cases we will not deny, but that he is always the guilty one, as some judges would have us think, we do not admit. Some cases in point:

A number of years ago I had a patient, a lady, whom I had under observation some time. She had a husband, a slow, meek, unoffending fellow, whose only vice was that about once in three months he took a three weeks' spree. His wife said nothing, did not complain, and gave most of her attention to her lover, a married man with an invalid wife. The invalid wife finally died and then there was trouble. The husband became unbearable. The bereaved widower put up the money, suit for divorce was instituted, brought to trial in six weeks, a decree

secured and the wedding took place in eight weeks from the death of the invalid wife. There was no need for such indecent haste, for the two had been living together as man and wife for years. The injured husband, the best person of the trio, is now a tramp.

The second case: The husband was suspicious of his wife and placed detectives on her track. She was traced into a house of assignation, her companion being a medical student. They remained three hours in this house. Suit was brought. The student went to a “smart” lawyer who fixed up a story for them. "The wife went there in answer to an advertisement for a model and remained for three hours waiting for the return of the landlady, and the student was there

on professional business." The story was so well fixed up and so solemnly sworn to that the judge was deceived, the wife brought counter-charges and she got the divorce instead of the husband, and also the custody of their child, a girl.

Case three : Another medical mix-up. A doctor found his wife unfaithful, secured a divorce and the custody of his children, a Bad boy and very sweet little girl. There was constant contention for the girl. Finally the judge heard that the fair defendant had been stenographer for a doctor friend of his, and called him up over the telephone. He gave her a glowing reputation and the judge gave her the girl. She did not want the boy. The husband says that the doctor who telephoned his "jolly" of the defendant's reputation was in such a position that he could not do otherwise. He set out on a still hunt and with the aid of the postoffice department has gained information which has led him to name the witness by telephone as another co respondent in the next legal conflict.

Case four: A patient of mine married

a friend of mine. She was a gay girl and she made a gay wife. One child, a girl, was born to them. They separated. Detectives were placed on her track and she was followed to a distant city and seen going into a house of bad repute with a man. Proceedings were instituted and while the trial was in progress I was called to her. I found her flooding profusely, made an examination and removed a placenta. She had been separated from her husband for about a year. On the third day she got up from her bed, exsanguinated from hemorrhage following abortion, nervous from weakness and excitement, made a pathetic and dramatic appeal to the judge for her child. all-wise and far-seeing individual said: "Madam, I believe you to be an honest woman; I believe you will bring up this child in the way she should go, and I give her in your keeping." She still has the girl and she is bringing her up in the way she went.

This

If our judges and our ministers knew as much as the doctors, how wise they would be!

CINCINNATI OBSTETRICAL SOCIETY.

Meeting of May 12, 1904.

THE PRESIDENT, SIGMAR STARK, M.D.,
IN THE CHAIR.

JOHN H. LANDIS, M.D., SECRETARY.

Presentation of Specimens.

DR. SIGMAR STARK: I have four specimens for presentation this evening, three of which are interesting because of their seriousness, and one because it represents in a striking manner a large multilocular ovarian cyst with a twisted pedicle.

1. Deciduoma Malignum -The first specimen is a deciduoma malignum, removed from Mrs. W., aged forty-seven, twelve days ago. About ten weeks ago the patient was admitted on my service at the Jewish Hospital because of irregular bleeding, together with a very offensive. discharge from the vagina. On examination a mass about the size of the hand and of the appearance of placenta protruded from the external os. Under anesthesia

this was removed, and the examining finger, introduced into the uterus, determined a loss of tissue in the right lateral wall of the uterus, surrounded by a fungous structure. Some of this fungous material was removed for microscopic examination. A diagnosis of deciduoma malignum was made and further interference desisted from pending the pathologic investigation. The patient was subsequently treated as after an abortion. She continued to improve, and as the report of the pathologist was that of normal placental tissue the patient was permitted to go home at the end of three weeks. About a month later her family physician, because of the recurrence of bleeding and offensive discharge, again removed a large mass which he took for placental remains. As there was a recurrence of this formation two weeks later he summoned me in consultation, whereupon my assistant, Dr. Wilkinson, who went in my stead, diagnosed a malignant intrauterine tumor, and again had her sent to the Jewish Hospital,

where a hysterectomy was performed. The operation was extremely difficult on account of the involvement of the base of the right broad ligament, colloid masses existing therein. By free dissection of the ureters and high ligation of the uterine artery I was enabled to make a thorough removal of the cellular tissue of the broad ligaments and that about the fornix vagina. The right iliac glands were also enlarged and likewise removed. The subperitoneal space and vault of the vagina was packed with iodoform gauze and the peritoneal cavity closed off by running catgut suture, a small opening being left in the middle for drainage. The patient has made an uninterrupted recovery. An examination of the uterus shows the whole inner surface invaded by a tumor having the gross appearance somewhat like that of bunches of small grapes, the growth completely replacing the right lateral wall of the uterus and becoming subperitoneal. The surface of the uterus shows a few small subperitoneal nodules, varying in size from a bean to a hazel nut.

2. Carcinoma of the Cervix.-The second specimen represents a carcinoma of the cervix involving the whole left lateral fornix and the base of the left broad ligament, removed by abdominal section six days ago in the manner referred to in Case I. The main difficulty experienced in this operation existed in the dissection of the left ureter, which was partly surrounded by carcinomatous infiltration, which involved the bladder wall immediately to the left and above the ureteral orifice. This portion of the bladder wall was excised and the mucous membrane brought together by a continuous catgut suture and the muscular wall and the superimposed fibrous tissue by a continuous Lembert suture of silk. Peritoneal folds of broad ligament, cul-de-sac and bladder closed by continuous catgut suture. Drainage of vaginal vault and broad ligament spaces with iodoform gauze. Patient has had no untoward symptoms.

Both of these cases belong to the category formerly classified as inoperable. Whereas, I must confess I have scant hopes as to freedom from recurrence in the future in the case of the deciduoma malignum, I feel more hopeful about the second case. Four years ago last February I presented a specimen of extensive malignant disease of the cervix and va

3. Multilocular Suppurating Intraligamentous Cyst.-The next specimen. is a multilocular suppurating intraligamentous cyst of the right side removed from Mrs. O., aged thirty-eight, twenty days ago. This woman has been an invalid for about two years, and during the past six months has been gradually losing flesh and growing paler, very likely under the influence of continuous fever. The viscera in the lower part of the abdominal cavity were all matted together and had to be separated before the tumor cou'd be reached. A horizontal incision through the broad ligament, undertaken with the idea of enucleating the tumor, proved futile on account of the intimate adhesion between the tumor wall and broad ligament, but lower down, through incisions. made both anteriorly and posteriorly, this separation became possible, although extremely difficult, the hemorrhage being frightful and almost uncontrollable, the tumor extending to the floor of the pelvis. An incision was made through the anterior layer of the broad ligament into the antero-lateral fornix of the vagina for drainage. The cavity of the broad ligament was firmly packed with iodoform gauze, one end being carried through the drainage opening into the vagina and the two layers of the ligament were brought together by a running catgut suture. The pelvis was likewise drained through the lower end of the abdominal wound by means of iodoform gauze. After the operation the patient was greatly exsanguinated and was revived through saline hypodermoclyses, and has since then been doing well. The tumor is about the size of a large cocoanut, containing several cyst cavities filled with a very foul-smelling (feculent) pus. Ovarian cysts oftentimes undergo suppuration, but those in the broad ligament do so very rarely. From the feculent odor of the pus I would imagine that the sac obtained its infection. through the colon bacillus.

4. Multilocular Ovarian Cyst.-The fourth specimen was removed from Mrs. K., aged thirty-eight, five days ago. This woman had been confined seven months ago after a very tedious labor, her previous confinements having been easy.

The presumption therefore exists that the tumor was present at the time of her last confinement. Two months ago she was seized with a rather severe pain in her abdomen, which lasted a few days. About two weeks ago she had another attack of excessively severe pain in the abdomen, which compelled her to go to bed and remain there up to the time of the operation. The abdomen rapidly increased in size and became exceedingly sensitive to the touch. A diagnosis of multilocular ovarian cyst with twisted pedicle and intracystic hemorrhage was made, which was confirmed by section. The operation was easy and the patient is doing well in every respect. The tumor contained two and one-half gallons of a bloody fluid, the growth itself was of a deep blue color, the pedicle showed two and one-half distinct twists and the Fallopian tube, which was involved in the torsion, was greatly swollen and of a deep purple color. There was likewise about a teacupful of broken-down blood in the peritoneal cavity.

Clinical Report of Fibroid Tumors and
Suppurating Ovaries.

DR. RUFUS B. HALL reported the following cases:

CASE I.-Multinodular Fibroid Tumor of the Uterus Complicated by a Suppurating Ovary. Mrs. B., aged fortyone, married, mother of three children, was referred to me by Dr. Coleman, of West Union, Ohio. She gave a history of having been conscious of the presence of a tumor for four and a half years. She had suffered repeated attacks of inflammation in the pelvis and abdomen. The last attack commenced December 12, 1903, and her illness continued until the operation. This attack was very severe, and for four or five weeks she was very ill, with chills, sweats and well-marked sepsis. In about seven weeks convalescence was established. It was then decided to have an operation as soon as the patient's condition would admit of it. When she consulted me she was very anemic, but the sweats and chills had disappeared for

some weeks and her general condition was improving.

She entered my private hospital on April 1, and was operated on the 5th and the tumor here presented was removed. She had a multinodular fibroid somewhat larger than a cocoanut, a large suppurating tube below the fibroid, and an abscess walled off below the tumor. The adhesions were very dense and the bowel adhesions were very difficult to overcome, The operation was completed in the usual way. The patient has made a perfectly satisfactory convalescence and was able to go home in four weeks.

This specimen and the condition found at the operation emphasize the necessity of advising operations for removal of fibroid tumors just as soon as they commence to cause trouble and before the patients commence to have attacks of pelvic inflammation.

CASE II. Multinodular Fibroid Tumor of the Uterus.-Mrs. G., aged thirty-eight, mother of one child fifteen years old, was referred to me by Dr. Norris, of Augusta, Ky. This case is of more than usual interest, inasmuch as this large fibroid was not discovered by the patient until in August, 1903. She had had profuse menstruation for three four years preceding the past three months. The menstrual periods came as often as twenty-five or twenty-six days, and lasted five or six days. The past three periods, however, were twenty eight days apart and lasted two days each.

or

The tumor here presented partially filled the pelvis, extended well into the abdomen and caused great inconvenience from pressure. The patient was advised to have an operation. She entered my private hospital on April 6 and the operation was made on the 11th. She had a perfectly smooth, easy convalescence. Her highest temperature was 99.5° on the second day; after that time it varied from normal to 99°.

The contrast between the two specimens and the conditions present at the time of the operation is very great. It illustrates the great difference in the extent of injury to the patient in an operation like this one compared with one where there have been repeated attacks of inflammation, as in the previous case.

CASE III.-Hematoma of the Ovary.Mrs. S., aged twenty-seven, married four

and a half years, was referred to me by Dr. Halderman, of Portsmouth, Ohio. The patient gave a history of having suffered constant pain in the left lower part of the abdomen and in the back for more than a year. She had been under the care of several physicians, but a positive diagnosis as to the cause of this condition had not been made. She took the rest cure for five or six weeks in November and December last. This mitigated the.pain somewhat, but did not relieve it, and as soon as she had been on her feet a few days she suffered as much as before.

At an attempt at examination the abdominal muscles were so rigid and the patient complained of so much pain that the exact condition could not be determined. For this reason she was given an anesthetic on March 14, when it was perfectly easy to outline a tumor to the left of the uterus somewhat high up. This tumor seemed to be as large as the uterus itself. The right ovary and tube and the uterus were fixed by adhesions. A section was advised and the patient returned home to consider the matter. After due consideration and with the approval of her physician she returned and entered my private hospital on April 11. operation was made on the 14th.

The

The patient was first thoroughly thoroughly curetted, after which the abdomen was opened. The intestines and omentum were found adherent to the tumor on the left side of the uterus. This tumor proved to be a hematoma of the ovary, also involving the tube. It held about four or five ounces of liquid. In separating the coil of bowel from the tumor the latter was ruptured and the contents were spilled. I had provided gauze packing for protection, however, and no harm came of this. The tumor was removed with the tube on the left side. The right ovary was adherent and the tube was diseased, but the ovary not perceptibly so. The tube was removed, leaving the patient with her right ovary and the uterus. The abdomen was closed without drainage.

The patient made an uninterrupted

recovery.

This patient will menstruate normally, which is a great advantage to her. She is no more sterile than she was before the operation. These women all tell me that they would rather menstruate, even if

they cannot bear children, than to have the menopause established by removing both ovaries. They are better physically and mentally than those women who are so unfortunate as to have to have both ovaries removed when they are young.

CASE IV-A Large Suppurating Ovary, with Long-Continued Sepsis.Mrs. S., aged twenty-six, married five years, mother of one child four years of age, a resident of this city, was referred to me by Dr. Wendel. The patient has had pelvic disease for two or three years. She had a hemorrhage corresponding with her menstrual period, early in January, and went to bed with an acute attack of pelvic and abdominal inflammation. The patient was seen at her home on April 13. She had been confined to her bed since her illness commenced. She was suffering from profound sepsis, with a history of having had repeated chills and sweats, and was very anemic.

Examination revealed a tumor about the size of a cocoanut in front of the uterus and to the patient's left side. She was removed to the private department of the Presbyterian Hospital on the same day and prepared for operation. The operation was made on the 18th.

After the abdomen was opened and the parts were well protected by gauze pads the tumor was aspirated and emptied of about two pints of very thick, foul-smelling pus. The puncture was closed by pressure forceps and the sac was enucleated without difficulty, until we got to that portion that was adherent to the outer pelvic wall, when the sac gave way. When the sac was brought into view there was found to be an opening in it the size of the index finger. Fortunately, however, very little pus remained in the sac, and it was easily controlled. At a point corresponding with the opening in the sac an opening as large as the index finger was found extending up under the psoas muscle for an inch and a half or two inches, from which pus was exuding. Nature was making an effort to open the pus cavity by this route. The bowel adhesions to the tumor were very extensive, but were separated without tearing the bowel. The right tube was distended to about the size of the index finger and contained pus. This was removed. The right ovary was not removed for the reasons given in the previous case reported.