af a young girl, for whom he tried to save a part of an ovary, and was obliged within six months to reoperate and remove a cyst the size of an orange. This disgusted him

with conservative treatment, but he involuntarily, yet successfully, practised it on another case, in which he operated and found the pelvic organs in an entangled mass. His surgical judgment dictated a hysterectomy, but this was out of the question on account of an absolute promise that both ovaries should not be removed. One tube and ovary were sacrificed, and a portion of the other tube and ovary were resected. In a few months the patient was absolutely cured of all her symptoms; she has no pelvic pain, her uterus occupies its normal position, she is in excellent health, and menstruates without pain. There are many cases analogous to these two. There are no fixed rules or welldefined principles to guide one in conservative surgery of the appendages. The patient's age, her social condition, the number of her children, her willingness to undergo a second operation if an attempt at conservation fails, may warrant the attempt. We cannot, even after operation, predict success or failure, since each may occur when least expected. The subject is yet in an experimental stage. In the treatment of longstanding pelvic suppuration there is again conflicting experience. Those men who claim the advantage of drainage thoroughly appreciate its plan. This is not simply an incision and insertion of a drainage tube. It is a thorough opening, the pus sacs are torn open, separated and packed with gauze and there is a wide open door for drainage. Any other form of drainage is not to be considered. For some cases the abdominal route is to be preferred. To illustrate the difficulty of selecting the proper operation for the individual case two instances occurring in Dr. Norris' practice in the past month were cited. They were both cases of large pelvic abscesses in women of about the same age and history. One had the diagnosis of appendicitis made by a capable man before being seen by Dr. Norris. He found the abdominal and pelvic conditions that warranted this complication and in consequence was fearful of attacking the case by the vagina. Had he known that the appendix was not involved he would have performed

the vaginal operation, for the woman was in a desperate condition. The abdomen was opened, widespread adhesions and a desperate pelvic condition were found which could not have been reached by vaginal drainage, and which, once attacked through the abdomen, could not be relinquished. The patient, exhausted by long suffering, died. The other case operated upon through the abdomen, had thorough drainage, the tubes, ovaries, and uterus were removed, and uncomplicated recovery resulted. Cases met in actual practice are of such doubtful character that one cannot always determine which route is best. If a hard and fast rule is to be followed, Dr. Norris favors operation through the abdomen. Operation by the vagina must establish thorough drainage, which is much more than a puncture of the vaginal vault and the introduction of a drainage-tube, and which, even when properly performed, will not alway effect a cure of the pelvic lesions.

DR. GEORGE I. MCKELWAY said that in the Philadelphia Hospital many patients were met who had large collections of pus in the abdomen and pelvis, and who were profoundly and septically intoxicated. Their condition usually results from septic criminal abortion. Formerly they were operated upon through the abdomen and many died. Now some of the surgeons in attendance have learned the free incision through the vaginal floor. This permits evacuation and drainage and gives better results. He does not consider it a final, but a tentative operation, the purpose of which is to tide the patient over a desperate condition. When this is accomplished a formal abdominal section usually follows. for the removal of diseased tubes, ovaries, and uterus, according as is indicated. This operation (vaginal incision) is condemned only by those having no experience with it or who have done it faultily. A case operated upon by an operator who says he never did it but once and never will again, came under Dr. McKelway's care in the Philadelphia Hospital.

A puncture on a level with the cervix. had been made with a trocar and cannula. The puncture was on so high a level that the sac was not emptied. For weeks it had been partially emptying and refilling, and

the woman's general condition was deplorable. Dr. McKelway made a large incision. in the posterior vaginal cul-de sac, broke up everything he could, washed out the cavity with hydrogen dioxid solution and packed it with iodoform gauze, but the woman's whole system was poisoned and she was too far gone to recover. cluding he emphasized his belief that in the majority of cases the vaginal incision is not the ultimate operation, but simply a tentative one that must be followed by abdominal section to complete the cure.

In con

DR. GEORGE E. SHOEMAKER'S experience coincided generally with what had been said. He deprecated the operative treatment of acute gonorrhea in cases whose condition did not absolutely demand it from danger to life. Cureting does not com

mend itself. Abdominal section for destructive gonorrheal inflammation of tubes is best deferred until nature has made her strongest effort to repair the damage. The cases best suited for conservation of the ovary are the non-inflammatory cases which are found in connection with growths of the uterus. Gonorrheal cases, in which there are extensive adhesions and destructive processes, are not generally cases for conservative treat

ment.

DR. C. P. NOBLE agreed with Dr. Norris, that if vaginal drainage is to be established, a large hole must be made. He always incises the vagina with a knife and enlarges the incision by inserting scissors and spreading their blades, so that at least two fingers will enter the abscess sac. The less that is done after this the better. He packs a pelvic abscess lightly, and never repacks it. He never employs a drainage-tube, and so far has never seen a case that did not close up nicely; and so prefers this treatment to that of repeated packings, or of the use of a drainage-tube. Either of these methods are frequently followed by sinuses.

In deciding the question of ovariotomy, Dr. Noble thinks his errors of omission have been greater than those of commission. Among poor people he finds the results from the conservation of ovaries and tubes is very satisfactory. He has tried it in many cases, and has resected tubes and ovaries for gonorrheal or puerperal infection. This class of cases, in his experience, has been very satisfactory. Nor has that referred to

by Dr. Shoemaker given bad results. In young women desirous of having children, tubes and ovaries can be left, if the patient is willing to take the chances of a secondary operation. At this stage of surgery it is the surgeon's business to leave them in. Dr. Noble does so, and frequently the patient is disappointed and has to have a secondary operation done.

DR. S. SOLIS-COHEN said that while he had no experience with the treatment of gonorrhea in the female he had had some experience with the diagnosis of the results. One subject alluded to by Dr. Fullerton and by a number of the speakers had been of great interest, namely, the liability of confounding inflammation of the tube and ovary with appendicitis. He had made this mistake and learned to try to avoid it. He had sometimes been called in consultation where the mistake had been made by those who ought to have known better than he how to avoid it. However, the two conditions are often associated. Whether or not the diagnosis is finally made, when appendicitis is suspected in addition to the other condition, it seemed to him that if operation was to be done, it were better done abdominally, because then all lies before the operator. He has seen cases, indicating that the combined condition may be originated in both ways; that is to say, a slumbering appendix may be wakened by the pus-tube or a slumbering pus-tube may be awakened by the appendix.

DR. FULLERTON, in closing the discussion, said that her object in presenting her paper was to obtain some light on the treatment of this troublesome condition. When the disease affects the interior of the uterus, the tubes, and the ovaries, it is in such an inaccessible site that it is practically incurable. Dr. Fullerton feels that the tendency has been to operate too frequently for conditions perhaps best let alone; or, at least, not treated by operative procedure. There are conditions such as those in which large pustubes or extensive adhesions exist, which necessitate operation, and then a very radical one seems most desirable. The best results are always obtained when one does not operate too soon after a recent attack, but waits until the inflammation subsides, unless there is necessity for immediate operation on account of the patient's condition.

THE PHILADELPHIA POLYCLINIC

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PHILADELPHIA, OCTOBER 22, 1898

THE FIFTIETH ANNIVERSARY OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY. WE call attention to the announcement elsewhere, in this number of THE PHILADELPHIA POLYCLINIC, of the plans of the committee appointed to prepare a becoming celebration of the completion of the fiftieth year of the life of the Philadelphia County Medical Society. It is the desire of the committee that a lively interest should be taken in this celebration by all the members of the County Society. The Philadelphia County Medical Society has exerted a powerful influence in shaping the opinion and the action of the American Medical Association, and of kindred bodies. It has done much to assist the efforts of those interested in raising the standard of medical education, and in suppressing quackery within and without the profession. The standard of ethics, which it upholds, is high and honorable. Among its membership have been in the past, and are in the present, some of the most distinguished physicians of the country; indeed, not a few whose fame is international. The scientific work done by the Society compares favorably with that of any similar organization, and among the papers recorded in its Transactions are some which have contributed to the literature of the pro

fession, and to the advancement of science, in a notable degree. Every member should be proud of the Society, and should determine to do his share to make the coming celebration in every respect worthy of the occasion, and of the organization.

Among the features of the Society's work which should not be neglected is the Mutual Aid Association. This is doing much good, but its funds are by no means equal to the demands upon them. Their growth from the accretion of membership dues must be slow and small, and earnest and active efforts should be made to secure a large endowment. There are some wealthy men among physicians, and many wealthy men in the community, who can be influenced by physicians; and in some way the importance of the Mutual Aid Association and its work should be so impressed upon them as to induce them to come generously to its assist

ance.

Medical Societies

The Philadelphia County Medical Society, which was founded on the 16th of January, 1849, is making preparations for its SemiCentennial Anniversary, which will be held in the middle of January, 1899. The Committee having the matter in charge has decided to have a formal oration delivered by Dr. J. Chalmers DaCosta, to be followed on Sunday evening, January 15th, by a religious service at which a plea will be made for the Mutual Aid Association of the Society, and which will be conducted by the Rev. Kerr Boyce Tupper. On Monday, January 16th, which corresponds with the date of the organization of the Society, the Society will have a dinner at Horticultural present and respond to toasts. Hall, at which prominent speakers will be

Business Meeting of the Philadelphia County

Medical Society, October 19, 1898.

A business meeting was held Wednesday evening, October 19th. DR. GEORGE ERETY SHOEMAKER in the chair. The following

nominations were made for officers for the year 1899 President, Dr. Solomon SolisCohen; First Vice-President, Dr. John H. Musser; Second Vice-President, Dr. George Erety Shoemaker; Secretary, Dr. John Lindsay; Assistant Secretary, Dr. Ellwood R. Kirby; Treasurer, Dr. Collier Levis Bower; Censor, Dr. H. W. St. Clair Ash. Nominations of delegates to the American Medical Association and to the Medical Society of the State of Pennsylvania were reported.

The Committee on Fiftieth Anniversary reported its plans, including an oration by Dr. J. Chalmers DaCosta, on the evening of January 14, 1899; a sermon by Rev. K. Boyce Tupper on January 15th, and a banquet on January 16th. Reports were made by various committees and were appropriately referred.

untiring energies toward making the meeting

a success.

The Nominating Committee brought in the following report, which was unanimously adopted: President, Dr. Duncan Eve, Nashville; First Vice President, Dr. A. J. Oschner, Chicago; Second Vice-President, Dr. J. C. Morfit, St. Louis; Secretary, Dr. H. E. Tuley, Louisville; Treasurer, Dr. Dudley Reynolds, Louisville; Chairman Committee of Arrangements, Dr. Harold Moyer, Chicago. Next meeting in Chicago.

The Bureau of the Medical Press was a prominent feature of the Exhibit Hall, occupying the speaker's rostrum in the center of the Senate Chamber.

VOL. VII-No. 44

OCTOBER 29, 1898

INSTANCES of the extraction of fragments of metal from the interior of the eye by means of the magnet, and the rapid recovery from the traumatism of the operation with preservation of the ball, and often of sight, have become familiar to the reader of ophthalmic literature. Since the utilization of the X-rays, and particularly the accurate methods of localization now in vogue, we have grown accustomed to the reports of successful cases. Yet the highly scientific character of both the diagnosis and treatment adds interest to each operation. Of the three magnets that have been clinically demonstrated to possess value, the Haab, the Lippincott, and the Hirschberg, each of which has its warm advocates, the

Hirschberg seems to be the most popular, partly, no doubt, because it is the least expensive, and partly because it can be stimulated by a portable storage battery, and does not require the strong current of the streets.

CASE I.-E. A., male, aged 35, machinist, was struck in the left eye by a flying fragment of steel chipped off from a rivet by another workman. A sudden sharp, stinging sensation and partial loss of vision were his immediate sensations. When he applied at the Jefferson Hospital some days after the injury, he had a small scar in the lower outer quadrant of the cornea, a laceration of the adjoining iris, a streak of opacity in the lens running backward, upward, and inward, and a clear vitreous. Through the

pupil, dilated with atropin, in the upper nasal posterior section of the choroid could be seen a small, linear metallic sheen, surrounded by a zone of aggregated pigment. On account of the opacity of the lens some doubt was felt as to the accuracy of the ophthalmoscopic findings, and to determine positively the presence of a piece of metal, several radiographs were taken, each with a five-minute exposure, by Dr. Wm. M.Sweet. The pictures showed the shadow of a linear body that was located by Dr. Sweet, according to his method, which has been eminently successful in many previous cases, in the position indicated by the ophthalmoscope. The eye was quiet and practically free from pain, therefore in the best condition for operation. Under antisepsis and cocainanesthesia, an incision was made through the sclera, from which the conjunctiva had been dissected and turned out of the field of operation, 1 cm. in front of the site indicated. The second largest tip of the magnet was introduced horizontally backward until its point had traversed the vitreous fully 1

cm.

A faint but unmistakable click was heard and the tip withdrawn. Clinging to it was the piece of steel, which measured 5-1—1 mm. No vitreous was lost. The edges of the scleral wound were drawn into apposition by conjunctival sutures. Recovery was uneventful. Now, four weeks after operation, the eye is entirely free from injection. The lens opacity has not increased, perhaps diminished, and vision is equal to that before operation. With the ophthalmoscope can be, seen a rectangular white patch, the sclera, surrounded by a mass of pigment, the former site of the foreign body.