one-half of the stimulation and their reaction becomes weaker than normal. When the pupil has neither a direct nor a consensual reaction but responds to convergence and accommodation, we speak of reflex immobility of the pupil. Preternaturally small pupils that do not respond to light but move during an effort of accommodation (Argyl Robertson) are of great significance to the neurologist because they indicate sclerosis of the spinal cord the process having reached the cilio-spinal region. If the direct reaction of one eye and the consensual reaction of the other fail, we speak of the reflex deafness of one eye. One sided failure of reaction not only of light but also of convergence and accommodation is due to peripheral lesions of motor nerves which have their ramifications within the eye. In paresis of the sphincter and dilator iridis, or of both, we get a weaker reaction. Paralysis of one or both of these muscles give us complete immobility of the pupil. Lesions irritating motor nerves may cause partial or total muscular spasm, and thus limit or suspend mobility. Disturbance of vision with reaction, during accomodation and convergence, is due to centripetal interruption of conduction in the reflex tract, optic nerve, chiasma, corpora quadrigemina, etc. No disturbance of vision and reaction during accomodation and convergence is due to the interruption of conduction in Meynert's commissure, sphincter iridis gangliæ, or the connection of these gangliæ. Lesions referring to this and the previous reaction either have a failure or diminution of direct and consensuel reaction to light in one or both eyes. We have bilateral diminution of mobility, with contracted pupils in lesions of the centripetal part of the reflex tract, accompanied by irritations. Diseases of muscles naturally lead to failure of reaction. The feeble reaction in old people is dependent on the rigidity of the muscles, probably due to fatty degeneration. Hippus, or increased mobility of the pupil, is due to clonic spasm from central irritation, or only functional disturbances, and is found in conditions like neurasthenia, psychoses, and organic diseases of the brain. In enlargement of the pupil, the irritation may involve the sympathetic and medulla, the pupillo dilator center, either directly or reflexly, and the nuclear or cortical lesions of the oculomotorius. It may result from a diminished innervation of the sphincter iridis in interrupted conduction of the centripetal portion of the reflex tract. The pupils are of equal size, and dilated. Direct or consensual reaction is diminished or suspended, but not that of convergence and accomodation. Certain poisons taken internally or applied locally, such as atropin, hyosamin, etc., paralysis of both muscles or atrophy and peripheral retraction of the iris. Contraction of the pupil may be dependent on irritation of the sensible portion of the reflex tract, paralysis of the dilator muscle, toxic influences, synechies, hyperæmia, and inflammation of the iris. In closing I wish to refer to an intrresting case from the practice of my friend, Dr. Chas. O'Ferrall, of our city. A short time ago he called my atten tion to a contracted pupil of one eye in a patient he was treating for glandular swelling of the neck, dependent on a constitutional cause. A treatment with iodide of potassium caused the swelling, as well as the contraction of the pupil to disappear. The contraction was due to irritation of the cervical sympathetic, and similar cases have been recorded in paralysis by pressure of a tumor. 215 SOUTH SIXTH STREET. Read before the Missouri Valley Medical Society, held in Kansas City, Dec. 18th and 19th, 1890. Since the time of McDowell, which is very nearly one hundred years, there have been those who have opposed this operation from one standpoint or another. Time, however, coupled with extended observation, has done much toward establishing these operations for the removal of the uterine appendages, upon a safe and scientific basis. Yes, even to-day, we find a certain class of men who decry the operation as uncalled for, or limit its scope to those cases in which it shall be deemed the only means left for saving life. Who are these men who thus consider this operation? I think we shall find them to be men who have had but limited opportunities for observation of the treatment of diseases of women, and who have given no attention to the pathological conditions which give rise to the symptoms which prompt operative interference in the mind of those who have ample opportunities for observing such cases. Again, I am sorry to say, though I believe it to be a fact, a certain amount of envy and jealousy prompts some to speak disparagingly and argue against evident fact. That there is some ground for envy among a class of men who are so exceedingly sensitive and ambitious, as are medical men, as a class, I think we must admit, for who of us, can, contentedly, see patients, who, under a conservative plan of treatment, while in our hands, pass into the hands of one, who from advanced or more radical ideas, if you please, applies a means to an end which accomplishes in a few short weeks, what we have failed to accomplish in a much longer period, perhaps, months or years, who, however generous he may be, does not dislike to see another carry away the glory, and may I not say, the fee. This is not a pen picture alone, but is supported by every day observation. Conservatism, the favorite expression with those who feel it incumbent upon them to interpose their protest from whatever standpoint, is no less an attribute of the operating surgeon or gynecologist, than of him who never operates. That the uterine appendages have been removed in the past for insufficient cause, is, undoubtedly, true, but I feel assured in saying that after these years in study of conditions both before and after removal, and after a careful comparison of operative with local and general treatment, together with consequent perfection in diagnostic acumen, those cases are very few which will now come under the knife to reveal a useless operation. I have no hesitancy, after ample opportunity for observation, in giving it as my opinion, that there would be many less chronic invalids, in our midst, were they subjected to abdominal section, either for the removol of the appendages or the rectification of existing disturbances not yielding to any plan of treatment yet applied. I think I shall be best sustained in this position, by those who have had most experience in the treatment of diseases of women, scientifically considered. By this plan for operative interference I do not mean hasty, reckless castration of every woman who happens to have a pain in the pelvis, but as a means for the relief of a pathological condition, after all due effort has been dedicated to her relief. Just here, I may say, begins the true sphere of a competent gynecologist, viz: to decide when local and general treatment shall have accomplished all that is to be expected of them, and if then operative interference offers hopes for improvement. When such a sphere in the practice of medicine shall be conceded to the gynecologist, I think diseases peculiar to the generative system of women will cease to be such a fertile field for unscientific local treatment and fees alone. By gynecologist I do not mean he who, perhaps, from the credulity of a handful of suffering women, sees a large number, that does not make a gynecologist, but opportunities well improved with a dedication of the subject specially as now taught and practiced by those who have had ample opportunity for investigation and experiment. Methods and means are now so perfected and taught in some of the special courses in our large cities, that one can, by devoting time and energy, become familiar with what otherwise might appear obscure and difficult. The pathology of intrapelvic troubles, elucidated by post mortem and operative investigation, has been reduced to such a degree of perfection and comprehension that diagnosis is rendered comparatively simple, and the indications for treatment placed upon a more universally scientific basis. I cannot better express the conclusion arrived at by our leading gynecologists in regard to intra pelvic inflammations, than by quoting Dr. L. S. McMurty, of Danville, Ky., who thus graphically classifies them: 1. Intrapelvic inflammations cannot properly be classified as parametritis and peri metritis, inasmuch as inflammation of serus and cellular tissues cannot be separated clinically or histologically. 2. Periuterine phlegmon of nonat (cellulitis of Emmett) is as rare as inflammation of the cellular tissue in other parts of the body. 4. Intra pelvic inflammation is as a rule peritonitis resulting from disease of the ovaries and fallopian tubes arising in puerperal or gonorrhaeal injection, or the miscellaneous injections carried to the endometrium by unclean instruments, tents or medicinal agents or from traumatism. 4. Pelvic peritonitis is symptomatic and never idiopathic. These conclusions must serve to show how utterly futile local treatment must be in a very large proportion of those cases of intra-pelvic inflammation. It must have been the observation of every one, even though his experience may have been limited, that very many of these cases when treated by the usual method of hot injections, iodine, glycerine, tampons, etc., though they may improve a little for the time, soon relapse into a condition varying from discomfort to a condition of absolute invalidism. Very many of these cases I believe, may develop insidiously with no well pronounced symptoms of peritonitis, in fact, I have often thought this class of cases to be considerably in the majority. It is this class of cases which require the greater care and discrimination in arriving at a proper course to be pursued. Whether the tubes and ovaries give physical evidence of disease or not we often find relief only in the line of operative interferences, either for their complete or partial extirpation. Polk and Dudley of New York, and others report successes from exercising portions of diseased ovaries, evacuation of cysts &c., thus obviating complete extirpation. The point I wish to establish is, that a much larger proportion of chronic female disorders than is generally supposed demand for their relief extirpation of the appendages or such interference as shall succeed where local treatments have failed. That class in which the operation is resorted to as the last and only means for saving life is largely in the minority and yields but poor results as a rule. During the present year I have operated upon ten cases for various troubles requiring the extirpation of the uterine appendages. I have had but one death, and that in one who belonged to the dernier resort class, she and her friends having refused operative interference until to late. The others have all shown marked improvement, in fact, every case save one showed perfect relief from the symptons which prompted the operation. My experience has been such that I am not slow in advocating the operation for the relief of symptoms which do not yield to other plans of treatment assiduously applied for a reasonable length of time. Generally we have physical evidences of organic trouble which shall aid us in determining upon an operation. but, even though we do not find such evidences, in view of the fact that the danger from the operation has been so minimized by experience and attention to detail, and since we find the effect upon the woman to be in no way objectionable, save that she ceases to be a child bearing woman, I am disposed to entertain the opinion that the resulting benefit from such operation by far outweighs all or any objection yet raised. While I entertain such hopeful expectations from operative interference, I must, at the same time, counsel the utmost conservatism in regard to hasty and unwarrantable operation. I should say too, that the operation should not be performed promiscuosly by those who have had little or no experience, for certainly statistics show that those most familiar with the technique of abdominal surgery, obtain the better results. Modern Surgery. BY A. J. BEST, CENTRALIA, KANSAS. Read before the Northern Kansas Medical Society, November, 1890. Mr. President and Gentlemen-The subject of modern surgery is one that might well challenge our highest enthusiasm, and has attained to such a degree of perfection and usefulness as to compel us to adopt the motto of a late convention, "Surgery and Hygiene, the medicine of the nineteenth century." For although the practice of medicine has made rapid strides and many wonderful remedies have been added to its armamentarium the charlatan still finds it a fruitful field to cultivate. The faith cure and the infinitessimalist, the Christian scientist and the wonderful discoverers, collect filthy lucre in exchange for their humbugs. But the surgeon occupies a field which they dare not cultivate. Men will adopt a humbug and hug their delusions when reason should teach them better. But let them break a leg or suffer any other great injury, and immediately the Christian science or faith cure delusion vanishes like the mists of the morning and their greatest anxiety is to procure the service of the best surgeon within their reach. They know full well that neither faith nor the thirtieth potency of a grain of chalk would ever prevent their bleeding to death when the femoral artery is severed. Comparing the status of surgery of to-day with that of half a century agone the improvement is wonderful, and is no more to be compared with the surgery of a few years ago than the "one hoss shay" to the electric cars of our great cities, With all the miraculous achievements of the pioneers of surgery, such men as Hunter, Petit, Payne and the great Kentuckian, who gave us ovariotomy would have to go to school before they could be competent surgeons. One of the ancients recommends as a painless operation for ingrowing nail that a pair of sharp pointed narrow bladed scissors be pushed rapidly under the nail to the root, severing in two parts, then with strong forceps quickty tearing away each part. It is said that the Chinese surgeon plugs up a wound, thus retaining the secretions and the patient dies. The modern surgeon gives the wound free drainage, keeps it clean, and nature furnishes the cure. Witness an amputation of ye olden time. The patient is strapped to a table and amid shrieks and yells, the surgeon with all the haste possible severs the limb, speed being the surgeon's highest recommendation. To stop the bleeding he plunged the stump into hot tar or applied the actual cautery, later torsion or the ligature was applied to the arteries and then the blessed boon chloroform took away much of the horrors of the operating table, and made practical many life saving operations which before were considered impossible. But still in all the important operations days and weeks of fever and suppuration were the rule and a large percentage succumbed to the strain. There was something else needed. The interest of humanity demanded it. It is said that whenever there is a great want, a great man is raised to fill it. Lister taught us antiseptics. The discovery of the causes of inflammation and the methods of prevention have revolutionized surgical science. With asepsis no portion of the human anatomy is too sacred for exploration. With the aid of science diseases of the brain are located and the trephine and bistury are fearlessly used. Under antiseptics the bones in compressed fractures are nailed together, dressing and plaster applied and the otherwise hopeless limb is saved. Amputation once the rule is now the exception. Life in a limb is a guarantee of its preservation. With asepsis wounds of the intestines formerly treated on the so-called expectant plan, probably because we expected them to die, are now carefully sought for, stitched and the sufferer given a chance for his life, and if perchance the cut is too small or too difficult to locate the whole tract is filled with gas and the lighted taper completes the diagnosis. The dread compli cations of the wounds at once perilling to life and limb are now dismissed. But even the glorious attainments of modern surgery like every other good thing may lead to abuses. Already the impunity with which the abdominal cavity is laid open has tempted some of our brethren to unjustifiable mutila tions. Why should female eunuchs be less repugnant to our sensibilities than those of the other sex. Let not the noble profession of surgery be dishonored by a mania for using the knife. Let not the itching desire for a little notoriety lead us into the uncalled for operations, but let us a physician, surgeon or specialist, work together to alleviate suffering and prolong life. The surgeon who attempts to practice his art without first informing himself of and attending to all the details of antiseptics is criminally liable, and I believe the court would so hold in case disaster could be reasonably traced to the neglect of such precautions as the Masters teach are essential. Provide yourself with a good strong valise, name it an emergency case and fill it with the following articles which I enumerate in the hope that some one can suggest others: One rubber sheet one yard by one and one-half yards, one ounce of five per cent solution of cocaine, five yards bi-chloride gauze, one yard of protective, four ounces ether, four ounces chloroform, eight ounces |