beneath firm and dense adhesions which required the free use of the knife to separate them. The base of the appendix had sloughed, and surrounding it was a small abscess-cavity containing about fifteen drops of pus. The patient made an uninterrupted recovery.

This case is most instructive, as it illustrates forcibly what I have been teaching for the past two years,--namely, that as it is impossible in cases of appendicitis to know the pathological conditions present at the seat of trouble, there is no treatment for the disease so reliable as the knife.

In those cases where an exploratory incision is indicated for pain. or disability to carry on the duties of life, the symptoms have been present for a long period of time, without, however, there being any immediate or apparently remote danger to life. The diagnosis in these cases is not only obscure, but in many instances impossible. In this group of cases we include various chronic pelvic troubles, intestinal adhesions, non-malignant abdominal growths, etc.

I could readily cite many instances that I have seen, not only in my own practice, but also in the hands of other surgeons, in which no idea of the true condition could possibly be formed prior to an exploratory incision, and yet in a number of these cases not only was a positive diagnosis made upon opening the abdomen, but, more important still, radical relief was obtained. I shall not have time, however, to enter more fully upon this subject, as the patient is now fully under the influence of the anaesthetic.

You will notice that I have made the incision through the belly wall in the median line. This should always be its situation, except when the symptoms are localized or refer to certain regions or organs within the abdomen. For example, if the symptoms indicate that the seat of trouble is in the stomach, the liver, the appendix, or one of the other organs, the incision must be made directly over its normal position within the peritoneal cavity. As the symptoms in the patient before us are not localized, the median incision is selected as being the best from which to explore all of the abdominal contents. I have now examined the pelvis, but fail to find anything abnormal. Enlarging the incision towards the umbilicus, and introducing my entire hand within the abdomen, I examine the small intestines, the large abdominal blood-vessels, and the kidneys. Continuing the investigation higher, I have ascertained the condition of the viscera in the upper segment of the peritoneal cavity. Thus far nothing has been found abnormal; the organs are apparently healthy and free from adhesions or new growths.

We shall now examine carefully the right iliac fossa. The cæcum evidently in this case is entirely covered by peritoneum, the mesocolon, as there is more latitude of movement than is generally present. Making gentle traction and endeavoring to bring the colon into view, I find that after reaching a certain point it becomes fixed. This means either that its limit of movement has been reached or that an adhesion prevents the bowel from being brought nearer to the median line. Keeping up gentle traction upon the head of the colon, I pass my finger around the bowel and find that the appendix is taut and its tip adherent to the side of the pelvis. This condition at once explains not only the fixation of the bowel, but also, I take it, the cause of the symptoms from which this patient has suffered, as these adhesions mean a pre-existing inflammation. The tip of the appendix has now been freed, and at once the cæcum comes into view. The appendix is somewhat thicker than normal, but not markedly so, and at its tip you can see distinctly the little fringe-like projections which are the adhesions that have been separated.

The slight thickening of the appendix, and especially the fact that it was adherent, settle in my mind the necessity for its removal. As the appendix is not attached by a fold of peritoneum, we at once place a silk ligature around the base and remove it. The mucous membrane is now curetted away from the stump, which is invaginated into the colon and held in position with silk sutures. As irrigation is not indicated, nothing remains to be done but to close the abdomen and apply the usual dressings over the wound.

I shall now make an incision into the appendix and expose its interior surface. Those of you who are near will notice the fin of a fish occupying the extremity of its canal. The mucous membrane is inflamed, and you will also observe the evidences of traumatism caused by the fin as it worked its way downward.

We have, then, in this specimen a full explanation of the symptoms in this case. It is one of those rare instances of appendicitis in which the symptoms failed to indicate the grave pathologic conditions present or to show a tendency to become localized. This is the second case of its kind of which I have a personal knowledge. The first case occurred in the practice of Professor Keen, of this city. He performed an exploratory operation upon a woman for severe abdominal pains which were not localized. The symptoms were so obscure that a diagnosis was impossible. Dr. Keen found upon section that the patient was suffering with appendicitis, and he removed the appendix. The macroscopic examination showed a catarrhal inflammation and a stricture in

the middle of the appendix; there was no foreign body. The patient made a good recovery, with entire relief from all her former symptoms.

The happy result of the operation which has been performed before you this morning will impress upon your mind the urgent necessity for appreciating the position which the exploratory incision holds in surgical practice. We have in this method of diagnosis a means which is not only perfectly safe, but also accurate in many instances. Although I do not hesitate to say that an exploratory incision is without danger to life, yet you must thoroughly understand that it is frequently fatal unless performed by a surgeon whose aseptic technique is beyond criticism. Dirt introduced within the peritoneal cavity will be followed by a septic infection just as certainly as microorganisms will develop in a culture medium in the laboratory. Again, the post-operative environment of a patient upon whom an exploratory incision has been performed can in no way cause the development of sepsis, and if this condition supervenes, the infection occurred at the time of operation. Sepsis cannot occur from external causes after the abdomen has been completely closed. Take, for example, if you please, the culture medium contained in a glass tube whose open end is closed tightly with a plug of cotton. After sterilization, it makes no difference where the tube is placed, or where it is kept, or what may be its surroundings, the culture medium remains sterile so long as the cotton plug is not disturbed. This is precisely the condition after an abdominal operation not septic at the time or followed by drainage. No germs from without can enter an abdomen tightly closed, any more than they can infect the culture medium protected by the cotton plug. Therefore the surgeon who has a septic infection following an abdominal operation under these circumstances must look to the operative technique, and not lay the blame for want of success upon the subsequent environment of his patient. I have referred to this subject, as it is important for you to know and appreciate the causes of death following an exploratory abdominal incision.

[The patient made a prompt recovery.]

The following is a report from the Kyle-Da Costa laboratory of an examination made of the appendix.

The Macroscopic Examination.-The appendix had been opened by a longitudinal incision which extended above and below the inflamed area and exposed the fin of a fish. The tissues surrounding the base of the fin are highly inflamed. The irritation caused by the foreign body in its passage down the appendix is marked by a well-defined line of inflammation.

The Microscopic Examination.-The examination of sections made from the inflamed area shows that the pressure and irritation of the foreign body had caused capillary thrombosis or a blocking up of the circulation which was almost complete. The obstruction to the circulation is further increased by transudate, and possibly by a proliferation of exuded corpuscles. The hemorrhagic area showed disintegration of the mucous epithelial cells, some having undergone fatty degeneration. If this process had continued, an abscess would have resulted, owing to the evident infection of the parts.

OVARIAN NEOPLASMS.

CLINICAL LECTURE DELIVERED AT THE LONG ISLAND COLLEGE HOSPITAL.

BY ALEXANDER J. C. SKENE, M.D.,

Professor of Gynæcology, Long Island College Hospital, and Dean of the Faculty.

GENTLEMEN,-Diseases of the ovary of the degenerative order will occupy our attention this morning. First of all, we shall consider ovarian tumors or ovarian neoplasms. There is a great variety of these neoplasms. I simplify the classification, so that you can easily remember it, as follows: tumors that can be controlled and the lives of the sufferers saved by surgical means, and those that are not so amenable to treatment and in which the tendency is towards the destruction of the individual. You will see at a glance that the latter class includes all the malignant diseases of the ovaries, fortunately the most rare. The most common are the simple cysts or cystomata, neoplasms made up of a single cyst or a number of cysts, usually the latter. First let us inquire as to where they take their origin in the ovary, because we shall find that according to their location in the ovary will be their character or anatomy to a certain extent.

The ovary is divided into a mature glandular portion, where are found the matured Graafian follicles, and a deeper portion, where we find the immature or rudimentary ones. In the glandular structure the ordinary ovarian cysts are developed; in the deeper structure we find another variety of cysts, differing somewhat from the ordinary cysts in their character. They are all cystic neoplasms, but they differ to some extent in their anatomical characteristics.

Let me also call your attention to another variety of cysts; they are formed in the neighborhood of the ovaries and are often confounded with them. They are the parovarian cysts, which originate in the parovarium, a number of convoluted tubules or ducts above the ovary, the remnant of a foetal organ; they seem to serve no purpose, and we never hear of them except when occasionally a cyst is formed in one of the ducts. These cysts grow in the same way as ovarian cysts. In