some gentlemen would have us do in these cases, but I ordered ovarine, and the woman took it. She took five grains three times a day. At the end of the first week she was happy, free from all distressing symptoms. After the first week she continued to take the same dose, when the usual symptoms slowly came on again, and then I ordered larger doses. The question I wish to ask Dr. Dunn is whether he has not found it necessary to increase the dose constantly in these people, or whether a certain standard dose has been sufficient.

As to the perplexing difficulty of having to remove the ovary by a second operation where only one has been removed formerly, I feel thankful to any man who will tell us his honest experience. I have not had the unfavorable experience that has been referred to except in two cases. There are two patients at a distance, not conveniently located, that I would like to operate upon a second time, if possible. But even these two cases would not influence me to change my disposition in trying to save an ovary, if at all possible.

The overpowering factor for success in these conservative efforts is an ability to read correctly the true condition of the or gans when we have them in hand before our eyes, and the use of sound judgment in dealing with them. It is often perplexing to make an accurate diagnosis before we operate. It takes a skilled man of large experience to do it, and the best of us do not always make a complete diagnosis. But there comes another diagnosis to be made when we are in the abdomen-what shall be left, and what shall be taken out? Had the uterus better be removed, or had it better remain? These questions test the mettle of the gynecologist. No doctor, young or old, be he ever so good in any other department of medicine or surgery, knows exactly what is a healthy ovary, for instance, unless he has had frequent opportunities, either as operator or assistant, to delve into the female pelvis, and has done so with that solicitous, studious spirit that is not often born in those who do not feel that their reputation and the dollar are at stake. Post-mortem study is of no avail, because of too rapid post-mortem changes. So, then, as there comes to the student a period of becoming familiar with normal heart-sounds and normal respiratory sounds, before he can tell what is abnormal in the chest, so there comes to the men who are working in the abdomen first some years of studentship

to learn which uterus or tube or ovary is healthy and which is diseased, which may be left or resected and which must be taken away. I have had to do abdominal section to remove an ovary not larger than a pea. The operation showed that it was the cause of the trouble, because the patient was relieved. So it is not chiefly the size of an organ that determines disease. Here excellent judgment is necessary in order to determine what needs to be removed and what can remain. But if we are studious we acquire some degree of judgment that will bear good fruit in the outcome. I have removed parts of ovaries in not less than twenty-five cases each year for the last three years, not only through a median incision, but by the vaginal route, and also through the Alexander incision. Having the round ligament drawn out of the internal ring, this can be stretched enough with forceps to introduce the finger. Thus I have frequently loosened the ovary and fished it up, inspected and resected it, or taken it out, if nothing healthy remained. It can be gotten out with the tube by this incision without doing violence to the ovarian supports as much as we do by the vaginal route. Three cases I have positive knowledge of have become pregnant.

As to the technique of resecting the ovaries, I have departed from ignipuncture. It not simply destroyed the diseased follicles, but too much of the ovarian substance; and one of these women has not menstruated, although she has part of an ovary in her body, since the operation. I find it better to puncture the follicles with a knife, or with curved scissors; cut out a segment of the projecting follicle, cauterize with strong carbolic acid, and stitch it with fine catgut. This is sufficient to destroy the epithelium lining of the follicle, and it does not do so much violence to the remaining substance of the

ovary.

Concluded in April number.

EXCHANGES.

SOMETHING RIGHT ABOUT CATGUT.*

ROBERT T. MORRIS, M.D.

SEVERAL major points and several minor points about catgut will be remembered more easily if we group them separately.

Major Point No. 1.-When buying catgut, order the sizes by American standard wire gauge. Different dealers have an arbitrary numbering of sizes, and that causes a great deal of confusion. An American standard wire gauge can be found in the hardware shops and in mechanic's work-rooms-and if you order sizes by that definite measurement, the dealer who receives the order can step around the corner and invest half a dollar in a proper little wire gauge which tells him how to number catgut accurately.

Major Point No. 2.-The form of catgut is important because of the ease or difficulty in handling it.

I prefer the sort sold by dealers in watchmakers' supplies. It is used for their bow drills, and goes by the name of "bow lines." Each bow line is one metre in length. As many strands as we choose can be removed from the bottle at the time of an operation, without contaminating the remainder.

Major Point No. 3.-Catgut is satisfactorily prepared by the formal process. process. The word "formal" is the proper contraction for the word "formalin." The word "formalin" is the trade term for a commercial preparation of a 40 per cent solution of formaldehyde gas in water. A 2 per cent solution of this commercial formalin is what we mean when speaking of a 2 per cent solution of formal.

Major Point No. 4.-Catgut raw, oily and dirty, is placed in a jar containing 2 per cent of formal. The bulk of the water should be three or four times the bulk of the catgut. The catgut remains in this solution for forty-eight hours, and by the end of that time it has become hardened and sterile. It can then be

From New England Medical Monthly, Vol. XVI., No. 12.

boiled in water without suffering damage if the formal is removed.

Major Point No. 5.-Formål is irritating to the tissues and it destroys catgut unless it is removed. Wash out the formal by putting the catgut in a bowl and letting water from the faucet run through it for twelve hours. Better attach a rubber tube to the faucet and drop one end of the tube in the bottom of the bowl of catgut so that water escapes upward through the mass of catgut carrying formal with the outflowing current. The catgut, which was hardened and sterilized, is now contaminated by the tap water and it needs to be boiled in water for final sterilization.

Major Point No. 6.-Boil the catgut in water for fifteen min

utes.

Major Point No. 7.--Put the boiled catgut in absolute alcohol and use it directly from the alcohol at the time of operation.

Minor Point A.-Catgut prepared by the formal process resists absorption in the tissues in proportion to diameter. We may expect that No. 16 American standard wire gauge will resist complete absorption for three weeks, while No. 26 will be absorbed in about a week.

Minor Point B.-If you wish to prepare a lot of catgut with greater resistance to absorption, add of 1 per cent of bichromate of potassium to the formal solution.

consequent

Minor Point C.-Catgut does not dry so quickly on removal from the alcohol if 5 per cent of glycerine is added to the alcohol. Minor Point D.—Catgut if placed in alcohol immediately after being boiled carries a good deal of water in its tissues, ly it is better to abstract the water by placing the catgut in one jar of alcohol for a day and then transferring the catgut to another lot of alcohol for permanent storage.

Minor Point E.-Catgut twists into knots while it is being boiled in water. To prevent this, bunches about the size of hen's eggs are firmly rolled in a gauze bandage and the bandage is tightly pinned before the lot is thrown into boiling water.

Minor Point F.-Boiled formal catgut shrinks to about twothirds of its former length, and is too elastic to be used with com

fort.

To obviate this, a strand before being used is pulled out to

its original length with the hands, when it suddenly loses its elasticity and remains at its original length.

Minor Point G.-If catgut has been taken out of the alcohol bottle and not used at an operation, boil it again before replacing it in the bottle.

For fourteen years I have depended upon catgut for use in all of my work excepting in certain bone surgery which required the employment of silver wire.

During these fourteen years I have occasionally taken up other materials for sutures and ligatures, but have quickly discarded such materials for catgut again. Kangaroo tendon seems to be as good as the best catgut, but it is more expensive and the sources of supply cannot be depended upon. I used up a lot kindly given me by Dr. Marcy, and found it excellent, but no better than my own good catgut.

Silk often works out of a wound or scar slowly and causes troublesome sinuses. I have at present in the hospital a patient whose buried silk sutures have been gradually coming out of an abdominal scar for several years. The excursions of silk sutures are well known. The idea that silk knots hold better than catgut knots is advocated principally by men who tie granny knots. The first thing that a surgeon should learn is the tying of a square knot-but I have seen granny knots tied by at least one distinguished surgeon.

Horse hair, linen, Chinese grass and various other suture materials are advocated from time to time by men who do not prepare catgut well.

Silkworm gut is an instrument of the devil when used for buried permanent sutures. About three years ago I read an article on the use of silkworm gut by a surgeon whom I knew to be a careful observer, and I was tempted to give up my good-enough catgut for something better. In the course of six weeks I employed buried silkworm gut sutures in some twenty abdominal operations for patients who had put confidence in me and had entrusted their lives to my care. At the end of the six weeks I found that some of these buried silk knots were coming out in strange places and some of them are coming out yet--three years elapsed. One patient died as the result of the burrowing of a silkworm gut knot in the pelvis several months after operation. Nearly all of the patients suffered in one way or another. The surgeon who wrote the paper advocating the use of the buried silkworm gut knot, has written another paper saying that he is