DR. GAIUS J. JONES, FOR PRESIDENT OF THE INSTITUTE.

"Some men are born great, some achieve greatness, others have greatness thrust upon them." This well known quotation has a special significance, when applied to Dr. Gaius J. Jones, of Cleveland. If he had not been born great he could not have accomplished the great amount of good that is distinctly traceable to his direct efforts. A long, honorable career is his. For the past thirty-five years he has taught his classes in the Cleveland College. Hundreds of physicians, now located throughout the United States, owe much to his greatness as a teacher. Kindly, practical and persevering in his determination that the students in his classes have only the best instruction, he has made a lifelong friend of every student who has had the opportunity to be taught by him. Now these same men and women desire the greatest honor that can be given by the homeopathic profession be conferred upon him. The Presidency of the American Institute of Homeopathy is a most responsible position. A great man is required to fill the place.

That Professor Jones is the man for the place is claimed by his innumerable friends. At their urgent request he has consented to be a candidate for President of the Institute. Dozens of letters have been received from prominent Homeopaths favoring his candidacy. He has not sought this great honor. It has been thrust upon him.

MULTIPLE OPERATIONS AT ONE SITTING IN

GYNECOLOGY.*

BY JAMES C. WOOD, A. M., M. D., PROFESSOR OF SURGICAL GYNECOLOGY IN THE CLEVELAND HOMEOPATHIC MEDICAL COLLEGE; FELLOW OF

THE ROYAL SOCIETY OF MEDICINE, LONDON.

In the July 1895, number of the North American Journal of Homeopathy, I published an article entitled, "A Plea for the Removal of all Lesions of the Lower Orifices of the Body at one Sitting." In that article I advocated at one sitting divulsion, curettage, trachelorrhaphy, perineorrhaphy, removal of adhesions of the clitoris and removal of hemorrhoids, if present. I described my method of operating, the technique being so simplified that the entire series could

1909.

*Read at meeting of the Cleveland Homeopathic Medical Society, January,

be done in from 30 to 45 minutes. Since then I have extended the principle of combined gynecologic operations until now it is not an uncommon thing for me to do at one sitting, besides the series of plastic operations just enumerated, celiotomy, removal of the appendix vermiformis, removal of the uterine appendages, ventral fixation or shortening the round ligaments, the entire series not requiring over 45 minutes or one hour's time. In addition to the operations enumerated I have done cholecystotomy and fixation of the kidney.

There are many factors to be taken into consideration in doing work of this kind. One must always know his patient thoroughly and must watch the effects of the first operations as he proceeds with his work. The most favorable cases for combined operative work are those women who are not too fleshy, whose haemoglobin is somewhere near the normal, whose kidneys are in good shape and whose heart and blood pressure are practically normal. Then, too, much will depend upon the operator and upon his technique. It would certainly be unwise for instance to include in a series of combined operations necessitating extensive abdominal work, the Emmet operation upon the pelvic floor. While from a cosmetic standpoint this is an ideal operation, it requires altogether too much time in its performance, and I believe so far as ultimate results are concerned it is not as satisfactory as the operation I am now doing in that it does not bring the levator ani fibers together in the median line where nature first placed them. Edebohls says that the limit of safe anaesthesia beyond which he is unwilling to protract operative procedures in elective cases is one and one-half hours. (1) This is purely an arbitrary statement as to time limit and each case must necessarily be a law unto itself.

The surgeon of some years experience who cannot do a divulsion, a curettage, a trachelorrhaphy and a perineorrhaphy, as well as an anterior colporrhaphy, looking after rectal lesions at the same time, in 60 minues, should no longer aspire o surgery. While I believe that the surgeon should always throw about his patient all possible safeguards, there is a tremendous advantage in placing her in bed with all necessary work done. There is nothing more depressing to the patient than the contemplation of another operation or operations after one or more has been performed. I have in one or two instances regretted doing too much work at one sitting; I have more often regretted not having done all that it was necessary to do. I do not believe that the young surgeon should undertake to do ex

(1) Kelly-Noble Gynecology. Vol. 1 p. 436.

tensive work of this kind at one time. However, with the experienced operator, if the patient takes the anaesthetic well, certainly the simple abdominal operations should be combined with plastic work, if called for. Even vaginal hysterectomy for cancer of the uterus or for complete procidentia, can be advantageously combined with plastic work upon the perineum and upon he vagina.

Previously to about 15 years ago combined gynecologic operations were rarely if ever performed. Since that time Doleris, Munde, Edebohls, Montgomery, Noble and the writer (loc cit) have written articles advocating the combined work. (1) As I have stated, if the patient's kidneys are not functionating normally, or other vital organs are seriously involved, too much should not be undertaken. On the other hand, we all know that not infrequently patients who are anaemic and who have serious cardiac or pulmonary trouble stand operative work very well. I have successfully operated upon advanced cases of exophthalmos, doing at one time extensive plastic and abdominal work. I perhaps can best illustrate my point by eiting a number of typical cases, dealing with almost all varieties of pelvic and abdominal operations:

CASE I. Patient aet. 48; exceedingly nervous, crying constantly; melancholia of suicidal type; complained of constant pain through the pelvis; there was indigestion, backache, bearing down sensation, leucorrhea, menorrhagia. She was anaemic from loss of blood and altogether in a deplorable condition. Examination revealed the uterus Sharply retroflexed, large and heavy with the fundus pressing hard against the rectum. Both ovaries were prolapsed, the pelvic floor was badly relaxed, and there was marked obstipation due to the pressure of the fundus against the rectum. The cervix was large, everted and indurated. There was tenderness in the region of the appendix, which could be easily palpated.

In November of 1908 I did a divulsion, a curettage, removing a large amount of debris from the uterus, a trachelorrhaphy, removing a large amount of cicatricial tissue, overcame the relaxation of the pelvic floor without building up the perineal body, dilated the rectum, overcame adhesions of the clitoris, opened the abdomen and removed a long thickened appendix, stitched the uterus in front and also did the internal Alexander operation because of its excessive size. The abdomen was closed with two layers of catgut, silkwormgut tension sutures and a buttonhole skin suture of catgut. Time of entire series of operations, 52 minutes.

This patient began to feel better almost as soon as she recovered from the shock of the operation, which was slight. The melancholia has gone, the constipation is overcome, she is eating well, is happy, is not flowing, and is rapidly gaining in flesh.

(1) Kelly and Noble. Vol. II.

CASE II. Patient aet. 28: one child two years old: labor prolonged, instrumental; was badly lacerated and the pelvic floor much relaxed. There was procidentia of the uterus when I examined her four years after the birth of her child with the fundus directed backwards; sensitiveness of the appendix with indigestion and severe headaches due to ptomaine poisoning. In May of 1907, I did a divulsion, a curettage, a trachelorrhaphy, removing a large amount of cicatricial tissue, particularly from the left side, an anterior colporrhaphy and a perineorrhaphy by my modification of the Mayo operation, divulsed the rectum and overcame adhesions of the clitoris. I then opened the abdomen and found an appendix filled full of fecaliths. This was removed in the usual way. I then did my modificaion of the internal Alexander operation. The uterus was large and heavy and the right ovary somewhat enlarged, diseased and prolapsed and the tube thickened. The husband who was present objected to having the ovary removed, taking all chances of future trouble. The abdomen was closed with two layers of catgut silkwormgut tension sutures and a subcuticular silkwormgut suture. Time of entire series of operations, 44 minutes.

This patient convalesced ideally and I have examined her within the last month. The uterus is in splendid shape, the ovary has apparently returned to its normal state, there is no trouble with the menstrual function and she is strong and well. She had been under the local treatment of a physician for three years who promised her that he would be able in time to so restore the vaginal walls and the uterine ligaments as to overcome the procidentia. I can but feel that treatment of this kind, under the circumstances, is malpractice. Anyone who has a complete procidentia of the uterus is going to remain in a deplorable state until that condition can be overcome. I recognize the fact that in the aged there not infrequently exist counterindications which make it impracticable to do surgical work. ever, the series of cases which I recently reported in the Medical Century (1) go to show that women of extreme age stand this sort of work nicely. I reported in that series one women of 78 who stood extensive repair work without the slightest inconvenience. In these days of surgical triumphs it is certainly a cruel thing to condemn a young woman of 28, whose uterus is completely prolapsed, to a life of invalidism.

CASE III. Patient act. 32; one child four years old; perineum very badly lacerated at that time; profuse menstruation, emaciation, constant pain in the abdomen, the pain localizing itself in the region of the appendix. Physical examination reveals two masses, one on either side of the uterus and intimately attached to it, which fact. together with the menorrhagia, led both her attending physician and myself to believe that she had multiple mio-fibromata of the uterus. However, when I opened the abdomen, after building up pelvic floor and repairing the cervix, I found a double ovarian haemotoma, the growth on the right side being as large as an orange and on

(1) February, 1908.

the left as large as a fetal head. Both were intimately adherent and on the left side the entire broad ligament was implicated with the ovary making one suspect that the condition might be due to an ectopic pregnancy. The right tumor was carefully delivered after breaking up the adhesions and tied off with catgut, the stump being covered with peritoneum. The left side ruptured during removal and a dark grumous matter escaped. Fortunately the intestines were carefully packed away. The appendix was thickened and diseased so that it was removed at the same sitting. A litre of the normal salt solution was left in the peritoneal cavity. The fundus, which fell backwards after the growth was removed, was suspended from the peritoneum. The abdomen was then closed with two layers of catgut, silkwormgut tension sutures and a subcuticular silkwormgut suture. Time of operation, 54 minutes. The patient was removed from the table in good shape and in October, 1908 she reported: "I can give a very good report of myself. I have never felt so well, have not any pain at all, have menstruated but once and then flowed for nearly two weeks. I am troubled with headaches occasionally but not a great deal. Have gained three pounds in the last two weeks and my friends tell me I never looked so well."

CASE IV. Patient aet. 40; severe attacks of pain in the right side which had been diagnosed both "renal colic" and "appendicitis." She had a very badly lacerated cervix, the uterus was large and heavy, there was much endometritis with a nasty discharge and a badly relaxated pelvic floor. On April 9, 1907 I did a divulsion, curetted the uterus, removing a large amount of cicatricial tissue from the cervix, built up the pelvic floor, opened the abdomen by means of a long incision, explored the kidney and the gall-bladder to find that both were apparently normal; removed a little thickened appendix, found both ovaries bound down tightly and the tubes distended to the size of the finger with a serous matter. The ovaries and tubes were both tied off with catgut and the uterus held in front by means of one catgut ligature and the abdomen closed with two layers of catgut, silkwormgut tension sutures and a subcuticular silkwormgut suture. Time of operation one hour and 15 minutes. The patient wrote me in October, 1907 stating that she is well and strong.

CASE V. Patient aet. 36; exceedingly nervous with marked indigestion, associated with frequent attacks of colic, and nausea and vomiting. The uterus was subinvoluted, there was much dysmenorrhea, and diarrhea with mucous stools. She was melancholic and had several times attempted suicide. I found upon examination tenderness over the appendix and over the gall-bladder. The uterus was retroflexed, the cervix badly lacerated and the pelvic floor relaxed. In August 1905, I did a divulsion, a curettage, a trachelorrhaphy, a perineorrhaphy and opened the abdomen through an incision long enough to admit the entire hand. I found the appendix infiltrated and intimately adherent to the caecum. The ovaries were both enlarged and diseased and I therefore removed them. In next explored the gall-bladder and found it distended with four large stones. I fastened the uterus in front, clcsed the abdomen below, made another