incision over the gall-bladder, removed the stones and amputated a part of the organ leaving a drain behind. This incision was closed with interrupted silkwormgut sutures. Time of entire series of operations, one hour and 30 minutes. The patient was removed from the table in good shape. Convalescence from the immediate effects of the operation was ideal. The patient, however, remained nervous and melancohlic for at least 18 months. Then she began to improve and is now in perfect health.

:

CASE VI. Patient aet. 28; three children; tubercular family history lacerations of cervix and the vaginal outlet; constant pain in the right side over McBurney's point, constant bearing down sensation, anaemia, indigestion, constipation with mucous stools, cold hands and cold feet, marked emaciation. In January 1908, I did a divulsion, a curettage, removing a large amount of debris, a trachelorrhaphy, overcame the relaxation of the pelvic floor, opened the abdomen and found the appendix peculiarly club-shaped, there being several constrictions in the outer third resembling knots tied in a tassel. The appendix was removed in the usual way. The right ovary was at least two or three times its normal size and the tube thickened; this was removed by tying each artery individually in fine Pagenstecker linen. The left ovary was also somewhat diseased and the tube thickened. However, the patient and her husband absolutely forbade its removal and the utero-ovarian ligament was therefore folded upon itself so as to bring the ovary out of harm's way. The whole uterus was somewhat retroposed, although the fundus was directed forward; it was therefore held forward by suspension. The abdomen was closed in the usual way. The patient was absolutely free from shock when removed from the table. No effort was made to hurry because it was my desire not to pinch nerve terminals. Each artery was tied individually. Time of entire series of operations, one hour and 10 minutes. Three weeks from the date of the operation she had a thrombosis of the left leg, which kept her in bed three weeks longer. I do not attribute this to the number of operations performed at one sitting, as it is an accident which is liable to occur whenever the abdomen is opened. She is still having trouble with the ovary left behind. While I think it will right itself in time, it is one of the contingencies liable to arise whenever an ovary slightly diseased is left behind after the abdomen is opened.

CASE VII. Patient aet. 36. Under the Viavi treatment for two years for a fibroid tumor weighing nine pounds. She is a charming little woman and was assured that the tumor was coming away "piecemeal," the "pieces" consisting of blood clots. The pressure symptoms became distressing and the right kidney was showing signs of involvement. She had had one child and the cervix and perineum were badly facerated. In October 1906, I repaired the cervix and perineum, opened the abdomen under nitrous oxide gas and found the tumor intraligamentary, growing down into the pelvis on the right side. It was delivered with a good deal of difficulty after the upper part of the vagina was cut across. The anaesthetic was not complete and the patient strained a good deal forcing the intestines out of the

abdominal cavity so that it was necessary to protect them with warm sterile towels. After a good deal of difficulty the tumor was eviscerated, turned out of its peritoneal bed and the bleeding points secured. All raw surfaces were covered with peritoneum and the extremely thin abdominal wound closed with catgut for the peritoneum and fascia, and a mattress silk suture supplemented by a superficial catgut suture for the skin. The patient was removed from the operating table in one hour and 20 minutes from the beginning of the operation and made an ideal convalescence. She is well, strong and happy today.

CASE VIII. Patient aet. 50; complete laceration of the perineum ; cancer of the cervix. In May of 1906 I repaired the perineum by the flap-splitting method, opened the abdomen and did a radical hysterectomy for removal of the cancer. The appendix was thickened and was therefore removed. The patient was removed from the table in good shape. Time of operation, one hour and 30 minutes.

CASE IX. Patient, aet. 44; married for 20 years; no children; has had several attacks of bowel obstruction and the right kidney was loose; inguinal hernia of the left side which has given her much trouble. The uterus was sharply retroflexed and the ovaries were bound down by adhesions. The appendix was thickened and there was obstinate constipation with mucous stools, and the patient was in a wretched run down neurasthenic state. In July of 1907 I did a herniotomy, opened the abdomen in the median line, explored the liver, gall-bladder and kidneys as well as the transverse colon for the purpose of determining whether or not these organs were involved; removed the appendix, both ovaries and tubes, a small fibroid from the fundus of the uterus and stitched the uterus in front and closed the abdomen in the usual way. I also removed a polypus from the cervix, dilated the uterus thoroughly, did a curettage and fixed the kidney by stripping the capsule. Time of entire series of operations, one hour and fifty-five minutes. Convelescence uninterrupted and the patient is today perfectly well.

CASE X. Patient aet. 24; one child four years old; cervix badly torn. Four months ago she had an attack of severe pain in the right side followed by flooding. This pain recurred at intervals so that she had to take to her bed and the question was whether or not she had appendicitis or gall-stone disease. There have been several attacks of jaundice with pain very characteristic of the passage of gallstones. She was in the habit of skipping a menstrual period every now and then so that when she missed one a short time before being taken ill she did not think much of it. At no time was there syncope of a marked character. However, the hemorrhage from the uterus has continued and she has lost a good deal in flesh.

On January 11, 1909, I thoroughly curetted the uterus, irrigated it with a bi-chloride solution, wiped it out with gauze, applied the compound tincture of iodine, fixed a badly lacerated cervix, overcame adhesions of the clitoris, dilated the rectum, opened the abdomen through an incision long enough to explore the gall-bladder and kidney; the gall-bladder was empty and there were no evidences of kid

ney-stone. There was a good deal of free blood in the abdominal cavity. This was sponged away, the adhesions of the omentum to the uterus overcome, and all blood clots removed. The patient had unquestionably had a tubal abortion of the right side and the tube still contained the placenta which was as large as a hen's egg. No evidences of the foetus were found and it is probable that it was absorbed when it was discharged into the peritoneal cavity. The tube and ovary were tied off with catgut, the ovary being very much diseased. The left ovary was enlarged and the tube thickened, and it was therefore removed. The appendix was at least five inches long and indurated; it was removed in the usual way. The uterus fell backwards after the appendages had been removed and it was therefore suspended by the Kelly method. A litre of the normal salt solution was left in the abdomen and the wound closed with two layers of catgut, silkwormgut tension sutures and a subcuticular silkwormgut suture. Time of operation, 55 minutes. The patient was exceedingly nervous in anticipating the operation, so that two H. M. C. tablets were administered hypo-dermatically and ether used as an anaesthetic. She had a mitral insufficiency but notwithstanding this fact she was removed from the table in much better shape than she was previous to the anaesthetic. Her convalescence was ideal and she left the hospital at the end of the third week.

The foregoing cases are typical of several hundred which I have in my case record. I am not reporting them for the purpose of exploiting my own skill and dexterity. What I have done can be done by any surgeon of reasonable skill, if he simplifies his technique and goes into his cases with a thorough understanding of his work. I have described my technique so often that it is unnecessary to take up your time by repeating the description again. (1) There are certain points however, which I desire at this time to again call your attention to and I will conclude this paper by summarizing them.

1. When the fundus of the uterus is amputated for fibroids or other nno-malignant lesions, and the cervix is lacerated, it requires less time to repair the cervix and to take care of the pelvic floor, if this is relaxed, than it does to do a complete hysterectomy. By conserving the cervix the vaginal vault is left in a perfectly normal condition.

2. While from the standpoint of asepsis it would be better to do the abdominal work first, and the plastic work subsequently, there is a large element of danger in operating upon the cervix after the

(1) (a) The Author's Text book of Gynecology. Second Edition.

(b) "A New Operation for Cystocele." Am. Journal of Obstetrics. Vol. LI, 1906.

(c) 'Prolapsus of the Uterus." Medical Century, Feb., 1908.

(d) "The Surgical Aspect of Indigestion and so-called Gastralgia." CLEVELAND MEDICAL AND SURGICAL REPORTER, April, 1904.

ovaries have been tied off. I had one secondary hemorrhage from doing this and the patient's life was only saved by re-opening the abdomen. As a matter of fact, the surgeon who has mastered his technique can go into the abdomen after the vaginal work is completed with comparative impunity.

3. The appendix should be examined in all cases where the abdomen is opened. If it is apparently normal, I do not remove it; but if the patient omplains of indigestion, constipation, diarrhea, and gaseous distension of the bowels, and especially if there be mucousenterocolitis, I remove the appendix in all instances. This fact I emphasized in papers presented to the Surgical and Gynecological Association of the American Institute of Homeopathy in June, 1900. (2) and the New York County Medical Society in March, 1904 (3).

4. If one or both ovaries slightly or badly diseased are left behind the responsibility of so doing should rest with the patient and her friends.

5. While I believe in conservatism I do not believe in foolish conservatism. When an ovary is irreparably diseased, it should be removed. If one ovary is left behind, I believe with the Mayos, that it is better not to molest that ovary by resecting a portion of it. I have during the last year removed four different ovaries which were so "conserved" by other surgeons.

816 Rose Buil.ling.

COUGH.

BY GAIUS J. JONES, M. D., CLEVELAND, O.

At this season of the year almost everyone, for a portion of the time, is engaged in the not very pleasant pastime of coughing. The properly indicated homeopathic remedy will modify or control nearly every case. I have been asked to write for the REPORTER, giving the chief indications for a few remedies to be prescribed in this condition. The remedies given below have been prescribed hundreds, and some of them thousands of times, by myself when the symptoms, which I give under each remedy, were present.

ACONITE: We have no better remedy than this for the primary or congestive stage of the various inflammations which produce

(2) Oride Transactions.

(3) THE CLEVELAND MEDICAL AND SURGICAL REPORTER, April, 1904.

cough. The cough is dry, hacking, not especially paroxysmal; occasionally the patient expectorates a little clear mucous, or mucous streaked with blood. There is no pus expectorated in this stage of the disease. There is an elevation of temperature, possibly some chilliness and a general restless condition. In ordinary croup, if given early, this remedy will cut short the disease, and this can be said with nearly as much truth in regard to bronchitis or pneumonia.

BELLADONNA: In cases in which Belladonna is indicated there is usually a high temperature, flushed face, and pain in the anterior part of the head. Frequently there is some tendency to drowsiness -stupor. The cough is paroxysmal, generally relieved by the sitting position. There is very little expectoration, although more than with Aconite. The pulse is full, and increased in frequency. There may be some chilliness, but generally the patient complains of heat. This remedy, too, is more indicated in the early stage of the disease. BRYONIA: Ths remedy follows aconite in very many cases. The cough is severe and accompanied frequently with sharp, lancinating pains throughout the chest, more particularly on the left side. So severe is this pain that the patient prefers to lie upon the affected side, or if sitting, will hold the side of the chest with the hands while coughing. The cough is aggravated by cold air, and relieved by warmth. It is also relieved by rest; talking, laughing or moving about will aggravate it.

DROSERA: This was Hahnemann's remedy for whooping cough, for which disease it is better indicated than any other remedy. The cough is paroxysmal, generally dry, although the patient is not hoarse as with Spongia or Phosphorus. It is aggravated by lying down, especially the fore part of the night. Occasionally a single dose of the 30th attenuation will prevent for that night the miserable paroxysm which has kept the patient awake for several hours, during the first part of several previous nights.

EUPATORIUM PER: This remedy is not used as frequently for a cough as it should be. It is especially indicated in those cases. which occur during a remitting fever. The paroxysm of fever generally occurring during the latter part of the forenoon. In Bronchial or pulmonary tuberculosis it is one of our best remedies.

HEPAR SULPHUR: Indicated for a hoarse cough, which is aggravated in the fore part of the day, and is beneficial in many cases of chronic laryngitis.

IPECAC: Indicated for a cough with rather profuse expectoration, accompanied with nausea and vomiting. Occasionally we get,