sion and cauterization with nitrate of silver was not applicable to children. He said that he had operated successfully upon a child at his clinic, no anesthetic being used.

DR. JACOBI said that he would reply to this question by asking another. Was it not better treatment to simply dilate the sphincter, since it required less time, and no preparation, or anesthetic?

DR. MURRAY explained that when he performed the operation in question, he had not had experience in stretching the sphincter. DR. HARRISON asked if permanent incontinence ever followed this procedure in children.

DR. JACOBI said that, as a rule, there was only a temporary loss of power, which was soon regained.

DR. HARRISON explained that he had asked the question, because in the case of a woman, whose sphincter he had stretched for the relief of a fissure, perfect control had never been recovered, even after the lapse of several years. He had frequently noted the association of fissures and polypi in the adult.

DR. MURRAY asked the reader if dysuria had been a common symptom in his cases. An affirmative reply was given.

DR. LEE remarked that he had had considerable experience with prolapse of the rectum in infants, especially in hospital practice, and had always found that in treating them it was important to insist upon prolonged rest in bed, the patient being made to defecate in the recumbent posture. No variety of bandage was of permanent benefit. Rest in bed during an interval of from four to six weeks must be maintained, combined with the use of enemata of cold water and astringent solutions; if the feces were hard and lumpy, they should be softened with injections of sweet oil. In cases that resisted such treatment, the speaker said that he was accustomed to effect a contraction of the parts by removing strips of the skin and mucous membrane covering the sphincter, and suturing the opposite edges of the raw surfaces. He added that he had had as many as seven or eight cases of prolapse under treatment simultaneously in a single ward at the Infant Asylum. He had met with a few cases of fissure in children which he had treated by stretching the sphincter, always giving the patient a few whiffs of ether beforehand; if the fissure extended high up the rectum he had also practised the method of incision. He had observed incontinence in the aged after dilatation, but never in the young.

DR. BYRNE said that he had observed a few cases of fissure and polypus of the rectum, but could add nothing to what had already been said. All of his cases of fissure had been accompanied by relaxed sphincter, so that dilatation was not indicated; he had made a free incision in every instance with good result. He desired to add with reference to the therapeutics of dysentery that the doses of acetate of lead usually administered were too small; he had given to an infant a grain every two or three hours without noticing any unpleasant effects. He had also seen a few obstinate cases of prolapsus recti that could not be cured by the ordinary means, in which cauterization longitudinally (and in one instance transversely also) resulted in perfect cures.

THE PRESIDENT closed the discussion with the remark that it was probably the general wish of the Fellows that the Society should be placed on record as upholding the idea that in patients below middle life, permanent incontinence after dilatation of the sphincter ani was rare.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF PHILADELPHIA.

Stated Meeting, Thursday, January 7th, 1886.

The President, B. F. BAER, M.D., in the Chair.

DR. HOWARD A. KELLY exhibited recent

SPECIMENS OF PYO-SALPINX, HYDRO-SALPINX, AND PAPILLOMA OF THE HILUM WITH GELATINOID THICKENING OF THE FALLOPIAN TUBE.

The histories of the cases will be given at some future time. DR. GOODELL stated that while he recognized the necessity for operation in pyo-salpinx he does not think it necessary in hydrosalpinx. He now refuses to operate in some cases of cystic disease in which one ovary may contain a cyst as large as an orange, or in which the tube may be distended to the size of a sausage, because the sufferings of the patient and her general symptoms are not severe enough to warrant the operation. In many of these cases the symptoms may all be removed by the rest treatment, and it should first be tried. Small cysts are frequently found in ovaries, especially when uterine fibroids are present, but they do not necessarily develop into large ones. In many cases the cause of pelvic symptoms can be diagnosticated by exclusion only, and even when small cysts or dilated tubes can be felt, treatment should be first tried, and will be sometimes successful without operation. He thinks the error of the present time is in the direction of too much surgical interference.

DR. MONTGOMERY remarked that there was a class of cases suffering from small ovarian cysts or distended tubes, in which the rest treatment or any other loss of time could not be thought of, and in which operation seemed imperative. This was on account of the pecuniary condition of the patient, who may be self-supporting, or who may be the only support of others, the suffering and exhaustion of the disease incapacitate them from work; relief is imperatively demanded, and he considered operation justified.

DR. GOODELL recognized this element of poverty, and has operated for this reason in some instances. He was led to make his remarks by a case now under his care. A lady was sent to him for operation after an opinion had been given by an experienced gynecologist of another city that relief could be obtained by operation only. On one side the ovary was enlarged, and the other ovary was prolapsed and tender. Rest treatment had wholly cured her. In these remarks he casts no reflection on any of Dr. Kelly's cases. Pus was present in all of them, and operation seemed to be demanded in all.

DR. BAER has been strongly impressed lately with the views expressed this evening by Dr. Goodell. Dr. Baer thought all conservative means should be tried before operating.

DR. KELLY replied that he had presented the specimens purely from an anatomical and pathological standpoint, and that he would

give the histories at some future time, when the results of operation are well demonstrated. In each of them operation was imperatively demanded to save life. It is in such cases as those presented this evening that the great work in the future must largely lie. If the details of ovariotomy have been perfected, in such cases as these the chapter is only being opened. They are not examples of Battey's operation or Tait's operation, but stand as representatives of classes of disease well defined, with equally well-defined indications for treatment. The extraordinary difficulty of digging such masses as these out of the pelvis, makes operative interference very fatal, although it is the only resort. DR. WM. GOODELL read a paper on

"A YEAR'S WORK IN LAPAROTOMY,"

which will be published in full in the Medical News.

During the past year he has had forty-four cases of laparotomy, with four deaths, as follows:

Of these forty-four cases, twenty-five had been operated on at his private hospital, with two deaths; twelve were operated on at the Hospital of the University of Pennsylvania, with one death, and seven were operated on at the homes of the patients, with one death. Of these four deaths, one only was due to septicemia, and that, a case of oophorectomy, occurred in a private room at the Hospital of the University. It was not, however, due to hospitalism, but the adverse complications of the case. The ovary and oviduct were filled with pus, and so matted by inflammation to adjacent structures that only a portion of them could be removed, and that in fragments. The pus unavoidably escaped into the peritoneal cavity, which was carefully cleaned, and a drainage-tube put in, yet a fatal inflammation set in. Another death was due to shock after removal of the womb containing a fibroid tumor with extensive adhesions, and weighing seventeen pounds. The two deaths after ovariotomy were not due to septicemia, and are somewhat mysterious. One case was operated on at the patient's home in Bedford, Pa., and Dr. Goodell did not see her again. The cyst was parovarian, weighing forty-three pounds, was without an adhesion and easily removed. The stitches in due time were removed, the bowels were opened, and everything did well for twelve days. Then obstinate vomiting set in, and the lady died on the seventeenth day. Six months previously she had had an analogous attack of obstinate vomiting, in which her life was despaired

of. The fourth death took place from a supposed attack of malaria, to which the patient was liable. Both ovaries had been removed, the larger one weighing about thirty pounds. There were omental adhesions and very firm parietal ones, needing a number of ligatures. She recovered promptly from the operation, the wound united, the stitches were removed, and she was allowed to sit up out of bed. On the seventeenth day malarial fever with bilious vomiting set in, and she died rather suddenly on the twenty-first day, with symptoms of heart clot.

Of the nine oöphorectomies, four were performed for ovarialgia, three for bleeding fibroids, one for epilepsy, and one for a menorrhagia which had resisted every known therapeutic measure.

In three cases of ovariotomy, all of them with papillary cysts, rupture had taken place a few hours before the operation; but, although the peritoneum seemed thickened and injected, no bad result followed. He considered papillary cyst to be benign in the very great majority of cases, and that the danger from the escape of ovarian fluid into the abdominal cavity was very much overrated. He had not refused to operate in a single instance of ovarian tumor, no matter how low the patient was, or how firm were the adhesions. He had consequently had several exceedingly difficult operations. Out of his twenty-eight ovariotomies, there were twenty-one with adhesions. In four, the adhesions were universal; in eight more, they were intestinal; and in three, they were uterine. This very large proportion of adhesions, when compared with those of European operators, he could explain only on the theory that physicians in this country have not yet been educated up to the idea of an early operation, and to a recognition of the evils of tapping. In the successful case of hysterectomy, a tumor weighing eight pounds was removed, together with a portion of the enlarged womb. As the uterine cavity was not invaded, the large pedicle was transfixed, tied, and dropped. The four exploratory incisions were made with the view of removing the ovaries, on account of fibroid tumors of the womb. But in each, the tumor was so fixed by adhesions that the ovaries could not be reached; and the patients had previously stipulated that, in that case, the uterine growth was not to be removed. All did well. So also did a case of pelvic abscess communicating with the bladder and rectum. It was opened per vaginam by means of the abdominal incision, by which its exact position and size were determined. . . . With regard to the technique of the operation for laparotomy, Dr. Goodell stated that he used the ordinary knot and the Staffordshire knot indifferently; that he now, in the long incision, cuts directly through the umbilicus, instead of going around it on the left side; that he includes the recti muscles and all the tissues in the abdominal sutures; and that, while not a very firm believer in the spray part of antiseptic surgery, he had resorted to the atomizer in every case but one, and that one did as well without it as most do with it.

DR. MONTGOMERY thinks Dr. Goodell should be congratulated upon his success, which is remarkable for operations in unselected cases in the United States. He thinks the knowledge of the safety attending the application of Monsel's solution to oozing abdominal surfaces very gratifying. He would have used it recently but for the fear of bad after-effects. He must, however, again enter his plea for the second ovary. In young women, small ovarian cysts are common; they are frequently found in post-mortem examinations when there had not been the slightest evidence during life of their presence; and, evidently, these small cysts do not necessarily develop into large ones. The two cases of secondary ovariotomy reported by Dr. Goodell are not sufficient to warrant the rule of removing the second ovary when it is but slightly diseased. As a counter-weight to Dr. Goodell's cures, he would mention that, in the instance of a young married woman from whom he removed an ovarian tumor, and in whom he left the other ovary, which was slightly affected, pregnancy has since occurred, followed by the delivery of a living child.

DR. KELLY remarked that Dr. Keith had had remarkably good results from the application to oozing surfaces of a solution of pernitrate of iron. He has observed the gradual disuse of carbolic acid in washing-waters in operations. Dr. Kelly prefers boiled or distilled water as used abroad, as he is sure that carbolic acid and other germicides are frequent causes of poisoning and bad results after operation. He asked Dr. Goodell: What were his rules respecting the drainage tube?

DR. BAER had experimented with Monsel's solution. In one case in which he used it, he attributed the fatal result to it. The coagulation by the iron is unsightly, and he should now consider it a last resort. He had had very good results from pressure, by packing sponges against the bleeding points, combined with external pressure. He withdraws the sponges at the last moment before tightening sutures, and then bandages the abdomen tightly. DR. GOODELL remarked that Dr. Montgomery was perfectly right in his defence of the second ovary, and he himself had performed double ovariotomy in only seventeen cases of the twentyeight. He did not believe that every ovary studded with cysts would inevitably degenerate into an ovarian tumor. So, in the case of slightly diseased ovaries in young married women, he would be disposed either to let them alone, or to remove the diseased portion only. But in women approaching the climacteric, or where other conditions would make it advisable, he would remove the second ovary as useless in itself, and as a possible source as future trouble. He has used the drainage tube but three times during the past year: once in the unfinished case of oophorectomy, again in the case of torn bladder, and in the case requiring over thirty ligatures, and with universal adhesions. In general, he uses it when a free oozing of blood is to be expected, but he regards it as a source of trouble, and removes it as soon as possible.