long was hanging out. I had her placed in the knee-chest position, and with my hand I replaced the cord, passing it well up into the uterus and above the head. The pains were rather feeble, and I gave her eight grains of quinine. Kneading the bowels, later on, I gave one dram of Squibb's fluid extract ergot, with no improvement in pains. At eleven I concluded to use the forceps, but after an hour's trial I had to give up the effort, having failed to introduce them. So I then asked for consultation. Dr. C. N. Ferguson was called, who arrived at 3 P. M. After examination he thought it right to give more ergot and quinine and use more kneading after trying for two hours with no advancement. The cord, however, had again come down, and we again, after the same plan, returned it, but it would not stay. We then gave chloroform and attempted to use the forceps.

Dr. Ferguson trying to introduce them, after an effort of twenty minutes succeeded in getting in the first blade, and after a fruitless effort of half an hour at introducing the second blade he gave up, and I undertook the job. After an effort of forty minutes I succeeded in introducing the other blade and locking the forceps, but the handles stood wide apart and could not be closed. I then tried with all my power for considerable time with no progress. Dr. Ferguson, a man of two hundred pounds weight, and very muscular, tried for a while; then we both alternately tried for an hour-still no progress. By this time we knew the child was dead, and we determined to open the head and let out the contents. Wrapping a scalpel to within a fourth of an inch of the point, and introducing it between my fore and middle fingers till I reached the fontanelle, and then with my right hand I inserted it into the head and cut an opening three fourths of an inch long. No sooner had the knife passed into the cavity than the water spurted out over me, the floor, and run down into the chamber until it was most full. I then proceeded to deliver the child, which was accomplished in about five minutes. After waiting a half hour the placenta did not come down, and I introduced my hand and found it firmly adherent to the anterior of the uterus, and was compelled to remove it entirely with my fingers. We had no unusual hemorrhage.

Having seen our patient comfortably placed in bed and for the time being doing well, we turned our attention to the child to see what we had. First filled the head with water as well as we could, but could not make it tense, the scalp remaining in wrinkles. It then measured twenty inches around, occipito-frontal measurement. We agreed that if

we could have filled it full it would have measured at least twenty-three inches. Next we noticed that it was very long, and upon measuring we found that she measured twenty-six inches long, and was more than usually developed. We, however, neglected to weigh it, which I very much regret. The best estimate we could make of the amount of water discharged was seven pints.

The after-treatment consisted of fifteen grains of quinine per day, three days, and the vagina and uterus douched out with hot water, half gallon, carbolic acid, one dram, twice a day, for fifteen days. Her recovery was uneventful.

This case was a very interesting one to us, owing to its many and unusual complications, funis presentation, hydrocephalus, and retained placenta―the membranes rupturing seventy-two days before the fetus was born. I wish to add that the lady-who is one of fair intelligencecontends stoutly that she knows from unmistakable evidence that her time for confinement was fully up when I first called, and that she carried the child for nearly twelve months. I mention this fact for what it may be worth.

CHARLESTON, KY.

THE CONSERVATISM OF MODERN SURGERY.*

BY A. T. M'CORMACK, M. D.

Conservatism is probably the most abused term in the vocabulary of the practicing physician. At its doors he lays all his lack of knowledge and progress, and too frequently he uses its soothing syllables to quiet the alarms of an anxious family when active, capable work might relieve his patient. This is true to a certain extent in medicine as well as surgery, but it is in the broad realm of modern surgery that one more often meets this so-called conservatism.

The older men present here realize best what modern surgery is. They remember when a thumb-lancet, an amputating case, a pair of obstetric forceps, and a cystitis-breeding gum catheter constituted a surgeon's armamentarium, when venesections, amputations, and trephinings were the limits of the surgeon's field. They remember, and so do we all, when localized induration was the signal for poultice, foul breeder of germs innumerable, and when timidity, falsely termed conservatism,

*Read before the Southern Kentucky Medical Association.

forbade incision and cure of abscess except as dernier ressort, but preferred that they "bust" or scatter. They have seen and gloried in the expansion of surgery until it has become a science. They have seen abdomen, chest, and brain brought into the surgeon's realm; have seen diseases cured that in their prime they never diagnosed. The older men should understand surgical diagnosis because its years are no more than theirs; the younger ones should know its details from their studies. Yet in my brief practice I have seen ectopic gestation treated as colic, syphilis as erythema. I have seen Behring's serum used on the last instead of the first day of diphtheria; I have seen a suppurating cervical lymphatic poulticed for twenty days; I have been called to operate on acute obstruction of the bowels on the fifth day, a hare-lip in the eighteenth year, and have seen several cases of hip and spinal disease waiting for treatment until deformity should establish diagnosis.

And the men who did these things prated of conservatism, and told their patrons, in confidential tones, that they were never rash, and that they only resorted to the knife or called in the surgeon when every thing else had failed. Oh, Conservatism, cloak of ignorance, favored term of blatant demagogy, synonym of tardiness and neglect, what deaths and deformities and invalidism lie at your door! How often have you lulled to repose the willing conscience of the doctor who has delayed, as well as the just indignation of surviving friends! How often have you been the weapon that has brought patients to men, who, lacking learning or skill or decision, make you their motto!

Conservatism in medicine, however, like Dr. Jekyll and Mr. Hyde, is two-faced. The one meaning "the desire of preserving what is established;" the other, "the effort to preserve from loss, decay, waste, or injury."

It is of this latter conservatism as used in modern surgery that I wish to speak especially to-day; of that active, practical, far-seeing method of thought and action which conserves tissues, health, and life. It is this which teaches us that localized suppuration should be relieved at once by free incision and the curette, and that the old medical puncture caused a dangerous delay. It is this which teaches us to remove as much as may be of the environs of cancer, and that any thing less than a radical operation in this trouble is not only a useless but a harmful operation. It is this view of conservatism that prompts us to use the curette promptly and thoroughly in threatened sepsis, or to extirpate the genital organs in beginning septicemia or pyemia after

childbirth. It is this which has substituted the vaginal for the suprapubic route in all possible cases of pelvic disease; which has inspired a Vineberg to resect or puncture cysts of ovaries rather than unsex women; which has given us the pelvimeter and preventive midwifery; which has caused a Harris to make discussions of mammary abscesses. unnecessary by telling us how to prevent them, and to make rapid deliveries in eclampsia or placenta previa safe by telling us how to dilate the os most readily. Gibney had such a conservatism in view when he taught us how to cure sprained ankles, or how to diagnose tubercular disease of hip or back in its beginning and then to check its course. Such a conservatism has made the trained nurse indispensable with the severely sick, and has substituted safe operative procedures for inconvenient trusses in hernia.

The conservative modern surgeon has brought asepsis and cleanliness out of a chaos of antiseptics and filth. He has made syphilis curable, and has proved that gonorrhea, one of the most insidious and dangerous of diseases, is hard to treat in male or female, and that most of us have been treating it wrong. He has substituted resection or exsection for lameness or amputation in chronic bone disease, and has made amputation at hip or shoulder bloodless. He has substituted metal plates and rapidity for end-to-end anastomosis and death-dealing delay. He has given us the curette, shown its dangers in the tyro's hands, proved its uselessness unless its use be thorough. He condemns the rashness of the overzealous and ignorant, as he condemns delay in the competent, but claims that the mortality of tardiness is greater than that of promptitude. He operates in appendicitis in the first twentyfour hours, or in extra-uterine fetation within an hour after initial rupture. He locates and removes tumors of the brain, drains abscesses in its substance, or lifts a plate of bone and removes the Gasserian ganglion, relieving trifacial neuralgia. He recognizes disease of the middle. ear and cures it instead of calmly waiting to see the patient die. He locates foreign bodies in trachea, esophagus, or intestines, with the fluorscope and removes them. He is a creature of life, of action, of decision and firmness. While a radical, he conserves every tissue nature can keep in order, and yet does not hesitate to remove or relieve any perceptible cause of disease.

Let us be conservative in its broadest sense; frank with ourselves and honest with our patients. Let us avail ourselves of the best scientific means to relieve, of the most accurate knowledge, of the most

experienced skill. Let us explain dangers and chances to patient and family, let us "be sure we're right and go ahead!" And especially in our profession let us be conservatives. Let us cling to its established order. Let us know its history, honor its heroes, glory in its traditions, observe its code of ethics. Let us as fellow laborers work together, aiding one another, for the common good of all humanity.

BOWLING Green, Ky.

AN UNUSUAL ESOPHAGEAL ANOMALY.

BY EDWARD L. DAVID, A. B., M. D.

Prosector of Anatomy and Assistant Demonstrator of Anatomy in the University of Louisville, Medical Department.

In December, 1897, as prosector to the Chair of Anatomy at the Medical Department of the University of Louisville, I came across the following unique anomaly. The subject was a well-developed male, thirty-five years of age, and had been a lunatic for years:

There were only two large openings in the diaphragm, the vena cava and the aortic; these occupied their normal positions, but nowhere was there an esophageal opening.

The esophagus passed through the aortic opening, between the crura in front of the body of the twelfth dorsal vertebra, then forward and to the left and entered the stomach opposite the first lumbar vertebra; the stomach was lower and more to the right than common, extending markedly into the right hypochondrium.

In passing through the opening the esophagus was in front of the aorta and had the right and left pneumogastric nerves on either side. They were not separated by the crura of the diaphragm, nor in any manner was there a semblance of a partition.

Besides above there existed quite a number of more common anomalies, as superior thyroid artery arising from the common carotid; the axillary artery dividing into two branches, the deep one taking the place of the brachial artery and becoming the radial; the superficial branch becoming the ulnar; the obturator artery arising from the deep epigastric.

After searching Gray, Morris, Quain, Treves, Gould, and Pyle's Anomalies and Curiosities of Medicine, and finding no mention of such a phenomenon, I report it, believing that it is the first reported case of such an occurrence.

LOUISVILLE.