nation if not defective is at least not active, that the patient when ill is handicapped by virtue of that fact. I have also been impressed that, in addition to this, defective elimination was a very important factor both in medicine and in surgery.

I simply want to bring out the points sufficiently to suggest a free discussion so that many of the points may be emphasized and other important ones brought out.

I believe it is on this account, with elimination already defective, that we get conditions that were discussed at the last meeting of this society, that condition which occurs during gestation, when by pressure or other influences this function is interfered with, and at the climax at its completion, or even before the accumulation of effete material in the blood, is so great as to bring about the conditions we discussed at that meeting, viz., puerperal eclampsia.

I think oftentimes in very many diseases characterized by excessive waste that this defective elimination is an important factor—in all of those where disintegration of material has been so great that elimination has not kept pace with the amount of products of disintegration that are thrown into the circulation-thus affecting the centers unfavorably. So it is in our work oftentimes, in the treatment of many diseases medically, that we have to use measures to increase this elimination, if possible, to make it keep pace with the additional waste that is going on, so that these products may not be accumulated in the blood. Then I am sure that when we come to the field of surgery that oftentimes an operation, capital it may be, that would otherwise be successful is handicapped by this very feature; that possibly the shock of the operation of itself will serve for the time being to lessen the integrity of this function on the part of the kidney. It is in this way too, no doubt, the kidney, perhaps being already disabled and with increased work required of it, that we get suppression of the urine and conditions like this that come up after severe surgical shock.

It is true that the kidney is responsible for normal elimination, and we know likewise that most of the remedies used are largely eliminated from the system by means of the kidney, and I believe that oftentimes we get a surcharge of the medication, we get a superabundance of the remedy in the system, because the kidney has not done its work as usual in eliminating the drug. With a kidney that is not operating, many of the drugs that ordinarily are rapidly eliminated by the kidney will not be so eliminated and we will get an accumula

tion of the drug in the system, and perhaps do harm rather than good. And it is true that the function is often materially interfered with because the kidney is required to eliminate the drug.

I think the kidney is responsible for elimination of many of the drugs that we give, and I would mention particularly the use of ether as an anesthetic. Under these conditions, unfavorable for elimination, the kidney is overstimulated it may be, or at least its function is materially lowered by the agent going to the kidney in such large quantities through the circulation, the kidney undertakes unusually rapid elimination of it, resulting in impairment of its function-the kidney is disabled by the action of the drug.

There are many questions along this line that have had my attention for a long time, and without additional argument I simply want. to bring the question properly before the society and ask for its discussion so as to emphasize in the lines of work that the various members are doing their estimate of the importance of the functions of the kidney and how the difficulties may be overcome.

I simply submit these remarks for your discussion.

LOUISVILLE.

Reports of Societies.

LOUISVILLE medico-chiRURGICAL SOCIETY.*

Stated Meeting, April 8, 1898, the President, Frank C. Wilson, M. D., in the chair.

Operation for Femoral Hernia. Dr. Ap Morgan Vance showed a hernial sac with some omental contents, removed from a lady forty years of age who had had hernia for twelve years. It has been irreducible and occupied the right groin. The variety of hernia could not be made out at first, but at the operation it proved to be femoral. After opening the skin, which was very thin, the sac was separated and was found translucent; floating in it were a number of little yellow bodies. I opened the sac and many of these little bodies came out; they look something like hydatids, but are probably composed of fat. I have never before encountered any thing like these in a hernial sac. major portion of the contents of the sac was water.

*Stenographically reported for this journal by C. C. Mapes, Louisville, Kentucky.

The

Discussion. Dr. Louis Frank: I saw Dr. Vance perform this operation. The little floating bodies I believe to be particles of fat which have been detached from the omentum. There were a great many adhesions about the neck of the sac to the omentum, and probably these particles became slightly adherent, in that way becoming separated from the omentum, afterward being rubbed off by the motion of the omentum in the sac.

Myo-Fibroma of the Uterus. Dr. L. S. McMurtry showed a specimen of myo-fibroma of the uterus. This is a combination, the top being a soft or edematous fibroid, the lower portion being nodular and fibrous. These nodules were distinctly made out in an examination through the vagina by touch, and one of them rested down upon the bladder.

In 1894 the patient, who was unmarried and aged twenty-nine years, was operated upon for this tumor by a distinguished surgeon in another State, but he considered it unwise to remove the growth. At this point you will observe the site of his incision, which evidently suppurated, and there was a line of adhesions down as far as his incision extended. I took out an elliptical piece of skin embracing the old cicatrix, and here you will see the lower layers of the abdominal wall which, being adherent to the tumor, made it difficult to get into the abdomen.

I found this a suitable case for doing a pan-hysterectomy-a total extirpation. After tying off the broad ligaments-and there was a cyst in one of the broad ligaments-I threw a clamp around, including the ovarian arteries, making a pedicle, which you will observe is the conical cervix uteri, then severed the tumor. The uterine arteries were tied and I removed the entire cervix down to the vagina. In closing the floor of the pelvis I closed the peritoneum over the vagina so as to convert the female into a male pelvis; that is, closed the peritoneum entire across the pelvic floor, without drainage, so that the rectum and bladder sustained the relations that would obtain in a male pelvis. The operation was done four days ago, and the patient has made a smooth convalescence; the bowels have moved; she is bright and cheerful; there has been no fever, and her pulse this evening is 92.

The operative treatment of uterine fibromata is of recent evolution and constitutes one of the most brilliant triumphs of modern

surgery. It has only been a few years since the mortality after operations of this kind was very severe; now it has been reduced until it is almost if not quite equal to the mortality following operations for ovarian tumors. Success depends upon the treatment of the pedicle. I have never seen such results occur with such uniform and easy convalescence after any method as by the Keberly treatment of the pedicle. That was the first method adopted for extraperitoneal treatment of the pedicle with the noeud of Keberly; it simplifies the operation, makes it very short, and convalescence is beautiful. The pedicle being made is reduced as small as possible, the peritoneum slipped down on the tumor fore end aft so as to let down the rectum and let down the broad ligaments, we then make the pedicle extraperitoneal and secure it at the lower angle of the wound, which gives us the best results. If the patient is reduced, feeble, and will not bear a prolonged operation, I think it is our duty to treat the pedicle in this way. If one is beginning an operative record in this class of tumors, I would urge upon him to begin in this way, with the extraperitoneal treatment of the pedicle with the noeud. If the patient will not stand an operation of an hour or an hour and twenty minutes, the noeud ought always to be used. The other method of treating the pedicle by supravaginal amputation, having an intrapelvic but extraperitoneal stump, a method which has now gained some popularity and known as the Baer method, is very satisfactory, but there are a large number of cases where the method is followed by unfavorable results. In eight operations which I have done in this way, three of them had very protracted convalescence on account of trouble with the ligature left buried underneath the peritoneum. If one has a suitabie case the method is a very good one. In the case I have reported the cervix was virginal, you will observe that it is conical, the vagina was small, and the amount of dissection to be done was comparatively slight.

I never decide what operation I am going to do until I get to the pedicle. In this case I did not know what procedure I was going to terminate with, and decided, after making the pedicle upon the plan that was pursued, that is complete hysterectomy, removing the entire tumor, uterus, cervix, etc., closing the floor of the pelvis without drainage, which is an ideal method, and I only determined to do that after seeing how easy it would be in this case. But even then, after you have secured the uterine arteries you will always find the recurrent vaginal branches will bleed, requiring tedious work in closing up the floor of the

pelvis, which will almost invariably extend the operation beyond an hour, and in an operation of this magnitude, which requires an incision. almost from the ensiform cartilage down to the pubes, the exposure and manipulation of the intra-abdominal viscera, however well protected they may be by sponges and gauze, is always attended with considerable danger. If the patient will not stand that much shock, if she is not young and vigorous, it is always better to do a supravaginal amputation, extraperitoneal preferably, or intraperitoneal even, rather than do this operation. I know the common objection to the Keberly operation is that it leaves a stump that has to come away which may protract convalescence.

Dr. A. M. Vance: Will Dr. McMurtry tell us the present status of removal of the ovaries for the cure of small uterine fibromata?

Dr. L. S. McMurtry: In certain cases it is still very firmly fixed in professional favor. Tait has been a great advocate of this operation, and he still practices it. Dr. Ross, on my recent visit to Canada, told me that in Ontario, where he has practiced this line of surgery for ten years, it was in good favor. He thought this was one of the most successful operations he had ever done in properly selected cases, especially those cases with menorrhagia in young women having for instance three weeks menstruation out of four, and where the tumor has not reached large dimensions, where it has not reached up to the umbilicus. The mortality of the operation is about 11⁄2 per cent. It is a quick operation, it arrests the hemorrhage, and in properly selected cases still has a firm place in surgery; but there is a tendency in surgery all the time as operations are increased in their technique to the very radical, and a great many men now animadvert against the operation, desiring to do an ideal operation to remove the tumor at once; but it is still an operation which is entitled to confidence.

The essay was read by Dr. William Bailey; subject, "The Inadequacy of the Kidney, etc." [See page 439.]

Dr. L. S. McMurtry: In line with the points made by the speaker the mineral waters have attained in the last five or six years an importance in therapeutics that was practically never known before. Perhaps the improved methods of sterilizing water and bottling it have had much to do with the matter, but there seems to be on the part of the medical profession an appreciation of the eliminative function of