and there are two reasons why these cases should be drained for the first twenty-four hours. That is, where adhesions are stripped loose, admitting that your cleansing is perfect and complete, there will be a weeping surface which will continue to weep for hours, and it is advisable to rid the peritoneum of such a culture bed as is necessarily left by drainage and aspiration every fifteen minutes to half an hour or hour, and later every two hours, as the discharge subsides. Second, there is another use of the drainage-tube, and that is an indication of hemorrhage. One of the most difficult things to distinguish in intra-peritoneal surgery and one of the most difficult things to diagnosticate is hemorrhage. In neurotic women who have a flighty pulse, rapid respiration, etc., you will be at a loss oftentimes to determine whether or not hemorrhage is going on unless a drainage-tube is used, and if hemorrhage occurs without the drainage-tube, its extent can not be determined. I take it these are of themselves sufficient reasons for drainage, and as the doctor has said, the glass tube with suction is the method of drainage par excellence in these cases. I have almost discontinued the use of gauze except when there is some positive indication for it, and believe that better drainage is secured by a tube properly placed.

One other point: I am sure great harm is done by failing to complete the toilet with great deliberation and care, by hurrying through the operation and failing to take care of the patient as she leaves the table, and as she is placed in bed, and as she is kept in bed for some time. She ought to be kept absolutely quiet; the intestines, omentum, and all replaced organs ought to be kept still, so as to avoid the dangers which will come from disturbing the relations, and secondary complications during convalescence.

Dr. A. M. Vance: One of the lessons to be drawn from the series of cases reported is, how absurd it would be for any one to attempt to take out such masses as we have seen by the vaginal route, even if the uterus was also removed. With eighteen or twenty inches of adhesions to the intestines, much damage might be done by attempting separation with the fingers through the vagina, and such damage might not be discovered until a post-mortem was performed. Vaginal operations for conditions of this kind are similar to subcutaneous ligation in conditions about the scrotum; they are necessarily operations done in the dark, and are fast becoming obsolete, as they should.

I am a firm believer in the use of the glass drainage-tube, the glass

well, as it is called, as it goes to the bottom of the pelvis, and that is where the fluid to be drained gravitates. I have been pleased, however, with the use of the gauze drain as advocated by Morris in appendicitis cases, that is, making a gauze well which acts as a capillary drain without introducing a mass of gauze into the tissues themselves. By wrapping this gauze in rubber tissue you really get a tube which can be removed as easily as a glass tube, and it acts with more integrity than does the ordinary gauze drain, and also avoids disturbing the tissues in its removal.

The technique as described by Dr. Cartledge is the very best, especial attention being directed to complete hemostasis. I know in olden times we used to think the peritoneum could take care of a great amount of fluid, blood, blood-clots, etc., but it was oftentimes at the loss of our patient.

The two lessons to be emphasized are: that it is impossible to operate upon such cases as Dr. Cartledge has reported by the vaginal method; second, that direct drainage by the glass tube or gauze well is absolutely necessary.

Dr. Louis Frank: I have been an earnest believer in the abdominal route ever since the discussion between the abdominal and vaginal methods has been brought prominently before the profession, and these cases confirm me more than ever in the position I have taken and frequently expressed. I have held that we do not know when we undertake an operation just what we will find; no one can tell previous to the operation just the condition which will be encountered, and in working through the vagina we are working in the dark. The cases reported illustrate the absolute futility of vaginal operations for the relief of such conditions. Like Dr. McMurtry, I am aware of cases which have been operated upon by the vaginal method and were not cured of the disease for which the operation was undertaken. I believe, however, that there are some cases that can be operated upon successfully by the vagina, but we are unable to tell previous to the operation which cases these are. Could we always make perfect diagnoses, we might then select the method best suited to the condition present. I take it that the majority of the work through the vagina should be merely preliminary to the work which is to be done from above.

Drs. Cartledge and McMurtry have expressed fully the latest points in the technique of operations in this class of cases. It has been my custom since I have been doing this class of work to always bring down

the omentum and pack it in between the inflammatory areas and the intestines. This is a feature which contributes largely to the success of the operation and final recovery of the patient. The omentum will soon shut off the inflammatory areas, and if septic processes supervene in these areas of previous infection, they will be entirely local; we will have an abscess or the formation of exudative material which can be detected and treated without infecting the general cavity.

As to the subject of drainage, I do not believe that gauze ever drains. There are some cases in which gauze may be used, cases in which perhaps it should be used, but in my opinion it should not be used with the expectation that it is going to drain, but rather as an hemostatic measure. We can pack gauze into the cavity and prevent hemorrhage, thus doing away with the nidus upon which bacteria feed, and in this way prevent septic troubles; but I do not believe it is through the drainage qualities of the gauze itself. By gauze packing we control the weeping; it will take up the serum which is exuded, and we do away with the pabulum for the bacteria. Therefore one of the most important points, and one which can not be dwelt upon with too much emphasis, is the matter of perfect hemostasis before closing the abdomen. Many of the bad results in these cases may be traced to bleeding; not only this, but the result of hemorrhage, leaving clots upon which the bacteria implant themselves, multiply, and grow.

I was much pleased to hear Dr. Cartledge speak of conservatism in these cases. I reported to one of the local medical societies a year or two ago several cases upon which I had operated, removing tubes and ovaries which were diseased, and leaving the opposite appendages, which were only slightly affected. I have lately operated upon another such a case, and so far have had no occasion to regret the conservatism practiced. In one of the cases the prognosis as to future usefulness of the tubes seemed extremely grave; each contained considerable secretion; there were a great many adhesions, which were separated and the fimbriated ends of the tubes opened and milked of their contents and replaced. So far there have been no bad results.

Referring to the point brought out by Dr. Skinner in regard to tuberculosis, I will not attempt to answer his question, leaving that for Dr. Cartledge in closing; but I have seen, as have also the other gentlemen present I am sure who do work in this line, extensive emaciation in cases of the kind under discussion without there being a tuberculous element, and I take it this will often occur in acute infec

tions. I remember one case of gonorrheal pyosalpinx who emaciated from one hundred and forty to less than ninety pounds, and since being operated upon four years ago has not only regained her former weight, but weighs at present one hundred and sixty pounds. In this case there was no evidence of tuberculous trouble, but emaciation was pronounced. I have another patient now under observation upon whom I recently operated, and who is in a similar condition. These cases were gonorrheal in origin, and could be definitely traced. One of the women was childbearing, the other was not. Shortly after marriage they began to have symptoms characteristic of gonorrheal infection, and this was also proven by microscopical and bacteriological examination. Since the operation these women would not be recognized by any one who had seen them previously; they have gained in flesh and their general health is perfect. I would not be inclined to regard emaciation alone as an indication that the pelvic trouble was tuberculous in character.

Dr. A. M. Cartledge: In answer to Dr. Skinner's question, I do not know, unfortunately, what per cent of cases of pyosalpinx in my practice have been tuberculous in character, owing to defective examinations afterward. I have only surmised as to the number, and of course that is worth nothing. I take it, however, that more of these cases are tuberculous than we have thought in the past. I make this statement because of the cases that have failed to get well, where there has developed an incurable endometritis. I believe that most of the incurable cases of endometritis are tuberculous in character, the result of an old tubercular salpingitis. I have two cases on hand now where hard cheesy tubes were enucleated, the operation being simple and easy, and in both cases there has resulted a persistent leucorrhea. I have curetted the uterus, and can not cure them. In one I have advised that the uterus be removed. I am satisfied that the condition is tuberculous. A recent report of Russell states that eight per cent of cases of pyosalpinx are tuberculous; some authors claim as high as twelve per cent are tuberculous. In regard to the question of emaciation and fever, that depends entirely upon secondary infection. So long as the disease remains confined to the tube, even if the contents of the tube have undergone caseation, there is no reason why the patient should go down hill faster than in septic cases; but once they become secondarily infected, then we will have the usual result of fever, chills, I think as a rule tubercular salpingitis runs a slower course than

etc.

that due to gonorrhea or sepsis; unless there is tuberculosis elsewhere, they do not display as much constitutional disturbance as some of the gonorrheal cases in the acute stage, and not as much as septic cases. following abortion. In the gonorrheal cases that have become chronic in character, the pus becomes walled off and sterile, and the patient may go about in comparative health for a long period. I have removed some pus tubes which had existed four or five years, the women going about and looking fairly well. The pus becomes encapsulated, so to speak, and the organisms die from lack of nourishment. I agree with what Dr. Vance has said about the wick packing. I am becoming more and more convinced that we should not pack gauze down into the cavity and let it remain there for any length of time, as some injury is done the structures when it is removed. If we will be more careful about this we will have fewer cases of fecal fistula. Whereas I used to pack an abundance of gauze down to the stump of the appendix in operating upon such cases, I now try to keep it away from the bowel, because its removal causes denudation of the peritoneum and invites the colon bacillus to traverse through, and as a result you may have infection and a fecal fistula. These cases would probably do better with no drainage.

Further Exhibition of Pathological Specimens. Dr. L. S. McMurtry: Lipoma of the left labia majora. This specimen is of interest only because of its unusual location. It is a lipoma of the left labia majora, which was removed September 29, 1898, from a girl nineteen years of age. The tumor is of interest especially because Kelly in his work says that such growths are extremely rare, and that no man has ever reported more than one case. There are very few such cases on record in surgical literature.

Case 2. Uterine cystoma. Here is a tumor that I removed September 20, 1898. The patient had been seen by four different surgeons before she came to me, and there was a unanimous diagnosis of ovarian cyst. It is difficult to realize, after the tumor has been in formaline solution for several weeks and has become very much shrunken, the magnitude of this tumor before the operation. It filled the entire abdomen, and had all the physical appearances of an ovarian cyst. You will observe here both the ovaries, the cervix, and here is a fibroid tumor starting from the fundus of the uterus which had undergone cystic degeneration. It is a typical fibro-cystoma of the uterus.

It