distribution causes symptoms of disease of the bladder or uterus. At other times the rectum may be the organ which complains, and is found to be suffering from pressure from a large and long uterns in retroversion or retroflection. Numerous cases of these varieties are met with. as in which if fibroid has existed, reasonablé hope may be indulged that atrophy of the tumor will take place, presented herself with a tumor so large that she could scarcely walk by throwing her arms behind her to balance the weight of the tumor. The tumor had been growing but one year, and fluctuated. One which will present to our minds No fluid could be obtained for examithe latter variety was in the hands of nation. Now ovarian tumors are Dr. G. J. Cook, and had been referred liable to begin after the menapause as to him by an excellent physician, who before, and may grow rapidly. Then had in vain treated the case for months according to all rules no certain as one of rectal disease. Upon exami- diagnosis can be made, and exploratory nation the doctor found only slight incision was determined on. This is an evidence of rectal disease produced by operation which has to be made in many pressure of a retroflected uterus, which cases by the best and most experienced was three and one-half inches in length, | men. In this case was found a fibrowith bilateral laceration and endocer- cystic tumor estimated to be of eighty vicitis. No further treatment of the pounds weight, with a base as wide as rectum was required. After appropriate the pelvis, and a prolongation of the treatment of the uterus, including re- tumor extending behind the uterus ten placing and retaining the organ for inches in length and three inches in months, trachelorraphy was essayed diameter, with the bladder attached to and continued improvemeut has rethe anterior surface. The entire strucsulted. ture was removed, and the patient survived twenty days. The only conclusion here is, that it was originally fibroid, as a small tumor had been noticed for more than ten years, and that when cystic degeneration took place it developed as rapidly as an ovarian tumor. When tumors are found in the pelvic or abdominal region, often no little difficulty is experienced in making a proper diagnosis. To make this more clear, a few of the well recognized rules may be mentioned. It is conceded that generally myomata and fibromata, or more correctly speaking, myo-fibromata, are of slow growth, requiring years to acquire a size for easy recognition. And on the other hand, an ovarian tumor may in a few months get so large as to make operative measures imperative. Cases are met with in which this rule becomes perplexing, and instead of rendering diagnosis easy, or at least aiding in it, only confusion results. A case in point: Mrs. O., æt. 52, an age On the other hand, if ascites exists, there will be resonance in front when the dorsal decubitus is observed, and dullness in the flanks, as water seeks its level, and the intestines, which will contain a little gas, will float to the front. Then placing the patient in the semiprone position it will be found that the sounds have changed positions; the dullness from the water is found around the umbilicus, where the resonance was, and the resonance in the upper flank where before the dullness was. So much for the rule, and now for the exception, two cases of which I have met with. There may have been peritonitis of an adhesive character, which has caused the intestines to become matted together and bound to the posterior wall of the peritoneal cavity so that they can not float. The last case met with may be worth mentioning. Miss M., æt. 20. Healthy; was engaged with others, in the cold winter of 1885, in a church festival during her menstruation, which was checked as a result. Amenorrhea when I saw her had lasted one year and the patient had been treated for some stomach or liver trouble. She was anemic, abdomen swollen and tumor fluctuating, but no change was found on being placed in different positions. Vaginal examination revealed nothing but the probable existence of previons pelvic peritonitis, as all the parts within were so bound together that complete immobility existed. Upon exploratory incision it was found that extensive papillary peritonitis existed, the bowels were bound backwards, the fallopian tubes were greatly enlarged and each contained at least three ounces of pus. They were both removed with the ovaries, except a very small piece of the left ovary, which was so involved in the exudated was and organized lymph, that it decided safer to leave it. Good recovery followed, with good menstruation, which still continues, now more than two years. One word as to the offensive discharges from the uterus and vagina. Discharges of disagreeable odor are almost constantly present in malignant diseases of the uterus, and when taken in connection with other spmptoms are generally reliable for diagnostic value, and yet are sometimes met with in benign diseases. Four cases of sloughing fibroids, in which an unfavorable diagnosis was made, were cured by removal of tumors. Two cases of obstruction of the cervical canal, with retention of secretions and excretions, which gave case rather than to the medical pro rise to very offensive odors, simulating malignant diseases, were immediately relieved by dilatation and other proper treatment. If the statements in this essay are true, what is the lesson? 1. That an assumption of knowledge as to etiology and pathology on the part of physicians, whether general practitioners, surgeons or specialists, without thorough, careful and thoughtful exploration in every available manner, is disgraceful to our science, ruinous to those who adopt it and disheartening to those whose afflictions force them to consult us. It is true that the so-called specialist often sees nothing but some departure from health in his own department? It is lamentable; but may he not as often shield himself with the statement that the practitioner of general medicine as often fails to see anything in the case but some general condition, as dyspepsia, liver complaint, scrofula, rheumatism. or other conditions? The time has passed when the opinions of any one man are taken for granted as true, without proof and the analysis of numerous cases to confirm them. There exist to-day such advantages in the division of labor and the construction of instruments of means of diagnosis, that when a failure to accomplish diagnosis is clearly demonstrated, censure should lie not against the profession, but should be properly attributed to the complications of the case. In other words, if a diagnosis can not be made, with all the available means at our command, the blame should attach to the difficulties of the fession. (The following specimen, described in the Proceedings in its proper place, the writer was led to present, at the request of Drs. Owens, Chambers, Wathen, Love and others, and as it bears directly upon the subject of this paper it is included here:) This is an ovarian tumor of three or four years's growth. The patient has been seen by several gynecologists of the country, and urged by some to have it taken out, and by others advised not to, as they regarded it a fibro-cystic tumor. She consulted me about a month ago, and I made an effort to obtain some fluid with a hypodermic needle. I introduced the needle above the umbilicus, as that was the point of fluctuation, but the needle was arrested after having easily passed through the abdominal parietes, by something that seemed tough as leather, and after fail ing in the examination I informed her that I would make an exploratory incision and be prepared to remove the tumor, if it was compatible with safety. After a month's preparatory treatment with tinct. ferri chlor., by which she improved in general health and strength, I made, with the assistance of Drs. John Chambers, F. Ferguson, O. Pfaff and L. M. Rowe, of Indianapolis, an incision of two inches, and found the tumor covered with a broad band, attached to something between the tumor and symphisis, and by omentum, but could not reach the lower part of the tumor. I then enlarged the opening to four inches, when I could see through the thinner part of the omentum a glistening tumor, although it was of darker color than natural. I ligated and separated the omental adhesions, tapped the tumor and found that the contents would not pass without difficulty through a canula. I then made an incision large enough to admit my hand, and removed the contents, which proved to be disorganized blood. The sac was then easily withdrawn, when it was discovered that the broad band spoken of was made by two pedicles, one from each side, and that they were twisted together and looked like two fingers, one lapped around the other. About two-thirds of the tumor was dead and dark-colored as you see, while the part below the omental adhesion was of the ordinary color. The line of demarkation is clearly seen, marking the gangrenous edge. You can see the line of demarkation, and that part of the tumor is dead. Here is where the omentum was attached, and I have no question in my mind but that this tumor's life has been partially saved by the adhesion of the omentum-a conservative act of nature to save the woman's life by preventing the complete death of the tumor. Another interesting feature is that it has two pedicles. When I cut it I found it was twisted together like a couple of fingers that way, (illustrating), and when I untwisted it, it showed the pedicles coming one from each side. Here is where I took off one. I have not examined it enough to say certainly, but I think here is the extremity of the fallopian tube on one side. Here (indicating) is unquestionably the extremity of the other tube, on the other side. I put a probe in there and followed it up, so I am certain of the presence of one ovary, and tolerably certain of the other a thing I have never seen before. The only way to explain it is that a diseased condition of each ovary occurred and grew, until finally adhesion took place between the two to make one tumor and two pedicles. I searched thoroughly, after removing the tumor, for the other ovary-that is, as much as I thought prudent. After you get a tumor out, and you see you can save your patient by not being two persistent, you feel very much like letting the scientific questions go, and saving the life of the patient. I felt around as much as was prudent for the other ovary, but failed to find it. had Here now is the evidence of the death of the tumor on that part extending clear through, and there was a large cyst within the dead partition wall, which is ruptured as you see. The woman fell down a year ago last winter, her feet slipping from under her on the ice, and she had a fall which she said "made her feel that something turned over in her," and then she had peritonitis. You can see very plainly we have gangrene of that portion of the tumor. The other part has been saved by inflammation and a new circulation. It was sustained mainly by the circulation of the omentum. The pedicles were bloodless. When the tumor was taken from the attachment the omentum bled so that it was necessary to ligate an artery separately after tying the omentum. Now here [indicating] is the kind of material that I got out of it, dark and dirty looking. Here is simply the remains of the sac between the two cysts, that was ruptured when she fell down. I want to show you the kind of material that was in the sac. This is a specimen of it; the fluid portion of it was about four gallons in quantity. The interesting point to the profession in this case is the fact that some of our patients are nearly dead when they call upon us, from neglecting the operation so long. This lady was fortyeight years of age. The operation was performed June 4th, day before yesterday. She has a temperature to-day of 99°, and she has not had a temperature of over 1003, and is as well to-day and in apparently much better health than before the operation, with the exception that she has colic. The point I make here is early operation upon ovarian tumors. The tumor stopped growing when it became gangrenous, and this fact, taken with the age of the patient, caused a very eminent gynecologist who saw her think it a fibroid undergoing atrophy on account of her age, but two months before I saw her it had begun growing again by means of the supply of blood from the omentum. Here then is a unique tumor, showing that apoplexy and gangrene occurred from the twisted pedicles, its life being preserved eighteen months from a new source of blood. But I call your attention to this line between the dead and living tissues, different in color from either, which in my judgment indicates that in the near future the dead part would have sloughed, and fatal peritonitis resulted. (She is now, August 15th, entirely well and about her business-a public lecturer). fortentous combination of their art, they met with useful substances which have since been employed in commerce, and have rendered useful service to Society. The discovery of the ultimate cause of life, and the origin of species, have now taken the place of the chimera of the Alchemists, aud I may say that the results are somewhat similar. Eluding the grasp of the investigator, life has not yet been caught, confined or bottled, so that a supply can be turned on at will, a true Elixer Vitat advertised and made an article of commercial advantage, but the phenomena connected with it have been rendered clearer to human intelligence, and we understand, as a result of the spirit of scientific inquiry of the nineteenth century, the majority of the laws by which nature works. We need not wonder then that one of the most striking peculiarities of nature, viz. Heredity, should have atthe attention of modern tracted inquirers. A first sight Heredity seems a simple problem, but this superficial impression will be speedily removed if we consider the important bearings it has upon the individual and upon society, or the numerous subsidiary questions which spring from it. A brief explanation of the word is necessary. In its broadest sense by Heredity is understood that power of generation by which parents transmit their moral and physical qualities to their offspring, or as Ribot[1] defines it "that biological law by which all being endowed with life tend to repeat themselves in their descendants." Serious issues arise from either of these definitions. |