history: About 2 o'clock on the morning of admission she was seized with a violent pain in the lower abdomen. For this she took some whiskey, and was somewhat relieved. At 9 o'clock

the same morning she started for market and was suddenly taken sick, becoming very weak and suffering from a violent pain in her abdomen. She returned home with difficulty and called in Dr. Hand, who advised her immediate removal to the hospital. At the time of admission she was very weak, and there was distinct tenderness over the abdomen with slight dullness on the right side. Immediate operation was advised and consented to.

When the peritoneal cavity was opened it was found to contain fluid blood and clots. The right tube was the site of a small rupture, and was tied off and removed. The abdominal cavity was washed out with hot saline solution, glass drainage introduced and the wound closed. The patient was very much shocked by the operation and reacted slowly. During the operation hypodermatoclysis was practised. The drainage-tube was removed on the fourth day, the wound healed by first intention, and the patient was discharged, well, on the twenty-third day,

The following case of hemorrhage from ruptured extra-uterine pregnancy illustrates the danger of delay as strongly as did the two previous cases the efficacy of prompt interference:

Mrs. P., aged thirty years, was a patient of Dr. S. Cooke Ingraham, of Wissahickon, this city, who furnishes the following history:

I first saw the patient on January 29, 1892. She complained of severe abdominal pains, of a bearing-down

character, and of a sense of fullness in the epigastric region. She had been married seven years, but had never been pregnant, and laughed at the possibility. For the past three years. the menstrual flow had been decreasing in amount, and for several months past had been very scant. The breasts were slightly enlarged, but the areola were not darkened. The glands of Montgomery were a little more prominent than normal. She had suffered from morning vomiting for the past month.

I was hastily summoned to see the patient on the morning of February 2d, and found her in a state of collapse, pulseless and with a temperature of 96.5°. She reacted to active stimulation and was sent to the German Hospital for immediate operation, a diagnosis of ruptured extra-uterine pregnancy of the tubal variety having been. made. Upon admission her pulse and temperature were normal. She did not complain of pain. Examination of the abdomen and per vaginam and rectum failed to reveal any mass, although a circumscribed area of flatness. could be demonstrated low down and to the right side. She continued in this condition until February 12th, when, at her own request, she was discharged. On February 23d she was readmitted at Dr. Ingraham's earnest request. At the time of the second admission the abdomen was markedly distended, being tympanitic above and flat below. Pulse 116, temperature 101.5°. She complained of considerable pain.

The following day she was operated on, and when the peritoneum was opened a fetus with clots and fresh blood gushed out. The ruptured sac

occupied the right iliac region, and was tightly adherent to the neighboring coils of small intestines, to the cæcum and to the vermiform appendix. After a prolonged and tedious dissection the sac was enucleated; this was accompanied by a very free bleeding, which necessitated packing of the cavity with gauze. The wound was closed with the gauze packing in situ. The patient died the following day of hemorrhage.

The immediate effects of an injury severe enough to cause a serious lesion of an abdominal viscus are sometimes so slight as to be misleading. Very often a patient with such a condition will walk to a conveyance or to the hospital, complaining only of a slight pain. In varying periods of time following the injury more decided symptoms will develop, viz: signs of hemorrhage, if the solid organs be involved, and early peritonitis if the hollow viscera be ruptured or torn sufficiently to allow their contents to escape. When this occurs operation is imperatively demanded without delay.

This is also true of hemorrhage consequent upon the rupture of an extra-uterine pregnancy, be it traumatic or spontaneous. In ectopic gestation operation will be necessary in every case at some period of its history; therefore, if a diagnosis can be made. or even a well-founded suspicion of the condition exists, rupture should not be allowed to occur. If rupture does occur, however, immediate interference is the only certain means of saving the patient's life. The longer the operation is deferred the greater the risk to life. Hasty operations, often necessitated by the patient's condition, are likewise less lia

ble to reach a favorable termination. Blood clots or intestinal or gastric contents cannot be washed out of the peritoneal cavity except by prolonged and repeated flushing.

The almost universal fatality of intraabdominal lesions of traumatic origin is so well recognized that it seems as if there could hardly be any question as to the wisdom of opening the abdominal cavity. I would not be understood as meaning that abdominal section should be used as a means of diagnosis, but on the contrary I believe that every known means, with attention to the most minute details, should be exhausted in establishing a diagnosis. When a diagnosis is impossible, abdominal section is justifiable only when it becomes the last and only chance for the patient.

I have refrained from using the terms exploratory and diagnostic incisions, believing that they not infrequently serve as a shield to cover a lack of diagnostic ability. It is a moral obligation resting upon every physician and surgeon to develop to the utmost of his ability the highest diagnostic attainments.

Aseptic surgery has undoubtedly been one of the greatest boons to humanity that this nineteenth century has brought forth. But to me it seems that it affords a great temptation to men who have not had experience and surgical training, and who have, therefore, not fully developed their diagnostic skill, to do operations which are not necessary for their patients' good or with a scientific precision.

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Dr. Richard Douglas, of Nashville, Tenn., followed with a paper entitled Acute Peritonitis.

Appreciating the condition under which the colon bacillus may escape from its natural habitat and become actively pathogenic, and knowing the supply is unlimited, the dose being governed alone by the integrity of the bowel, naturally we accord to this bacillus the first place in the causation of peritonitis.

In obedieuce to the teachings of experimental work, the surgeon must accept the classification of Pawlowski of two forms of peritonitis:

1. That produced by chemical agents with which we are not concerned.

2. That produced by infection. The latter is more tangible.

The latter is more tangible. It is

fully in accord with our idea of the genesis of the disease. It harmonizes with clinical work. With Mordecai Price, the author agrees that every case of general peritonitis has a demonstrable cause, and that cause is septic in character. Pathological manifestations of peritoneal infection are subject to many variations which, in a great measure, indicate the virulence of the poison and guide us in forming a prognosis, but to simplify matters, the author considered it under two heads, which indicated the microscopic. and macroscopic changes, the results of general peritonitis.

It is an indisputable fact that the type and, virulence of the inflammation is largely dependent upon the origin, hence in our bed-side work we may consider the subject under the following etiological classification:

This is direct infection of the peritoneal membrane through penetrating wounds of the abdomen, either accidental or surgical.

This form embraces all cases of contamination of the peritoneum occurring from extension of adjacent infected areas, as leakage from mural abscesses or puerperal infection.

Visceral perforation or rupture and direct inoculation of the peritoneal membrane with escaping contents, as in perforating typhoid or gastric ulcer, appendicitis or rupture of gut or bladder.

Infection by emigration of microorganisms through visceral wall of impaired resistance, as in incarcerated hernia, intestinal obstruction, ruptured ovarian cyst.

The author then reported a few illustrative cases. One case was reported of general purulent peritonitis. The patient recovered, and the author considers that it was due entirely to free incisions, thorough irrigation and ample drainage.

THIRD DAY-MORNING SESSION..

Dr. George J. Engelmann, of St. Louis, read a paper on History of Vaginal Extirpation of the Uterus, in which he stated that at the New Orleans meeting of the Association he was interested in vaginal hysterectomy, which he presumed was a comparatively new operation with very recent modifications; but Dr. Lewis, of that city, called his attention to an old French pamphlet showing that the operation had been done in the '20's. Since then he had found it was done still earlier precisely as it is done today, the operation having developed step by step.

Dr. Lewis, of New Orleans, in the discussion stated that the first vaginal hysterectomy was performed by Dr. Dabourg in the little town of Autell, France.

Dr. Edmond Souchon, of New Or leans, read a paper entitled Reminiscences of Dr. J. Marion Sims in Paris.

In 1860 Dr. Souchon had just entered into the study of medicine in Paris, and was attached to the service of Prof. Velpeau. In the spring of the following year he by accident met Dr. Sims, who had come to Paris with a letter to Velpeau from Valentine Mott, of New York. At this time Dr. Sims knew nobody in Paris and could

not speak a word of French, so that the meeting of young Souchon was a very great help to him in his intercourse with Velpeau and the other surgeons of the French capital. Sims' great object was to get a case on which to demonstrate the success of his operation for vesico-vaginal fistula. Velpeau procured a case upon which Sims operated successfully before a large audience of students, doctors and professors in the operating theatre of the old Charite.

The ovation Dr. Sims received was very great and gave him the start that made him the universal surgeon we all know him to have been. Wherever Dr. Sims traveled and located he had more calls than he could attend to. The Doctor's success, however, was not without hard moments, for twice he met cases that came very near terminating disastrously from the effects of chloroform. But their final recovery only increased the admiration of all for Sims' fine qualities as a

surgeon.

Dr. Soucher relates in his paper several instances of Dr. Sims' generosity and gives a graphic account of the generous and sublime manner in which Dr. Sims came to his rescue in a trying moment of great distress.

Dr. Souchon's paper ends in words of highest praise, enthusiasm and love for the great and good man that Dr. Sims was.

Dr. George H. Noble, of Atlanta, Ga., read a paper entitled A Case of Carcinoma of the Parturient Uterus; Removed Three Days After Confinement; Recovery.

The specimen he presented was one of carcinoma of the parturient uterus removed by vaginal hysterectomy three

days after labor. The woman had previously been confined, sustaining a laceration of the cervix uteri, which, perhaps, was a factor in the cause of the disease. In the first few months of the last pregnancy the patient was treated locally by her family physician; but there was nothing to cause a suspicion of malignancy. Almost the entire vaginal portion of the cervix was destroyed, less than one-fourth of its circumference remaining intact. The induration extended deep into the uterine tissue, but could not be felt beyond the limits of that organ. The roughened ulcerated surface was easily traced for a considerable distance within the cervix, the os being dilated to about five centimeters in diameter. Her condition was unpromising, and surgical interference was clearly interdicted, so the os and vagina were cleansed thoroughly and lightly dressed with gauze. She was then placed profoundly under the influence of morphia sulphate with a view of arresting labor, securing rest and recuperation sufficient to permit evacuation of the uterus, which occurred spontaneously twelve hours later. The child was poorly nourished and lived only a few weeks, finally dying of inanition.

What is the advantage of hysterectomy over Porro's operation, and if hysterectomy is preferable, should the vaginal or abdominal method be given precedence over the other? To the first question the author answered that hysterectomy undoubtedly promises. more to the mother than a Porro operation in cases where the disease is confined to the uterus, and he says that when the cancerous mass can be successfully

to do it, as Porro's method merely bridges the woman over the puerperal state and leaves her to her fate. In radical removal there is a promise of

cure.

In answer to the second question, the author said it is evident that the method of operating must depend largely upon the character of each individual case. Thus the vaginal operation may be done when it is desirable to take advantage of the diminished. liability to shock, even though the large size of the uterus may render the operation more tedious.

The main point in the paper was to show the feasibility of hysterectomy in the puerperal state for cancer of the uterus, as the case reported clearly demonstrated, even though it is too early to claim immunity from the return of the disease.

Dr. John A. Wyeth, of New York. City, contributed a paper entitled Ligation of Arteries.

The author said that in August, 1894, in an operation for the removal of a malignant neoplasm of the upper left jaw, which involved sphenomaxillary fissure and part of the orbital cavity, it became necessary, as a preliminary operation, to ligate the external artery. In cutting down upon this vessel by the usual incision-the point of bifurcation of the common carotid artery being, as demonstrated by him in a study of 121 subjects, opposite the upper border of the thyroid cartilage-he found quite a network of veins crossing from the median line of the neck to the internal jugular immediately over the point of ligation, and spreading from one-half an inch above down to the bifurcation