Good spirits; voice natural; appetite restored. The position on the back is carefully maintained. The urine is normal, and has been drawn at intervals of three hours, except while a catheter remained in the bladder. The cold coil was maintained only a short time. There was never a temperature above 99.5°.

27th. The wound was dressed at the end of a week.

29th. Bowels moved with the aid of a cathartic.

July 4th. The patient weni home.

There was at no time any evidence of suppuration in the suture line. The external portion of the larger sutures became detached in from fourteen to twenty-one days. From other experience it is known that the whale tendon disappears in from five to seven days.

This case shows that if a patient suffers from extreme shock, and recovers from it, the further progress may be as favorable as though there had been no shock at all. The recovery of health became ultimately complete.

EXTIRPATION OF THE UTERUS AFTER THE METHOD OF FREUND.

IV. Mrs. J., aged thirty-nine, having had an epithelial degeneration of the os uteri two years, and having had removal of the morbid growth in August, 1884, and again a thorough removal in April, 1885, and having a return of the growth with repeated hemorrhages, yet having a fair degree of vitality, submitted to the operation July 13, 1885.

The cavity of the uterus was three inches, and the whole organ movable.

The examination of the uterus post-mortem, however, showed that the neck and the lower part of the body was enlarged, and that the disease extended into the broad ligaments.

The patient died of shock twenty-eight hours from the close of the operation, without having had any reaction. There was not, however, an extreme fall of temperature, 96.5° being the

lowest, fifteen hours from the close of the operation.

The operation was done by an incision from the umbilicus to the pubes. The broad ligament was seized with forceps, and tied with ligatures of fiddle string, intended to remain permanently, and on the inside of the ligatures the broad ligament was cut. Then deeper ligatures were applied, and a cut made on the median side of them, pressure forceps being employed to arrest any bleeding until the vagina was reached. The uterus was carefully dissected from the base of the bladder, and the vagina itself was cut and partly torn, and the uterus was lifted out. There was found to be such a thickening of parts by morbid deposit, that the opening into the vagina could not be satisfactorily tied with sutures.

The following are the steps of the operation and the time:

9:15 A. M. Commenced anesthetization.
9:36 A. M. First incision.

9:40 A. M. Peritoneum opened.

9:50 A. M. First ligature on the broad liga

ment.

9:53 A. M. Second ligature on the broad ligament.

10:02 A. M. The first cut in the broad ligament.

10:15 A. M. Both broad ligaments cut. 10:27 A. M. Hypodermic injection of cocaine, .020; digitaline, .001; s. morph., .014. 11:30 A. M. Uterus removed. 11:06 A. M. Suturing begun. 11:18 A. M. Suturing completed. 11:24 A. M. Dressing completed.

The whole time, two hours and nine minutes. If the diagnosis of the extent of epitheliomatous infiltration had been made, the operation would not have been undertaken.

The proceeding in this case showed the practicability of making such an operation as might be safe to life, if the uterus were the only seat of disease.

The patient died of shock, and not from any impurity of the air to which the peritoneal cavity was exposed. The amount of blood lost was very small.

The experience of this operation showed that the change of air contemplated by means of its

rarefaction by heat, which is felt in the operating room, is impracticable with an outside temperature of 90°, as was the case on this day. To remedy this difficulty, an arrangement has been made to blow air into the basement by a Sturtevant fan, which is run by an engine. A room in a large establishment can have an exhaust connected with a smoke stack, which will secure a change of air and fulfill the indication of frequent change of purified air.

V. Mrs. S., aged thirty-one, confined with her third child three months ago, when it was discovered that she had an ovarian tumor.

Several attacks of severe pain led to the suspicion of the existence of adhesions. The violence of these attacks, some of which were of a colicky nature, led her to submit to an operation.

The night before the operation the pulse was 83 and the temperature 98.6°. A cathartic was given, and no breakfast allowed. The morning before the operation, ten grains (.65) of quinine were taken in place of the breakfast.

1. November 11, 1885. An incision was made in the median line, four inches in length, not reaching up to the umbilicus.

A considerable amount of ascitic fluid escaped as soon as the peritoneum was incised.

A Spencer Wells' trocar was then introduced, nearly evacuating the tumor.

The flaccid tumor was lifted out, carrying with it a portion of the omentum, and some loops of intestines, which were immediately covered with a towel wet with warm carbolized water.

2. The pedicle was next clamped by a cord, which was a piece of fishing line, attached in place of the chain, to a Chassaignac's ecrasseur. It is suggested that a strong silk braid makes a better cord than that here employed.

The pedicle was next cut off close upon the tumor, including the oviduct.

3. After pinching with pressure forceps what appeared to be the mouths of vessels, the raw surface was covered with peritoneum by sewing, with fine whale tendon, the opposite peritoneal edges, making a continuous suture. A ligature of aseptic fiddle string was then applied for additional safety, after which the pedicle was dropped into the pelvis.

4. The adhesions were cut off one after another, and treated the same way. One intestinal adhesion was so close that a portion of the tumor was left upon the intestine. The surface of this was scraped and sewed in, so that no part was left uncovered by peritoneum.

5. The wound was closed by four lines of suture: First, the peritoneal surfaces by a continuous whale-tendon suture; next, the muscular and connective tissue in the same way; then a continuous cutaneous suture, the needle being passed deep into the tissues, carrying a portion of aseptic fiddle string; and, lastly, a fine continuous suture of whale tendon, in order to secure an accurate closing of the cutaneous margins.

6. Iodoform was dusted upon the surface; then carbolized oil was applied; then sublimated cotton of considerable thickness; next a pasteboard, to afford a good surface for the bandage; and next, a roller bandage of adhesive plaster, covered by a muslin roller bandage; and over all this, finally, an elastic rubber bandage. This latter is generally applied for temporary pressure upon the abdominal contents, to be discontinued in a few hours.

At 10:45 A. M., after the dressing was completed, there was a hypodermic injection of s. morph. one half grain (.033), with digitaline. one fiftieth grain (.0013).

11:45 A. M. Pulse 80, temperature 98°. From this absence of depression of temperature, it appears that there was very little shock.

2:00 P. M. Pulse 110, temperature 100°. 6:00 P. M. Pulse 96, temperature 101°. The employment of the cold-water coil was commenced and continued all night.

12th. 12:30 A. M. Pulse 104, temperature 100.4°.

2:00 A. M. Pulse 108, temperature 101.5°. The temperature never rose above this. The convalescence was uninterrupted, and the patient went home in four weeks.

Sufficient morphia was given to counteract any sense of discomfort. Quinine was administered every day, and the bowels were kept open by the daily use of a pill containing aloes, nux vomica, and belladonna.

VI. Mrs. M., aged forty-three, mother of

several children, first became aware of a tumor eleven months ago. The tumor proved to be very multilocular, weighing ten pounds. There was a larger weight of ascitic fluid than of the tumor itself.

The incision extended from the pubes to a point two inches above the umbilicus, revealing a tumor of an elliptical shape.

After the escape of a large amount of ascitic fluid, the pedicle was clamped as in the preceding case, cut off next the tumor, after which the tumor was drawn out from the abdomen, presenting its shortest diameter transversely to the incision, after which a considerable omental adhesion was cut and sutured, so as not to present any surfaces uncovered by peritoneum.

The extremity of the pedicle was then treated as in the last case. A small artery was found spouting, having slipped out from the grasp of the clamp. This was tied without much delay, and concealed under the serous covering by sutures.

The ascitic fluid was not completely removed from among the intestinal folds, thinking that, under the antiseptic precautions, the presence of the fluid was a less evil than the contact of sponges. A careful "peritoneal toilet" was not attempted.

The wound was closed as in the last case, there being nothing but animal substances employed for ligatures and sutures. In two weeks the ends of the sutures outside of the skin came off, and on the twenty-eighth day, December 23d, the patient went home.

It will be interesting to follow the symptoms a few days.

November 24th. A cathartic. November 25th.- Quinine, twenty grains (1.29), in the morning.

10 A. M. Pulse 84, respiration 16, temperature 98.5°.

Two days before the operation the pulse had been 108, and the temperature 101°, after riding two hundred miles.

Previously to the operation, a hypodermic injection was given of s. morph. one fourth grain (.016) and digitaline, one fiftieth grain (.0013).

From the commencement of anesthetization

8 P. M. ture 102°. Morphia, one fourth grain (.016) by the mouth.

Pulse 130, respiration 22, tempera

9:20 P. M. Pulse 120, respiration 22, temperature 100.8°.

12:00 м. Morphia, one fourth grain (.016). No more hypodermic injections were given. 29th. 2:30 A. M. Pulse 138, respiration 22, temperature 100.8°.

8:45 A. M. Pulse 140, respiration 24, temperature 99.2°.

Tincture veratrum viride given in a dose of four minims (.26). She sleeps the larger part of the time, and is free from any expression of pain.

1:40 P. M. Pulse 132, respiration 24, temperature 98.8°.

The appetite for ice has diminished, and she has taken a little beef tea. Morphia, one fourth grain (.016). grain (.016). The coil is discontinued.

6:00 P. M. Takes a little milk with whisky. Pulse 144, respiration 26, temperature 99.2°. 8:00 P. M. Morphia, one half grain (.032).

9:40 P. M. Pulse 132, respiration 26, temperature 99°. 28th. 8:10 A. M. Pulse 144, respiration 26, temperature 99°. Sulph. quinia, five grains (.32). She takes some milk and whisky.

1:20 P. M. Pulse 148, respiration 26, temperature 99°. Takes a little coffee and toast. Fl. ext. digitalis, six minims (.39).

3:00 P. M. Pulse 124, respiration 26, temperature 99°.

It is interesting here to note the apparent effect of the digitalis, reducing the rate of the pulse twenty-four beats in one hour and forty minutes, or about one beat to four minutes, without changing the rate of the respiration or the grade of the temperature. The pulse remained permanently stronger and less frequent, and nothing more occurred to occasion any anxiety.

Morphia was exchanged for codeia; one grain being given whenever there was any expression of pain, and fl. ext. digitalis in onedrop doses once every hour; afterward once in three hours, for a few days.

Quinine was given in doses of five grains (.36) three times a day, and three times a day a pill prepared by McKesson & Robbins, containing

manner as already described, employing only animal sutures and ligatures.

The tumor was multilocular, not admitting of much diminution by trocar, and requiring an incision ten inches in length.

The lowest temperature of shock was 95.8°, fourteen hours after the operation.

The highest temperature reached was 102°; for a short time on the sixth day.

The cold coil was applied when the temperature approached 100°, and kept on until the reduction of the temperature and the comfort of the patient required its removal.

9th day. The patient has been thoroughly purged, to relieve a diarrhea believed to depend upon an imperfect evacuation of the colon.

Pulse 98, respiration 30, temperature 99.8°. 15th day. The abdominal tenderness has disappeared, but the patient is troubled with anorexia, nausea, and diarrhea.

The wound is dressed for the second time. On the first dressing the union seemed to be perfect, except a suppuration at the lower end. Now the parting of the cutaneous adhesions has extended and a similar opening appears at the top.

Pulse 104, respiration 24, temperature 98°. 16th day. Pulse 100, respiration 24, temperature 97.5° in vagina.

Smoked with relish for the first time since the operation.

A suppository of cocaine .13 arrested the diarrhea.

The anorexia continues.

A suppository containing morphia .016 and cocaine .13 was introduced twelve hours after the first one.

17th day. She took a teaspoonful of eggnog every hour during the night. A change of the dressing reveals two points of suppuration, one at either extremity of the suture line.

Pulse 120, respiration 28, temperature 98° in mouth.

Some hypodermic injections of whisky, 20 minims (1.30 cc.) each, were given, reducing the pulse from 130 to 120 beats in a minute.

18th day. Pulse 140, respiration 28, temperature 98° in vagina, falling in the course of the day to 97.6°.