cine a hundred years ago. The practical use of this discovery has saved millions of lives. Since then the various means employed to prevent disease and proleng life have resulted in increasing the longevity of man from twentyeight to over thirty-five years. And it might be said, if the profession had the power granted them to institute measures and have them legally enforced to suppress all avoidable causes of disease, perhaps the average life of man would be double what it is now, and the time allotted to man would be verified. A great many things might be named as avoidable causes of disease, but the two principal causes that result so disastrously to life, and which might be avoided, are alcoholism and syphilis. But as long as politicians rule the country we can have but little hope of curtailing, to any great extent, the baleful influence of the use of spirituous liquors as a beverage, either in a moral or sanitary sense. As it regards syphilis, by the united action of the profession, I think some legal regulations might be effected to measurably suppress the disease.

The number of deaths resulting from these causes (alcoholism and syphilis), no doubt, will overreach 100,000 annually in this country alone. We can learn but little from census reports in this particular, as but few cases, comparatively are returned in accor lance with the cause of death. This is mainly due to deference for the feelings of family or friends. Then again, comparatively speaking, but few die directly from the effects of ardent spirits, but mostly indirectly; and whatever disease may directly produce death is the one reported, although alcoholism was the primary cause. It is estimated that over 65,000 die annually, directly or indirectly, from its use. Probably nine out of ten of the murders and homicides committed in the United States are done under the influence of alcohol. Then, in order to prevent this terrible human slaughter, entire suppression of its use as a beverage would have to be effected.

As to syphilis we have to examine the records of children's hospitals where that disease is treated in order to get a reliable statistics, and then, perhaps, we will not obtain more than half the mortality resulting from that disease,

as no doubt half the children of syphilitic parents are either still-born or die within a short period after birth, and are never taken to the hospitals for treatment. Then, again, it is one of the most prolific causes of abortion.

As to consumption, which destroys about 12 or 14 per cent of the human race, the present aspect as to curtailing its ravages seems to be somewhat gloomy, although many sanitary scientists entertain the utopian idea that the time is not far distant when we will be able to control its prevalence.

The grounds upon which this hypothesis is based is of course the use of antiseptics and disinfectants. This plan is in accordance with the view that consumption is a contagious disease, but so far, I believe, it has not been advised by our scientists to isolate the patients as it is in all other diseases of a contagious nature. This plan was tried in Naples and Portugal over a hundred years ago by enactment of laws on the part of the governments of those countries. Physicians were compelled to report all cases under a penalty of fine and even banishment for failure. The poor patients were sent to the hospital, and the director was bound, under penalty of going to the galleys, to set apart the clothing of the patient. His room was declared to be infected, and must be renovated. The law was similar to that governing the management of the pest. Even the enforcement of these severe laws had no ameliorating effect as far as diminishing the prevalence of the disease was concerned, and in time they were abolished. If the disease is really contagious, one might suppose, a priori, that such positive measures of isolation and renovation would soon have greatly reduced its prevalence and finally have stamped it out. But there is much doubt as to its contagious character, and this view is greatly strengthened by the reports of Brompton Hospital. If we take the population of the attendants of all kinds in that institution, and an equal number of the outside population, we will find the disease is not more frequent among those within than it is among those without, according to numbers. This may be due to cleanliness, but if the disease possessed any positive feature of contagiousness as applied to diseases in or

dinary of that class, there should certainly be more of it within the hospital than without, taking equal numbers of people. Since the theory of its etiology being due to a microbe has become prevalent, and consequently its contagious character more fully believed in, heredity is not regarded as a factor of any importance. I can not help dissenting from this view. I have been familiar with so many cases where consumption was a marked characteristic of the family, that I can not resist the conclusion that heredity played an active factor in its development. I have had under my observation and care many cases wherein they had no opportunity to contract the disease by contagion. Yet I believe the disease may be acquired independent of heredity influence, by exposure, by bad sanitary surroundings, by previous frequent attacks of pneumonia or bronchitis. But I believe if persons predisposed by heredity could be prevented from intermarrying, the disease might be greatly curtailed in its prevalence. But of course such legal restraint could hardly be operative among a free people, as it would be regarded as class sumptuary legislation.

No doubt the time is not far distant when many other means of preventing disease and preserving health will be in our power to put into practical use. Some advance has already been made in the prevention of epidemics. This consists mainly in many instances in the observation of sanitary laws; in a word, true cleanliness, both in person and premises. Very few epidemic diseases of a dangerous character, outside of the ordinary contagious diseases, prevail where strictly sanitary conditions are. observed.

"A great requisite to health is the preservation of all the leading organs of the body in a condition of regular and proportionate activity; to allow none to become too languid and none too active. The result of this harmonious activity is a pleasing consciousness of existence, experienced when the mind is withdrawn from all exciting objects, and turned inward on its own feelings. A philosopher once remarked that he never considered himself to be in perfect health except when he was able to place his feet firmly on the turf, his hands

hanging carelessly by his sides, and his eyes wandering over space, and thus circumstanced to feel such agreeable sensations arising in his mere bodily frame that he could raise his mind to heaven and thank God that he was a living man."

WEST POINT, KY.

SOME RECENT CASES IN PELVIC AND ABDOMINAL SURGERY.*

BY L. S. M'MURTRY, M. D.

The following group of cases is reported to illustrate a variety of pathological conditions and operative measures in pelvic and abdominal surgery. All the cases occurred in the author's practice during the last three months, and have not hitherto been reported or published. In every instance possible I have here the pathological specimens illustrating the diseased conditions encountered in the operations, which I will submit for examination. With two exceptions the cases were all "late cases," submitting to operation only after so-called conservative methods of treatment had been exhausted.

CASE 1. Dermoid Ovarian Cyst; Ovariotomy; Recovery. Recovery. Mrs. W. R. M., aged thirty-six, mother of three children; last labor in July, 1887; applied to me me for treatment January 24th of the current year. She had spent the entire winter in bed, and had been under treatment for almost a year for uterine disease; suffered severely with pelvic pain, irritable bladder and rectum, and bearingdown discomfort.

A firm tumor occupied Douglas' space, encroaching upon bladder and rectum. The uterus was normal in size, movable, and anteverted. Dr. W. H. Bolling, of Louisville, had examined the patient some weeks previously, and gave the opinion that the growth was ovarian. I advised removal of the tumor

by abdominal section. The operation was performed on February 1, 1890, Drs. Bolling, Ingram, and H. H. Grant being present. I here present the tumor, and will pass it around

* A paper read before the Kentucky State Medical Society, May 14, 1890.

for inspection. You will see that it is a dermoid tumor of the ovary, containing teeth and hair. The patient gave a history of a severe attack of peritonitis, and hence extensive adhesions were encountered.

The cyst ruptured while I was separating it from the bladder, which necessitated irrigation of the peritoneum and drainage-tube. The patient made an easy and uninterrupted recovery. The highest temperature and pulse marked less than one hundred, and she did not require a dose of opium. The drainage-tube was removed on the third day. From the size and rotundity of the tumor, lying in Douglas' pouch, it will be seen how readily it could be mistaken for the displaced fundus of the

uterus.

The bimanual touch would correct such an error. The removal of this tumor relieved all the distressing symptoms and quickly restored the patient to health and activity.

CASE 2. Fibroid Uterus; Hemorrhage; Removal of Appendages; Recovery. Mrs. J. M. B., aged thirty-one, married seven years, never conceived, for several years had suffered severely with pelvic pain, with irregular and profuse menstruation. During the past year the pain had grown more severe, and the protracted hemorrhage was telling plainly upon her general health. She was anemic, nervous, and easily exhausted. Opium was a necessity at every menstrual flow, and she was menaced with all the horrors of the morphia habit. The bimanual touch disclosed several fibroid tumors upon the peritoneal surface of the uterus; one on the anterior surface was quite large. Three years ago after the uterus was curetted she suffered a severe attack of peritonitis.

On February 4, 1890, I opened the abdomen and removed the uterine appendages. The uterus was a mass of sub-peritoneal and interstitial fibroid growth. The ovaries and tubes were disintegrated by long standing inflammation, as you can readily see from the specimen here. They were enveloped and tied down in a mass of organized exudate, the result of localized peritonitis. These bands of false membrane were constantly contracting, and the ever-recurring menstrual flow thickened and tightened them, intensifying her suf

fering. The removal of the ovaries and fallopian tubes relieves the menstrual pain and congestion, arrests the exhausting hemorrhage, and will cause arrest and atrophy of the fibroid growths.

This lady made a rapid recovery from the operation. The hemorrhage following the enucleation of ovaries and tubes was such that a drainage-tube was required. It was removed on the third day. It is now three months since the operation, and the effect upon the general health is most gratifying. The hemorrhage and pain have not recurred, and her health and strength are restored. This operation is one of the most satisfactory in the entire field of pelvic surgery. It is now the universal testimony of those seeing much of pelvic surgery that with fibroid tumors of the uterus is invariably found diseased condition of the uterine appendages. dages. Removal of the appendages arrests hemorrhage and also the growth of the tumors. The mortality from this operation in skilled hands is only two and a half per cent. In appropriate cases it yields brilliant results.

CASE 3. Fibroid Uterus; Copious Hemorrhage; Removal of Appendages; Recovery. This case is analogous to the preceding. Mrs. C. P. H., aged thirty-six; mother of three children; youngest child six years old. Has been an invalid for four years; conspicuous symptom, hemorrhage. The menstrual flow is copious, excessive, and irregular. Hemorrhage brought on at any time by walking, exertion of any kind, and emotional disturbance. Has been in bed the greater part of three years past. She states that in July of last year a physician administered ether and curetted the uterus. This operation was followed by such copious hemorrhage that the tampon was necessitated. An attack of peritonitis supervened.

Two fibroid tumors can be readily felt by placing the hand on the abdomen; the growths rise almost to the umbilicus; the uterus was nodular.

I opened the abdomen on March 13, 1890, and removed the uterine appendages. Dr. H. H. Grant administered ether, and Dr. Julia Ingram assisted me. Drs. T. P. Satterwhite, W. H. Wathen, and Ewing Marshall were present.

One ovary you will observe, in examining the specimen, is cystic, and the diseased condition of both tubes and ovaries is similar to that exhibited by the specimen just presented with the report of the preceding case. The patient made a prompt recovery after the operation, and the result of the operation is all that could be desired. The hemorrhage was promptly arrested; the fibroid growth shriveled perceptibly during the four weeks the patient remained in the hospital before returning to her home in the interior of the State. From a letter just received she writes that she is constantly improving in strength, and that she has resumed her domestic and social duties after four years of invalidism and suffering.

CASE 4. Gall Stones; Suppurating Gall-bladder; Cholecystotomy; Recovery. The following case is unique, and presents interesting points in diagnosis, pathology, and treatment:

Mrs. J. E. W., of Jeffersonville, Indiana, consulted me early in March, with the following history: She is twenty-four years of age, the mother of two children. For three years past she has suffered severely from paroxysms of biliary colic. During the past year the attacks have increased in frequency and severity. The paroxysms last from four to eight hours, and chloroform inhalation is required for relief.

The ingestion of a moderate meal, over exertion, or excitement are sure to bring on a paroxysm. Her dietary is limited to a few simple and soluble articles, and she habitually abstains from supper. Her normal weight is 136 pounds; she has run down to 104 pounds. She has never been jaundiced. She is pale and has the care-worn expression of pain. At my suggestion she ate supper on March 11th, and suffered a severe colic. Morphia failed to relieve her, and chloroform inhalation was required for her relief. A pyriform tumor could be outlined in the right hypochondrium, which I ventured to pronounce to be the gall-bladder. She was anxious for something to be done for permanent relief. At my request, Dr. J. A. Ouchterlony saw the patient with me, and concurred in the opinion that she was suffering from retained gall-stones.

This lady came to Sts. Mary and Elizabeth

Hospital, and after two weeks of rest and careful attention to her diet I did cholecystotomy. The operation was performed on April 22, 1890. Dr. Wm. Bailey administered either, and Dr. Julia Ingram assisted me. Drs. J. A. Ouchterlony, Chas. Lucas, and Dr. Watkins, of Jeffersonville, were present. The incision was three inches and a half long, made directly over the gall-bladder in a vertical direction. After separating the adhesions by which the gall-bladder was attached to contiguous viscera, I delivered that viscus through the incision. It was quadruple the normal size, and the walls very much thickened. After careful spongepacking to protect the peritoneum and contained organs beneath, I incised the gall-bladder at its fundus. About four ounces of mucopurulent fluid were evacuated and two large biliary calculi were removed. I here present the stones for your examination.

You will note that the large size of the stones made their exit through the duct impossible. After thoroughly evacuating the gall-bladder, I explored the duct with my finger and could find no stones lodged in the duct.

The introduction of a rubber drainage-tube, and stitching the incised gall-bladder to the edges of the incision in the abdominal wall, completed the operation. The tube ceased to discharge after ten days, and was removed. The opening gradually closed. No bile was discharged at any time, only clear mucus. The progress of the patient after the operation was easy and uninterrupted. From my daily record of her case I find that the pulse was never faster than 86, and her temperature did not exceed 99°.

A seidlitz powder was the only medicine prescribed. Dr. Simon Flexner made a microscopical examination of the fluid from the gallbladder, and found it to contain cholesterin, pus-corpuscles, and debris. The result of the operation is all that could be desired. The patient is completely relieved of all her symptoms, eats heartily and of articles which heretofore were sure to bring on pain. She rapidly improved in nutrition, and at the end of five weeks after the operation returned home. From an examination of the large stones removed it is apparent that intestinal peristalsis stimu

lated the gall-bladder to contraction, forcing the stones to engage in the duct which could not admit of their passage. The retention of secretions and irritation had begotten inflamma

tion of the gall-bladder.

Evacuation of the gall bladder and removal of the stones did away with the mechanical and pathological causes of suffering and impaired functions. This operation has not been performed often in this country, and has been only recently brought to appreciative recognition. It was done by Marion Sims a few years before his death. He gave it the name of cholecystotomy, and brought it prominently before the profession. Tait and Thornton have done the operation repeatedly of late and with admirable results. Mr. Tait reports fifty-five cases with fifty-two recoveries. I had the privilege of witnessing the operation at Mr. Thornton's hands last year. It is one of the most brilliant achievements of modern abdominal surgery, and in skilled hands is safe and successful in the relief of a most painful and serious condition of disease.

CASE 5. Large Uterine Myoma; Supra Vaginal Hysterectomy; Recovery. Mrs. M., aged forty-six, mother of three children, observed an enlargement of the abdomen about three years ago. It gradually increased, and gave no special trouble during the first year. It was recognized by the family physician as a fibroid tumor of the uterus, and it was hoped that the menopause would bring arrest of growth and atrophy of the tumor. The growth, however, persistently increased, and continued to grow even more rapidly after the menopause. I was called to see this lady on April 5, 1890. Her condition was most distressing to contemplate. The abdomen had the appearance of the full term of pregnancy. The tumor occupied the entire abdominal cavity. She was emaciated, suffering severely from pressure symptoms, and confined to bed. She was able to retain but little food, vomiting daily, with all the distress of pressure on bowel and bladder. The feet and legs were swollen. On April 22, 1890, I did supra-vaginal hysterectomy. Dr. Julia Ingram assisted me, and Drs. Wm. Bailey, Chas. Lucas, C. Skinner, F. W. Samuel, and Watkins were present. The

tumor was a soft myoma of the uterus, and had undergone cystic degeneration, giving distinct fluctuation. The abdominal incision was eleven inches in length; about two pints of ascitic fluid were discharged. Firm adhesions attached the surface of the tumor to parietes, omentum, and intestines. As separation progressed the denuded surfaces bled freely and necessitated sponge-packing. The tumor having been released from adhesions (the omentum was tied and cut away), was delivered through the long parietal incision. The broad ligaments were tied and divided down to a level with the internal os uteri, and the entire mass, including ovaries and fallopian tubes, was removed. The fallopian tubes were so large that when first seen I mistook them for the small intestines. Large venous sinuses coursed over the surface of the tumor. The pedicle was secured with Koeberle's serrenoud and fixed in the lower angle of the wound. The incision was closed with silk sutures, and the peritoneum carefully stitched around the pedicle.

The tumor weighed sixteen and a half pounds. It was a soft myoma. The so-called fibroid tumors of the uterus, or fibro-myomata, for clinical purposes must be divided into two distinct classes. The nodular fibroid is altogether different from the soft myoma found in this case. The latter grow more rapidly after the menopause, are soft and edematous, and the patient is rescued only by complete removal of the tumor, of which the uterus is the nucleus. This operation is one of no mean magnitude, and can not be executed upon an emaciated and exhausted patient without considerable shock. In this instance the shock was promptly relieved by filling the abdomen with hot water. The patient rallied promptly, and made an uninterrupted recovery. The wound healed throughout by first intention, and the nœude came away on the eighteenth day. The patient returned from the hospital to her home in the city quite well at the end of five weeks.

CASE 6. Sarcoma of the Uterus; Total Vaginal Extirpation of the Uterus; Recovery. Mrs. H. W. S., aged fifty-eight years, was referred to me by her physician with the diagnosis of malignant disease of the uterus. The promi

nent symptom was hemorrhage. There was