Three years after the operation she was no better. She left her home and was under very considerable expense because she was assured that the operation would clear up every disagreeable symptom and she would be a well woman. The nervous system of the woman was more at fault than the organs of the pelvic cavity. I treated her and know my statement is correct.

I could report the very radical treatment of the endometrium by injections of iodine, five days after confinement. An active inflammation followed, which placed the patient's life in peril for several days.

I could cite many other unnecessary operations of which I have personal knowledge, from the American operation in which the subject is obliged to use a napkin because of paralysis of the spincterani, down to the circumcision of every male child as soon as born. A prominent Hebrew lately told me that many Jews did not believe in the strict following of the rite of circumcision, and only had it done when the abnormal condition of the organ made it necessary. Of these unnecessary operations *Dr. Goodell says in an article on "The Effect of Castration on Women:"

"What effect upon a woman has the removal of her ovaries? Unquestionably there usually follow the annoyances of the change of life. These, in my experience, are long spun out, because when menstruation has been abruptly and artificially stopped, the change of life, especially in young women, takes more time to become fully established than when menopause has been naturally induced. *Consequently, years may elapse before the victim of the operation escapes from the perspiration, the flashes of heat, the skin-tinglings, the numbness of the extremities, the nerve-storms, and all other vasomotor disturbances, the name of which is legion. My experience, therefore, coincides with that of Hegar, who says that "the artificial menopause induced by the operation if often attended with more serious complications than those which are not rarely observed in the natural change of life."

Then, again, the unwelcome fact cannot be shirked that mental disturbances may be traced directly to the removal of the ovaries as a cause. These are manifested by brooding, by low spirits, by melancholy and even insanity. Every ovariotomist has met with such painful episodes in his practice. Glavaecke, who has made a study of this subject, goes so far as to declare that "in almost all cases the mind becomes more or less affected, and not infrequently melancholia results." Keith has stated that 10 per cent of his patients who recover from hysterectomy subsequently suffer from melancholia or from other forms of mental disease. *I have now a patient under treatment, whose ovaries were removed two years ago, who suffers from severe hysterical at tacks and other nervous manifestations. She was promised relief, but is no better than before the ovariotomy.

Yet this result must come, not so much from extirpation of the *Medical News.

womb, which is merely a muscular bag, as from the associated ablation of the ovaries, of which the womb, physiologically, is only the appendage.

Whether this deplorable event is due directly to the nerveshock of the operation itself, together with its emotional environment, whether to the abrupt arrest of an habitual flow; or whether to the absolute need of the ovaries for mental equilibration-is yet an open question. We know, however, that sexuality is a potent factor in woman as well as in man, and that even certain sexual functions-such as coition, menstruation, gestation, parturition, and lactation-of themselves tend not infrequently to disturb the mental poise. I am disposed, however, in a measure to attribute the attacks of insanity in those women who have lost their ovaries to their brooding over the thought that they are unsexed; and if brooding may be deemed in itself a mental aberration, Glavaeck's sweeping statement is not an extravagant one."

Now as to the number who die from disease of the uterus and its appendages: "The death rate from chronic diseases of the appendages is greatly overrated, so much so that, in my opinion, more deaths result from the operation of removing the tubes and ovaries, in the hands of even the most successful gynaecologist, than from the disease itself. Knowsley Thornton states that "in his own experience pyosalpynx is not necessarily a fatal disease." In my experience, after the patient has safely passed through the acute stage of the inflammatory attack, her life is in very little danger. Chronic diseases of the appendages usually affect the well-being of the woman, but they ordinarily do not threaten her life in any other way than by the wear and tear of prolonged discomfort. This may shorten her days, but fatal attacks of peritonitis, even in so-called leaky pus tubes—if such ever exist―are the exception.

To cure the ill-health of a woman whose appendages are diseased, or to relieve her suffering, a surgical operation is by no means always necessary. Many women with adherent tubes and ovaries, and, for the matter of that, some even with pus in these organs, suffer either no inconvenience whatever, or very little indeed from that condition per se. There are, again, others who have pains or aches only at their monthly periods. But let their health break down, say from influenza, from malaria, from overwork or from nerve-strain, then sympeoms may arise from hitherto latent pelvic lesions. Yet, in most of these cases, if the woman can be restored to her former condition of healththat is to say, to that which she enjoyed just before the final break-down-she will lose her local symptoms and become symptomatically well. On this matter I can speak positively, for many a patient has been sent to my private hospital in order to have her distinctly diseased tubes and ovaries removed, who has been restored to health without the use of the knife. Now, by by the term "restored health" I do not mean that the treatment has released the adherent appendages, but that it has freed the

woman from every pain and restored her fully to all her social and domestic duties and pleasures. She has been cured so well as to be able to row, to swim, to dance, to take long walks, to ride on horseback and to exercise in the gymnasium-what better vouchers of good health than these can be given?

I will go yet further and assert that cases with all the subjective and all the objective symptoms of ovarian or of tubal abcess have been cured by me without any operation whatever—the pus having disappeared either through absorption or through inspissation. What is still more strange, in a few cases of abcess of each uterine appendage-very few, I will acknowledgethe treatment by massage, electricity, local application, and by a general building up tof the system was followed by conception, pregnancy and parturition. These were cases in which I did not advocate castration until other means had been tried first, but all had been sent to my by their physicians for the purpose of having the ovaries removed."

*

"My reasons for this conservative treatment are, that the complete extirpation of these organs, as I have shown before, tends to destroy the sexual feeling, to disturb the mental equilibrium, and to produce prolonged nervous perturbations, all of which majority of physicians and all laymen look upon women decome from the abrupt and untimely suspension of menstruation. There is yet another very excellent reason for this advice: The majority of physicians and all laymen look upon woman deprived of their ovaries as unsexed. Just as castration is in the male, so the analogous operation is in the female deemed a sexual mutilation to which common consent attaches a stigma. No woman would marry a eunuch, and few men would wed a woman deprived of her ovaries."

It may be well for those inclined to be reckless to remember that prosecutions have been instituted for damages in some cases as the following shows: "Imlach's case is a celebrated one in medico-legal jurisprudence. This skilful surgeon, after removing the appendages of a woman, was prosecuted by her for unsexing her and by her husband for spoiling thereby his marital pleasures. The special committee appointed to investigate Imlach's numerous cases of castration at the Woman's Hospital, in Liverpool, reported that they found "a distinct loss of sexual feeling to such an extent as to cause serious domestic unhappiness in not a few instances." The correctness of this report is corroborated from cases in my own practice, of engage ments broken off, of conjugal estrangements, and of marital infidelity."

As I have stated in the beginning of this paper, I believe in conservative gynaecological treatment. I believe in that treatment which has in view only the good of the patient. I believe in trying the safe medical measures and applications thoroughly before resorting to the dangers and uncertainties of a surgical operation. I believe there are many outside causes of disease which, if found and removed, would cure the internal trouble.

I believe that occupation, home surroundings and climate have to do with the setting up of disease and of keeping it up I believe there are other organs in the body of a woman besides the uterus And I believe, to treat disease successfully, the whole physical and mental make-up should be gone over carefully and the diagnosis made without leaning or bias in any particular direction. Gynaecological medical treament should be given carefully at all times, while a gynaecological operation of any magnitude should only be gone into after mature deliberation by two or more physicians and surgeons of good judgment. I be lieve in consultations, they often hold back the reckless and impetuous. A consultation, held for the good of the patient and not for appearances, will often give nature the one chance it needs. I believe in surgery. I believe in medicine. I believe in anything that will help the sick; but the sole and only purpose of any medicine or operation should be the good of the woman who places her well-being and perhaps her life in our hands.

UNUSUAL FORMS OF APPENDICITIS.

(By Howard Crutcher, M. D., Chicago.)

The typical case of appendicitis does not always appear in practice. The classical case-pain and tenderness in the inguinal region, fever, rapid pulse and slight tympanitis-has many variations. It is my purpose to point out some of these unusual symptoms, since we are tolerably familiar with the typical cases.

The vermiform appendix is a true "Coxeyite"-a tramp; it wanders from point to point, has no real home, and, like its prototype, is exceedingly liable to stir up trouble.

The old line, "Satan finds some mischief still for idle hands to do," applies with especial force to the treacherous tube at the base of the caecum. It strays upward to the liver, it wanders after the spleen, it seeks the companionship of the Fallopian tube and it displays peculiar fondness for the urinary bladder. I have twice seen it bound to the Fallopian tube, and last winter removed one appendix seven inches in length which was attached to the bladder. At the present moment I have in charge a young mother with what I and others believe to be a case of leftsided appendicitis. When her child is old enough to wean with safety, unless there be an acute aggravation, I shall operate. A surgeon of Brooklyn reports three such cases all confirmed by post mortem examination. It were better to have such cases confirmed by early operation.

It is our duty to recall these facts whenever we are confronted by a suspicious case of abdominal pain, and in these days of aseptic surgery and exploratory operations we ought not to hesitate long in coming to a conclusion insuring greatest safety to the patient. The day of the infallible diagnostician has passed. We know enough to-day to be sure of nothing and to operate because we do not know instead of because we do. Too many

lives have been lost between the treacherous lines of diagnosis. As to the time for operation-the sooner the better. Our indicated remedies are the only sure guides that I know of, and they are only relatively sure. They cure what is curable, and frequently palliate what is incurable, and when they fail us we know as well as we can know anything that the case demands other measures. My experience is that the remedy acts promptly if it acts at all; and I have witnessed the most gratifying results from medication in apparently severe cases. I say apparently, because no malady is more deceptive than appendicitis, and it is well to remember this in any case. Slight pain, if persistent, justifies surgical relief, in my opinion. The most desperate case of appendicitis that I ever saw was almost painless; perforation came and death was near at hand before the attending physician recognized what the trouble was. He had been misled by the mildness of the pain. Some cases, probably acute strangulation, are relieved very promptly, probably spontaneous relief of the stricture.

Of the technique I need say little. I prefer the short incision along the trend of the external oblique, the burying of the stump by a purse string stitch, and the closure of the wound by four layers of sutures, the three first of chromated gut and the last of plain gut. Where no pus is found the patient is up and around in ten days. Pus, the child of delay, or cowardice, more properly, means a longer convalescence. Perforation, unless kept by adhesions from the peritoneum, generally means death. In conclusion, when the indicated remedy fails to give prompt relief, operate without delay.

Ind. Inst. of Hom., 1894.

URÆMIA.

S. H. Spalding, M. D., Hingham, Mass.

Indiana Inst. of Hom., 1894.

We enter the discussion or study of the uraemia with much interest, for there seems to be much in the condition not thoroughly understood.

Good authorities tell us that "uraemia is a term employed to indicate the presence in the circulation of various substances peculiar to urine. Which of these is the exciting cause cannot as yet be determined."

Now, here is a sad uncertainty to be cleared up at the outset, and I am sorry to say we shall have to leave the finding of the exact cause of the condition to future investigation. We may assume that an excess of urea in the blood is, if not the proved exact cause, at least the most probable cause of the symptoms which we, unfortunately, so often meet. We know that as the urea secreted each day more nearly approaches the normal amount, our patient's condition improves, and the measurements of the urea excreted give a fair index of the progress of our patient.