located in the right inguinal region that extended down to the scrotum, so closely associated with the abdominal wall that I could not make it out at first. The history was that of a tumor growing from above downward. There was no impulse on coughing, no evidence of true hernia. The patient had indigestion, a darting pain and distress, and was losing flesh rapidly, preventing him from going on with his business. The family physician introduced a small trocar, but could find nothing. I saw him after that and considered his case one of omental hernia. We placed him in a position with the hips elevated to see whether an impression could be made. There was no impression made, and the patient finally consented to an exploration. I began my operation with the expectation of seeing an omental hernia with the intention of removing it and the sac above. I cut down to the growth and enucleated it from each side, the tumor reaching far up in the inguinal canal. It was separated without much difficulty and proved to be one of the cases of hernial tumors which Dr. Ill has described. (Dr. Vander Veer reported several other interesting cases.)

Dr. Edward J. Ill, of Newark (closing the discussion): Dr. McMurtry in his remarks spoke of the extreme rarity of carcinoma of the umbilicus. In my paper I have collected twentyone cases of carcinoma of the navel from which I have excluded three, as probably of another nature.

ABDOMINAL SECTION FOR DIAGNOSIS.

By Clinton Cushing, of San Francisco. In the excellent book of J. Greig Smith, on abdominal surgery, he says, in speaking of exploratory incisions of the abdomen, "No incis

ion ought to be merely exploratory." The exploratory incision of of the skilled surgeon is widely different from that of the tyro. Where the former will make a correct diagnosis, in ninety nine out of a hundred cases the latter will fail over his tenth. case."

However skillful the surgeon may be, I do not believe he can make an accurate and correct diagnosis in more than nine out of ten cases of abdominal disease by any method of external examination, if we leave out of consideration cases of ovarian cysts and uterine fibroids.

Therefore, I think that the author quoted is in error, and that his quoted statement should not be allowed to stand unchallenged. In spite of the fact that great progress has been made in latter years there still remain a considerable number of cases of abdominal disease of a serious character, upon the nature of which equally skillful and intelligent surgeons will disagree. This statement applies to cases of obstruction of the bowels, to disease of the vermiform appendix, to affections of the liver and gall bladder and of the kidneys, and to pus collections in any part of the abdominal cavity.

The real facts, in many cases of ruptured extra-uterine pregnancy, are only clearly made out at post-mortem examinations.

Exploratory incision is looked upon by Mr. Smith as a serious operation, followed by a trying illness. In my hands it has not proven so. The se rious part is the disease that warrants the operation, and not the operation itself, for with due care and cleanliness there is not one chance in a hundred that any bad results will follow

the opening of the peritoneal cavity for the purposes of diagnosis.

I would not have it understood that I am an advocate of careless or reckless work, but where the symptoms are grave and growing steadily worse, and the life is at stake, if the symptoms point to some obscure disease of the abdominal cavity there should certainly be no hesitation in clearing up all doubts by an exploratory incision if there be strength and vitality left to withstand the slight shock that attends the opening of the peritone um.

In illustration of the ideas advanced, Dr. Cushing reported five typical cases where exploratory incision revealed unexpected disease and which resulted in the recovery of the patients, who otherwise would doubtless have died.

I was

months before they occur. called to see a case in which there was considerable hæmorrhage at the time of delivery. I learned for the first time that the woman had had chronic malaria, and she said to me that before her pregnancy began she had bled very alarmingly at her menstrual periods. In a woman in whom uræmic cachexia has developed, Bright's disease is present, or there are any indications of lowered vitality, it is important to deal with that case long before the time of delivery, and it has been my habit for several years to charge my hypodermic syringe with a solution of ergot, and to give positive instructions that there shall be hot water ready at the time of delivery.

Dr. H. W. Longyear, of Detroit.: One point touched upon in the paper should be emphasized a little more,

DRESS.1

Dr. J. H Carstens, of Detroit (opening the discussion): There are one or two points that I want to criticise. The use of ice in post-partum hæmorrhage is bad practice, because I think ice is not an aseptic agent. I should prefer to use a remedy which is very common and universally known, and one you can obtain anywhere. It will stop post-partum hæmorrhage as promptly as anything possibly can, and it is vinegar.

Dr. William H. Taylor, of Cincinnati: You doubtless know the witty reply to the question as to how early a child's education ought to begin, which was that it should commence twenty-five years before its birth. I think the treatment of puerperal hæmorrhages ought to begin several

ANNALS OF GYNECOLOGY AND PEDIATRY, Oct. 1892, p. 1-17.

after-birth by the Credé method. Where the after-birth is immediately expressed after delivery of the child by an inexperienced person, it is liable to result in hæmorrhage.

Dr. John M. Duff, of Pittsburg: The subject under discussion is one of the most important connected with obstetrics. A physician in my city of thirty years' experience as an obstetrician, and who sometimes points his finger at me for my preparation in my emergency cases of labor, had a case of post-partum hæmorrhage. He sent for me, and when I reached the house, a lady came to the door and said there was no necessity for me. The woman was dead. illustrates the importance of preparation for emergency cases.

This

Dr. W. P. Manton, of Detroit: I do not see any cases of post-partum hæmorrhage in my own practice. I

do see them in consultation practice sometimes. In that class of patients who are particularly liable to postpartum hæmorrhage I watch them carefully during pregnancy and labor. I agree with Dr. Longyear that the too early removal of the placenta by the inexperienced results in postpartum hæmorrhage.

Dr. Joseph Hoffman, of Philadelphia: In the matter of post-partum hæmorrhage I am theorizing. I have never had a case. I do not think they ought to occur. I think the habit of some obstetricians in leaving the house in a very great hurry after the child is born is fraught with danger. No obstetrician ought to leave the house without carefully examining the patient. This is a general practice with me. I do not use ergot. do not believe it is necessary, and I think its use may in many respects be dangerous.

I

Dr. A. Vander Veer, of Albany (closing the discussion): I desire to express my thanks for the kind way in which the Fellows have discussed my paper. In my address I spoke of packing the uterus with iodoform gauze. I believe it can be done with the patient in Sims' position with a duck-bill speculum, the uterus being held in a fixed position by the tenaculum speculum. The sound is quite a useful instrument for this purpose.

Dr. E. E. Montgomery, of Philadelphia, presented a paper on SACRAL RESECTION; ITS PLACE IN PELVIC SURGERY.

He described the operation, the methods of performance, and advocated the resection of the sacrum on one side below the third sacral foramen, in order that the nerves making their exit from the foramen

on the other side should be undisturbed. He claimed that the operation had a distinct place in all diseased conditions of the lower and middle part of the rectum, and advocated it particularly in place of colotomy, where the disease could be removed, and considered it superior to colotomy in the fact that it afforded an opening which, being closely attached to the bone, was less likely to contract, did not require the patient to assume an unnatural attitude in order to evacuate the bowels, and the situation enabled the patient to wear a pad which would more effectually control the evacuation. The operation, also, was the only one which afforded the patient a chance, in those cases in which the disease had extended from the rectum to the uterus or upper part of the vagina. It was applicable to cases in which the uterus alone was involved, where the vaginal canal was undilated, the uterus more or less fixed by inflammatory exudation or the presence of previous tubal touble, although in these cases it may be questioned whether it is preferable to do this plan, or to open the abdomen and reach the uterus from above, with the patient in the Trendelenberg posture. He also proposes it as a suitable method of reaching and draining some collections of pus in the retrouterine cavity, where Nature had already erected barriers above, that prevented the infection of the general peritoneum. In such cases the cavity could be cleaned out, flushed and drained without the danger of exten

sive infection.

A CLINICAL REPORT OF GALL BLADDER OPERATIONS. BY RUFUS B. HALL, M.D., CINCINNATI, 0.

He reported seven cases, all of the

gall bladder operations that he had made, in three of which the common duct was obstructed from three to seven and nine weeks respectively. The case with obstruction for three weeks recovered from the operation.

The case with obstruction for seven weeks had gall stones for eight years before operation, and at the time of the operation had a stone impacted in the common duct, and malignant disease at the head of the pancreas and obstructing the common duct. The case with obstruction for nine weeks had a stone so firmly impacted that he had to incise the common duct for his removal. The three cases were in extremis at the time of operation, from the long-continued cholæmia. The cases for seven and nine weeks died from exhaustion on the third and sixth days after the operation. The remaining cases in which the cystic duct was obstructed recovered, making five recoveries and two deaths. With the light of his experience the author would hesitate to advise an operation in cases where there had been complete obstruction of the common duct for seven to nine weeks. The powers of recuperation in such profound and continued cho. læmia is so feeble that we can hardly hope for other than a fatal termination. The author of the paper is strongly inclined to the opinion that there is a causative relation between gall stones and malignant disease in and about the gall ducts and head of the pancreas. He thinks that the long years of continued irritation from the presence of gall stones and the consequent repeated attacks of hepatitis favor the development of malignant disease in and about the gall ducts. He urges early exploration in

obscure hepatic disease of a number of years standing, even if a positive diagnosis of gall stones cannot be made, and cites a case in which he removed ninety-one gall stones under similar circumstances. In that case the patient had pain in the region of the gall bladder and liver, but no other signs of gall stones. If early operation was made there would not be so many cases of obstruction of the common duct with the high mor. tality following that complication. If all of the cases operated upon, where the common duct was obstructed could be tabulated, the mortality would probably be very great. On the other hand, the operation in cases where the common duct is not obstructed the mortality is very small. These facts should be sufficient to warrant early exploration.

DISCUSSION ON DR. HALL'S PAPER.

Dr. Edwin Ricketts, of Cincinnati: I have recently opened the abdomen the thirteenth time for obstruction of the gall duct. There is one procedure that I want to criticise that was resorted to by Dr. Hall, namely, incising the common duct for the removal of common stones.

I think that if we introduce a short glass drainage tube, not very large in circumference, into the common duct after the gall bladder is stitched to the peritoneum, and wash out the common duct through the glass drainage tube by means of warm water, that the syringe will dislodge the stone or stones from the common duct. I have seen some of these obstructions relieved in that way.

Dr. W. H. Myers, of Fort Wayne: I had a lady under my observation some months ago in whose case I re

moved six gall stones. There was obstruction of the cystic duct. The cystic duct was obliterated in that case, but the fistula did not close up. The mucous discharge continued afterward, and the patient left me very much displeased on account of the fistula remaining open. I could easily have removed the gall bladder.

Dr. Rufus B. Hall, of Cincinnati (closing the discussion): I desire to thank the gentlemen for their kind. remarks and to refer to one other case that I have in mind, that of a gentleman who has passed more than three hundred gall stones in the past year. The gall stones are nearly all the same size and vary from the size of a split pea to a pea. He suffers terrific attacks of pain every two weeks. DISCUSSION ON DR. MORRIS' PAPER.1 Dr. Edwin Walker, of Evansville: Something like fifteen years ago Dr. Louis A. Sayre, of New York, called attention to certain neuroses which arose from adherent prepuce in the male, and also mentioned some cases that had occurred in young girls. I circumcized quite a number of children with different forms of neuroses, including chorea and epilepsy. My results were highly satisfactory for a short time. I remember the case of a little boy who had as many as twenty epileptic seizures in a day. After the operation he did not have a seizure for several months, but they eventually returned and his condition was as bad as before.

Dr. Joseph Hoffman, of Philadelphia: Dr. Walker's remarks remind us that there is nothing new under the sun. We all know that, Mr. Baker Brown saw all of the difficulties

1 ANNALS OF GYNECOLOGY AND PEDIATRY, January, 1893, p. 215.

and perversions of sexuality in women as being due to the clitoris, and he did the operation of clitoridectomy so frequently that he was severely criticised by his brothers in the profession. I had under my observation a very remarkable case of "hysteroepilepsy" in a male child, which was due entirely to adhesions of the prepuce around the glans. This was relieved and the boy, now some two years since, has not had a recurrence.

Dr. W. P. Manton, of Detroit: I desire to thank Dr. Morris for his excellent paper. I see every year a large number of women, and the majority of insane women, as is well known, practice onanism. I have no doubt that the preputial adhesions. may have something to do with the constant desire these patients have for rubbing the parts.

Dr. George H. Rohé, of Catonsville, Maryland: In my paper to-morrow I shall endeavor to impress upon the Fellows of the Association the importance of early taking these cases in hand. If we expect any great benefit to result from surgical interference for neuroses, or psychoses, it must be early, before the morbid habit has been firmly established. I am grateful to Dr. Morris for his researches, and I shall take opportunity to verify them in my practice.

Dr. A. H. Cordier, of Kansas City: Dr. Sayre advanced similar views a few years ago and specified clearly the class of cases that should be oper. ated on as giving rise to reflex symptoms, etc. I have in a number of instances operated on cases early before structural changes had taken place in the central nervous systemand thereby cured the patients.

Dr. Robert T. Morris (closing the