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Paper by DR. J. H. VAN EMAN, Kansas City, subject, "Abdominal Surgery; Report of Forty Cases."

(See original department.) Discussed as follows:

DR SCHRADER:-We believe every word that Dr. Van Eman has said is honest and correct. Also what he has done under very unfavorable circumstances and by good, honest work, and I think under all the circumstances at the time these operations were performed, when such labor was doubt there that we know nothing about. I congratulate the doctor on the good work that he has done and on his honest report.

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third and seventh cases, enough to scare anybody to death. But I do not lose them as fast now.

DR CROWELL:-Coming from Kansas City, as I did, I feel very proud of Dr. Van Eman, and feel very proud that he is here to stand up and keep up the reports of Kansas City as an honest city, especially a city of honest Gynecologists. After the first case, he lost five consecutive cases; enough to have made any man-except somebody from Kansas City-abandon the work. But we can persevere until we get these marvelous reports of 100 cases without a death. We are but striving to do better than that; some in other countries and other larger cities where they have easier cases than we do. But the doctor speaks in his report of one or two cases having died of anesthesia. I would like him to point out the reason for believing that.

I would sooner think that the patient died from shock, and possibly with some degree of hemorrhage, but to die from anasthesia, and at that time, 1 very much doubt whether that were possible. In regard to the mortality in private houses, it is hardly in keeping with the majority I presume. However, it depends very much on the character of the hospital. In my opinion, there is no place where we can perform laparotomy with the same degree of success as in a hospital with all the necessary technique and competent nurses. It is not every hospital that has good nurses. And it may be due, as I am somewhat conversant with the hospital facilities in Kansas City, to efficiency of the nurses. Again the doctor speaks of a patient dying for the want of an action of the bowels. Now to arrive at that conclusion is not so easy. That an action on the bowels ameliorates and improves the patient recovering, in some cases is not untrue. But the patient depending on the movement of the bowels, seems to me rather stretching the point. We have very good authority now, and I think always have had the endorsement of English authorities that to dilate for movement of the bowels four or five days is the proper treatment. A number of gentlemen once insisted on the movement of the bowels with salines, now use opiates, and in certain classes of cases by use of morphine keep the bowels moving for some days.

Speaking about having to curet some of these cases: I believe that it is a very good practice as recommended by quite a number, to curet these cases, at the same time, and then we have I think undoubtedly a full reflex system and better convalescence and better involution after the operation.

DR. ADAMS:-I would like to say that I had the pleasure of seeing at least two or three of these cases; one at St. Joseph's Hospital; a girl I believe, and in this case I had something

to do with the patient, but I congratulate the doctor on the honesty of his report and his views. It is the line of a man's work as he means it, good, bad or indifferent, that teaches a lesson, of which we can give instructions, and not to take, as we might do, a number of cases who say they are perfect and leave those which are imperfect out of the list. The doctor, as I have known him for a great many years, has taken the real true distinet, honest, open and above board way of instruction, and from the work he has done, I congratulate him and am proud that I am from the same town where a man can come forward and say that he is honest at least in his convictions.

DR WARD:-I agree with the doctor that water is the only thing to put into the belly. I had a case not long ago in removing the ovaries where I used carbolic acid so strong that my hands were made white with it. would like to inquire of Dr. Van Eman why he reports some of his hospitals as bad surroundings, or what the Kansas City idea is of a hospital.

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DR. VAN EMAN, (closes the discussion). The first case was of a young girl of seventeen. The family doctor and the girl's brother came up to Kansas City to talk to me about the case. Said the girl was certain to die in a short time unless there was something done, and in talking over the case, there were no promises made; it was simply the last resort. The girl had been told there was a chance for her life if she was operated on, and without an operation death was certain and near, and she wanted a chance for her life. I told her brother and the doctor that I thought the chances were exceedingly poor; I did not think she would live. That was before I saw her. I went to that town in the shortest possible time I could get ready; usually when I go into a strange neighborhood I have taken my man to give the anesthetics with me, and paid his expenses. I sent into this town, and looked the men over; there were five doctors. I said I want a gentleman who can give the anesthetics. I knew nothing about these men. The only one I had ever seen was the family physician, and I had talked to him less than an hour on the road.

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they drew straws to see who would give the anesthetic, and of course the last men of the five that I would have picked out to give it, got the long straw. While I was getting ready he was a long time getting the anesthetics; sent word back two or three times that she took it very badly, and when she was brought in I ought to have refused the operation. She made no more motion, no more signs of life except the heart beat and respiration than if she were dead. It was not a tedious operation. Of course with a delicate slender girl with a tumor just removed of the size and weight that it was, it was no trouble to fill up her abdomen or the cavity. But she died just the same. The most responsible man second to the operator, is the man who gives the anesthetic.

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The second case was a woman who had been pregnant. When she came on the table she was in the same condition as the other. Now I do not know what you call it, but they never recover. They die. And I have good reason to believe that you can kill with an anesthetic. Why do they die? Some say because their time comes. heard a man say, in talking about a case that had a tumor, some years ago, that he was afraid to operate on it for fear he might lose his surgical reputation. He never had any surgical reputation to lose, and, has never had any since. I think it is our duty when we know that a woman has but one chance in a thousand for her life, and she asks for that chance, to give it to her. I have but one rule of action with my patients, and that is to do to them as I would have a surgeon do to

me.

Another gentleman wanted to know, and seems to think I am a pretty honest sort of a fellow, but don't understand why you get better results in private houses than you do in hospitals. I think I can tell him., I generally arrange to have the best nurse I can find anywhere, and then as we say, sometimes, I have camped out beside the patient, and I have been both nurse and doctor, and I think I am a pretty good nurse. I have staid from five to six days in those cases in private houses where I was not entirely satisfied with the nurse, and let other business go. Now that is where I get my results in private house.

Take the hospital where there has been so many different diseases and sick people, besides we have all learned that dirt means death whether it is under your nails, on a woman's skin or on your instruments. Take a woman in our houses, they are generally good housekeepers, and if there is any dirt about the house, she is used to it. Her powers of resistance are such that she can kick off most any ordinary germ. Take her to the hospital, she is half scared to death by the noise, or some fellow brings a lot of dirt there in his nose and begins to cause a lot of microbes and becomes infected. Now there is more truth than fun in that. And that is why I never had any trouble with private cases. Then I think I can prepare a room in a private house, and select my room, as good as the general hospital.

Now the medical man and the nurse are getting an education today that have a vast advantage over us fellows who attended college twenty-five years ago, when they had not taught germs and didn't know anything about them. In the way we were taught, we go along, we have everything ready and make some little break in force of habit, and we spoil the whole thing.

I saw a man once, who stands very high in surgery, who was attending a patient. Everything had been cleaned and boiled up that that time, when he took an old dirty syringe and filled it with water and washed out that gall bladder. No difference how much that man had done, he spoiled the whole thing with that syringe. That is where we fail sometimes. I am sorry to say that so far as I know, there is not a hospital in Kansas City but what is a general hospital. Now another gentleman wanted to know why I thought in that operation, that the girl died because she did not get her bowels moved. If I could have gotten the gas and everything out of her bowels, she might have gotten well. I believe that is the principal cause of her death. I do not know. The only thing that would have settled the ques tion afterwards, would have been opening up the abdomen. Under the circumstances it could not be done. They say to me in my fatal cases that they think there has been butchering enough done.

Now about curets. The question whether a woman should be curetted at the same time she is operated on or just before comes up, or did come up. I think I would have increased the cases a little more if I had curetted at the time or just before.

I think there is very few women I would risk; I would not on my own kinfolks. In the case that I spoke of where you have a discharge, it is a better plan perhaps to clear up thoroughly the vagina and dilate with curet. If you do not do it, then it ought .o be done six or eight weeks after, as on as they recover.

Another gentleman wanted to know what I used arter the incision; if .. Washed the abdomen out with pur carbolic acid. I made that operation on the 5th of February, 1880; had several doctors around, because I though they knew more about it than I did, and I did not know very much; had never seen that kind of an operation. Well I made a very nice operation, at east I thought so. I used to be very nuch afraid of leaving a little bloor in the cavity. One of the doctors said, you had better wash that out with a strong carbolized solution, and I commenced to get ready to do that, and J stopped to think what I was doing, and I said, No there is nothing to wash out. I have used carbolic acid so strong it would whiten the peritoniti. I did use in the earlier cases, after I got into the cavity, a weak carbolized solution. I do not use anything now but sterilized water after the time I pick up the knife, and do not think there is anything any better and there is no danger.

One of the gentlemen was a little bit hard on me; he said that the first place I had five successive deaths. You will remember in the second case I used thermo-cautery. I had been with that Ohio man, Dunlap, and had seen him leave lying out below the ligatures so I tried something else in my second case, I used thermo-cautery. It was a private house and I took care of it myself. If I had operated as they do now, I have no doubt there would have been no trouble, but I used thermo-cautery. One thing more about hospitals. The Sisters' Hospital at Kansas City at that time was a rather small frame house, which had been built a long

time before as a residence, bought by the sisters and turned into a hospital; an old frame house. In that a good many different people had lived with their different habits and methods, and there was nothing new as we know, and every kind of a case had been in there. It was a Railroad Hospital and everything else. More than that, I did not know a great deal about nursing that kind of cases and the nurses knew less, and those girls were put back in rooms that were dark and not very well ventilated and not any too clean. We do not have those kind of rooms now, as we have torn those buildings down. It was in the time of Auld Lang Sine, but we did the best we could. Perhaps in those two cases with a large accumulation of pus, I ought to have been more conservative and tried to evacuate that. Perhaps I might have succeeded. Now if I wanted to make a particularly favorable showing in this case I could report it 25 consecutive cases without a death but I did not do that, and I do not intend to, and in the reports that I have made to the association, if I can not be anything else, I will be honest.

DR. M. R. MITCHELL of Topeka, read a paper on "Neurology of the Female Organs." (See original department). Discussion as follows:

DR. HALL-The value of this most excellent paper of Dr. Mitchell's is most apparent to every physician, whether he be a general practitioner or a specialist. I cannot conceive anything of greater importance than what is in this paper. The man who can even overcome the difficulties of attending menstrual disturbances in young girls and these conditions of the skin and especially the face, will confer a boon upon the female part of our community, and he will also confer a boon upon the average practitioner. Those conditions have annoyed me, and the only way I have been able to get out of it is to tell them that they must put up with it, and after 'they get through they will have no further trouble. I am very glad Dr. Mitchell has brought up this paper, and it should be to us an important lesson. It shows to us the importance of investigating more thoroughly. It is a daily experi ence that we meet with and something

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that we should endeavor to make great efforts to overcome. The pembrology, and all that sort of pain is apparent to us all, yet it is not always possible to so readily overcome them. I can recall a case years ago, a lady, mother of a large family, who had first gastrology; had always been a healthy woman, always born children without undue pain. In other respects, in a normal condition apparently. Had perhaps reached the age of 40, and yet she suffered from these pains. I gave her medicine without end. I became tired of my dosing, and told her in spite of her previous health, there must yet be some condition back of it, and that condition must be located in the uterus, or its appendages. This was in 1885. I examined the uterus, there was not very much wrong with it. A slight catarrhal discharge from the uterine cavity, and on general principles, without having found much cause to effect, I began dilating the cervical canal. I believe that in this case it was the inception of this labor, and we had the beginning. It was only a little while before I took a trip to New York, before I treated this lady. She had headaches, and all sorts of things, and it harmonized so perfectly that in conversation with a doctor there, I was convinced that my treatment of the case to a great extent was directly in the right channel. The lady was relieved promptly and to this day has had no trouble. I congratulate Dr. Mitchell on his paper, as it is just this kind of papers that do us good and general practitioners as well as specialists.

DR. ROSS-I would like to show my appreciation for Dr. Mitchell's paper. Recently I have had experience in this line, and one case was a woman I saw four months ago. During all the time previous she has had an excellent physician, and had requested the doctor to make an examination of the womb. She had attributed all her trouble to indigestion, weakness and everything of that kind, to the fact of her having lost two children within the last two years. He told her it was all wrong. He was not able to obtain an examination for a week. All our treatment consisted of was keeping the woman perfectly quiet. Yesterday

I saw the patient. She had ceased to have her spells entirely. Digestion was good, no more pains, and she felt good enough to do her own work again.

Another case came to me, a banker's wife, who had opportunities to travel, and has been suffering about six years with painful dysmenorrhoea, neuralgia. I prescribed about a month ago and she refused an examination, and not until week before last I got one, when the woman came into the city, having had one of her severe spells, headache, backache, and all symptoms, and I found a strongly retroflex uterus. Her husband thought she had consumption; had become a swarthy color, skin dry and very nervous. We examined the urine and in fact had gone over all the ground I could think of, and still persisted in thinking that was the cause, when making an examination, we found, as I say, strong retroflex uterus. Extreme nervous condition, pain in her stomach, which she complained of a very great deal, and I do not believe there is any organ in the body that can affect the digestion as the uterine troubles. So one can multiply case upon case, but the peculiar relation between the uterus through the sympathetic system is well brought out in Dr. Mitchell's paper.

DR. MITCHELL closes the discussion.

There is one point I might call attention to, and that is in reference to diagnosis in surgical procedures as well as in medical treatment. It is sometimes a very difficult matter in these complications to trace the faults and we cannot be too careful in weighing a case and taking in the whole situation, so as to arrive at an intelligent conclusion. Sometimes the busy surgeon overlooks a case simply from the want, perhaps, of due appreciation as to the positive necessity of correct diagnosis. These symptoms are often treated to a certain extent, without an intelligent apprehension as to the real cause of this trouble.

DR. B. B. DAVIS, of Omaha, read a paper on "Ureteral Surgery. (See original paper in this issue.)

Discussed by

DR. HALL-I have had some little trouble with the ureter, and I think

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any one is likely to have. The paper has to me been exceedingly interesting; it is a subject which perhaps has recently engaged our attention more than ever before, and from the fact that more abdominal surgery is being done where the operation involves the area occupied by the urethra. Frequently in the cases that I have had I have had nothing serious and nothing but what has recovered. I might report a case which I operated on recently for a trouble, speaking of arriving at a diagnosis in these cases. I had a patient some time ago, and it had for a long time some trouble with the urinary organs. I think at one time I got about 8 ounces in 48 hours of urine secretion, and every little while she would have a spell of very scanty secretion or urine, pain in the left side, with no trouble, nothing that could be detected. Besides this, it was thought to be a case of chronic cystitis. Having her under observation some little time, I was unable to agree with this opinion. Sometimes the urine would be perfectly clear, but she suffered intensely with pain, sometimes requiring morphine. I resolved to cut down and see if I could find anything. Opening the abdomen I found nothing so far as I could detect in the urethra. And all I could find was an adhesion of the omentum. She had an abscess in the vagina with a little pus escaping. I examined with various means, but the result has been that the patient is absolutely cured, has no trouble now with pains, no trouble with the secretion of urine; now passes urine regularly with ease; urine is clear, and the results have been satisfactory. Where it was due to the adhesion of the omentum and possibly obstructing the urethra, urine contained large quantities of urates and phosphates, and now has none of them, and I think will be a permanent

cure.

DR. SCHOOLER-I thank the gentlemen of the society for bringing the subject before us at this time. Until recently there was little attention paid to diseases of the ureter. It is perhaps known that stricture sometimes exists, and that calculi sometimes obstructs the passage of the ureter. But surgical measures were not adopted for the relief of these dif