in the morning and going to 1011⁄2° in the evening. She also complained of griping pains in the lower portion of the abdomen, and her pulse was above a hundred. The wound was examined, and was found to have united except at lower angle, from which a profuse discharge of a sero-sanguineous fluid, non-odorous, took place and continued, necessitating frequent changing of the dressings. There was no distension of the abdomen and no tumor that could be discovered. This state of affairs continued until the seventh day, at which time the discharge became offensive, and the wound and surrounding integument began to look very bad. With Dr. Butler assisting I took out the stitches on the morning of the eighth day. Each tier of sutures down to the peritoneum had been dissected up, and the whole wound was very foul. At the lower angle was an opening in the peritoneum which communicated with a cavity completely walled off from the general cavity, in which I found the missing gauze pad I now show you. It measures seven inches in length by five in width, and weighs one hundred and sixty grains. The condition of the wound was such that closure by suture. was out of the question, and apposition was effected by strapping with rubber plaster, two silkworm gut sutures being introduced well away from the edge to relieve in a measure the tension. The patient never had a bad symptom after the pad was removed. She convalesced very slowly, the wound granulating from the bottom in a satisfactory manner. The patient left the infirmary on June 10th, with a very firm cicatrix, and up to the present writing with no evidence of its weakening. Of course she wears a good abdominal supporter.

It will be seen from the above description of the case that nature employed the same means of expelling the foreign body that she did in the case reported by Dr. Elsner, with the addition of a profuse serosanguineous discharge which finally became purulent. Unfortunately, I am unable to give the exact location of the pad ab initio or to trace the path to its final resting-place as he did. But from the pain and the fact that it was overlooked by the operator and an accomplished assistant, it must have been behind the intestines. Nature's first task was to protect the general cavity, after which she selected the weakest spot and accomplished the journey thereto with expedition. If it had not been removed, and I frankly confess if the nurse had not reporte! a flat pad missing I would not then have correctly diagnosed the case, nature would have eventually safely expelled it from the body.

In 1884 Dr. Wilson succeeded in collecting thirty cases in which the

accident had occurred, more than two thirds of which had not been reported. His was the first case reported in the United States. Dr. Coe says he could have added five cases, all unreported. Dr. Herman J. Boldt reports two cases occurring in his practice; one died and one recovered. Dr. MacLauren also reports two cases, both of which recovered.

In April, 1892, in Revue des Malad. Femmes, there was an anonymous report of a case. Eight months after section for fibro-myoma a gauze compress, 26 cm. in length and folded on itself four times, spontaneously passed per rectum. Patient had no symptoms until four months after the operation. In this case the perforation of the gut was unaccompanied by severe symptoms. Also case of salpingectomy. No relief followed, and a vaginal hysterectomy was done. Still unrelieved, and when several months had elapsed another celiotomy was performed. While separating intestinal adhesions the bowel was injured, and a gauze strip 35 cm. in length, also folded four times upon itself, was extracted. Ten cm. of the bowel was resected. An intestinal fistula. resulted, which healed spontaneously, the patient making a good recovery. In two other instances a similar error was detected soon after operation and patient returned to operating-room and the foreign bodies (one a clamp, the other a sponge) removed.

In Hygeia, 1891, No. 12, M. Salin reports an instance in which one year after he performed an ovariotomy the lower portion of the abdominal wound opened, a large quantity of foul pus was discharged, and on closer examination a large gauze compress was withdrawn. Fecal fistula resulted, which healed spontaneously.

Dr. W. T. Bull published a fatal case that occurred in New York Hospital from a sponge. The pathologist of one of the leading hospitals told Dr. Boldt of two additional instances-one a sponge, the other a clamp, neither of which had been reported. The doctor also says he has been informed of five other cases (unreported) in which death was due to overlooked foreign bodies.

Drs. Wilson, Coe, and Boldt express themselves as to the best methods of guarding against such accidents. Dr. Wilson says his case has taught him: First, not only to count sponges, but instruments; second, to use as few of each as possible; third, to always have a fixed number in use, and do his own sponging; fourth, forceps should not be too small, and the same number should always be used; fifth, do not have too many assistants-he had rather have one than three, none

than five; sixth, after all instruments have been counted by the assistant, the operator should himself verify the count.

Dr. Coe says: First, never introduce any but long handled clamps into the cavity; second, to use pads sterilized in packages of a dozen, each set being separately counted immediately after using; third, the sutures are under no circumstances to be tied until every pad is accounted for.

The method adopted by Dr. Boldt in his practice is, first, sinall pads as temporary tampons are entirely discarded-long strips of sterile gauze being used with a clamp attached to the end protruding; second, sterilized towels are used to protect the peritoneal cavity in preference to gauze; third, for smaller surfaces, large gauze compresses to which a piece of silk or tape is attached, and to that a pair of forceps is applied; fourth, no pad for the operation is allowed to be torn or cut to meet any emergency; fifth, no pads are permitted to be thrown on the floor, but must be placed in a receptacle for that purpose; and sixth, all pads and forceps are controlled by a double count both before and after operation. The abdomen should never be closed until all towels, pads, etc., have been accounted for.

All of the above measures I heartily endorse, and believe the accident is least liable to occur to the operator who depends least on his assistants and most on himself, and who has only the necessary paraphernalia. If you do have to depend on an assistant or nurse, they must be reliable, true, and tried. More than once while assisting in operations have I concealed a pad or sponge to test the nurse, and found her sadly deficient; she reporting that she had them all when I had one in my hand. Most operators have too many assistants and instruments. The trite saying that you never know with what you have to deal until you get into the cavity is responsible for the latter, while "reasons of state" in all probability are prominent factors in bringing about the former.

I wish now to call attention to one or two points that will aid the surgeon in recognizing the presence of a foreign body, if, in spite of the above precaution, the accident should occur, and render it possible for him to relieve the patient as safely and at the same time sooner than nature when thrown on her own resources.

In the first place, a sinus which persists in spite of all efforts to close it is valuable evidence that all is not well within; second, if added to this there is a copious discharge of a sero-sanguineous fluid,

later becoming purulent, and third, slight fever and loss of appetite; fourth, griping pains which persist and become more severe; fifth, local tenderness and resistent or boggy area, or sixth, a well-defined tumor, it is certain that a foreign body is endeavoring to make its escape — either one left with intent as a ligature or accidentally as a gauze pad. I had two cases in which the ligatures attached to the pedicle, on each side in a double oöphorectomy, made their escape, in the first one via a sinus at the lower angle of the incision, the other, which I show you, via the rectum.

In the second case both came through the abdominal wall via a sinus, both patients having a long, tedious convalescence. If it is possible to accurately locate the offending object, an incision should be made and it should be removed.

In regard to accidentally leaving foreign bodies in the abdominal cavity, Dr. H. C. Coe says that he was an accomplice before he was the chief offender in a sin of this sort, and therefore employed extra precaution to avoid such an accident, and on one occasion reopened the wound three times searching for a missing sponge which turned up in a pail. After this he made it a rule never to put a fresh sponge in the cavity until its predecessor had been removed, and then if possible to keep it under his own eye. He went on in this way for seven or eight years, and says he had begun to think this accident would never happen in his practice. But it did, and when he least expected it. In a simple salpingotomy four gauze pads (4 x 6 in.) were used, and although all were accounted for by a most conscientious nurse and two assistants before the sutures were tied, one was left behind. Subsequently a mural abscess developed at the upper angle of the wound; on opening it the pad presented itself and was removed, the patient making a good recovery. He reports this case in the article already referred to in this paper.

With such an experience before us, let the surgical Pharisee who says, "I am holier than thou," beware.

The data made use of in the preparation of this paper were derived from the papers by Dr. Wilson in 1884, Dr. Elsner in 1895, Dr. Coe in 1897, and Dr. Boldt in 1898, and from all of them I have quoted freely, and all who have noted the difference in the mode of termination now and formerly in pre-aseptic days can echo Dr. Wilson's words, "Verily, there is something in using aseptic sponges."

LOUISVILLE.

HYSTERECTOMY: UNUSUAL SURROUNDINGS.

BY OSCAR E. BLOCH, A. M., M. D.

Assistant to Professor of Clinical Surgery, University of Louisville.

April 29, 1898. Patient, Rebecca B., age thirty-nine; married, no children; previous history good, family history good.

Condition when first seen, weak, anemic, almost exsanguinated from profuse metrorrhagia; lower limbs edematous; pains in abdomen and back.

Examination showed presence of a large uterine tumor, presumably fibroid, completely filling true pelvis and thoroughly obstructing circulation.

Patient had been cognizant of presence of the tumor two years; had been a sufferer all that time of pains as described above and of profuse hemorrhage, but had deferred operation until this time, when the symptoms had become so grave that it was necessary to operate at once. Mrs. B. absolutely refused to go to any infirmary, but was willing to submit to the operation at home. So preparations were made for operating at patient's home. The carpet was removed and floor thoroughly scrubbed; curtains, pictures, and all unnecessary furniture were taken out of the room; ceilings were swept and woodwork cleansed. The patient was subjected to the necessary shaving, scrubbing, and bathing. Water was strained several times and boiled. Basins were provided, and instruments, sponges, dressings, and ligature material were sterilized in Arnold sterilizer.

The operating(?)table was an ordinary dining-room extension-table, and was entirely too wide for working comfortably; at the suggestion of Dr. Schwartz, two of the leaves were removed and placed perpendicularly to their usual position, thus reducing width of table sufficiently to permit comfortable work, and with a chair to afford us the Trendelenburg position, we were ready. Chloroform was chosen, and although the patient was under the anesthetic two hours, she never suffered from nausea or any unpleasant symptoms at all.

The incision, made sufficiently above the symphisis to avoid the bladder, was directly through linea alba into the very organ we were attempting to avoid.

We simply placed clamps over this opening in the bladder, and proceeded to explore the pelvis. The tumor was found tightly wedged