The old advice occasionally given to just such suffering females we well know-go get pregnant, it will straighten all your irregularities. It's true it may, but more probable in such a case it will not. Because a woman's womb is pulled back and fastened, there is no reason why she is free from possible conception, but of course she is less liable than if the uterus was in normal position, especially if much flexion of the neck exists. But the fact that they do become pregnant when every reason seems to indicate absolute inability, places us responsible to cope with same when it does

occur.

Something is going to happen as tension is put upon these adhesions, pain, irritation and inflammation result. If the cause of its incarceration is of mild origin, nature may overcome it and no doubt frequently does. Such, however, could be more promptly relieved by careful attempt at replacement of the patient in knee-chest position manipulation through rectum with the cervix brought down with forceps in vagina. If too severe a light gas anesthesia with patient on back is advised by a great many. Personally, I do not approve of it, adhesion which holds so firm as to resist to the extent of giving unbearable pain are very dense and such exertion applied under anesthetic might result in serious tears and possibly dangerous intraperitoneal hemorrhage. Again no matter how positive, we are never certain of the entire extent of a trouble in the pelvis-the rupture of a cyst or small abscess would prove an unfortunate complication. Not until more extensive. research has been made and more systematic study of the woman's uterine know the true relation between the two.

Again the danger of the bladder from pressure of the uterus when confined to the pelvis, not only from rup ture but the irritation set up by pressure may to develop an obstinant cys

ger in operating on pregnant women over the non-pregnant (condition not involving the uterus itself). The fact that we are subjecting two lives to the ordeal instead of one makes the decison of operation selected only as a means of saving the life of the mother or to preserve the continuity of pregnancy.

I believe the chief element of danger of abortion rests mainly in the care of the uterus during the operation. Avoidance of all unnecesary manipulation protect same as constantly as possible with large gauze pad frequently emerced with hot salt solution at even temperature. As in the type of case reported, there is comparatively no danger from this standpoint if these precautions are folowed.

In consideration of the above case the question of whether the best judgment was used in removing ovary and tube from the standpoint of sane conservatism, is a point for consideration. From a macroscopical view we had a large soft uterus pulled backward and to the left side by adhesions which spread over the hypertrophied and inflamed left tube and ovary below which adhesions were the evident result of previous surrounding inflammation, the origin of which most likely was in the tube, with no evident pus present would I have been justified in resecting the ovary after freeing all adhesions and doing nothing else trusting the inflammatory condition to be a mild catarrhal type which would subside.

No doubt great and possibly complete relief from immediate pain would be obtained by freeing the adhesion thus liberating the uterus and also the tube and ovary from their mal-position but the extensive adhesions pointed to the fact that the condition was chronic. In its present state it would readily, under proper environments, develop into a pyosalpinx. The danger of infection to the uterus after parturition if not before, the added irritating effect of the encroaching uterus

as pregnancy would advance, made me feel the most conservative plan was complete extirpation. In reference to explaining the character of temperature and pulse I cite the same as a very interesting point in the case. The pulse was rapid before operation, from 90 to 100, hence I was not alarmed at it ranging ten to twenty beats higher after operation and in connection with the slight temperature which I applied to the expected surgical efect, expecting the same to disappear in a few days. but as it persisted I grew more concerned as to the cause. The intermit tent pulse occurring did not tend to make the case more encouraging. The plasmodium was looked for but not found, all uterine symptoms had ceased, no vaginal discharges or odor. The patient feeling better every day with the appearance of perfect convalescence. Leukocyte count normal, urinalysis normal. Digestion good, bowels free and normal.

Could the manipulation of the uterus disturbing the pelvic circulation be in an indirect way a factor? In connection with this point Dr. Sheldon offers the following for consideration: "Siepmann and Hitschmann state that the fetus and placenta produce a chemical substance which is toxic to pregnant animals-Zwifel says that the liver destoys these toxins-Firth, Lockmann and Wolf claim that when an over production of these toxins are formed or absorbed into the system, or when the liver is unable to destroy them, toxic symptoms, even to eclampsia occur. If this point be the manipulation of the pregnant uterus, especially in the last case may have stimulated an overaboundance of these toxins into the circulation and the persistent toxic symptoms although mild showed the inability of the liver to cope with the additional labor thrown upon it. I have had herewith just such persistent temperature occur in two other cases following abdominal operation on non-pregnants, with absolutely no apparent cause, finally to run their course and disappear with

THE SURGICAL TREATMENT OF PULMONARY EMBOLISM.

At the meting of the Association of German Men of Science and Physicians held in Dresden last September rendelenburg of Leipzig proposed a procedure that his hearers must have thought bordered on the impossible, namely, the operative treatment of plmonary embolism. Starting with the fact that patients in whom this fatality occurs frequently do not succumb imemdiately, but may live for minutes or hours, Trendelenburg by work on animals and cadavers has attempted to devise a technique by which the pulmonary artery may be opened and the thrombus extracted from the main trunk or its larger branches. His first idea was to effect the removal of the clot by means of a special aspirating syringe,

He

and he actually tried this in the case of a human subject, but failed, as the patient, a woman of sixty-two, suffering from carcinoma of the colon who suddenly went into collapse from pulmonary thrombosis, was found to have the complication of an old adherent pericardium, so that the exposure of the base of the heart was rendered very difficult. now describes (Zentralblatt fur Chirurgie, January 25, 1908) a somewhat different mode of procedure which he thinks ought to prove practically applicable. The heart is exposed by making a large osteoplastic flap of several ribs and the soft parts which is turned back so as to allow free access to the upper part of the organ. The petricardium is incised over the base of the heart, and a specially formed blunt hook somewhat resembling a metal catheter is passed around and behind the aorta and pulmonary artery. The vessels are pulled forward, the pulmonary artery is compressed with the finger by pressure against the hook, and is opened by a longitudinal incision a little higher up. The thrombus is then sought for by means of a polyp forceps or similar instrument, and if found is extracted. The

wound in the vessel is closed with a long narrow clamp applied parallel to its long axis and the blood is again allowed to circulate. The cut edges are caused to protrude several millimeters when the clamp is applied, so that the incision can

be sutured at ease while the instrument is in position. This operation has not yet been tried on the living human subject, but in an eight weeks old calf Trenbranch of th pulmonary artery an ardelenburg was able to remove the left tificial thrombus consisting of a piece of lung taken fro manother animal and introduced into the circulation through an incision in the jugular vein. The compression of the great vessels, which lasted something over a minute, did not seem to embarrass the hearts action and the animal recovered from the operation.

-Medical Record.

ALCOHOL IS MADE FROM POTATOES.

Denatured alcohol is promised to replace electricity as the fuel of the future, says The Delineator for January.

Prominent influences are at work to promote the use of denatured alcohol. The New York company that is back of it has as its president a member of the United States consular service who re

signed his diplomatic position to serve in this capacity. Argument brought to bear at legislative sources this year succeed in having the revenue tax removed so that denatured alcohol now sells for

fifty cents a gallon. The department of agriculture at Washington has extended its co-operation by introducing and distributing through the country this seathe farmers will be able themselves to son a new variety of optato from which produce the alcohol. And there has just

been placed on the market an alcohol flatiron, stove and lamp burner, the entire set selling for only seven dollars. They operate as simply and readily as those run by electricity and at a cost of one cent an hour, which is cheaper even than kerosene.

Publication Office: 532 Altman Building.

A

O. L. McKillip, M. D., Managing Editor,

THE PROBLEM OF THE PACIFIC

COAST.

There should be a great deal of sympathy and co-operation assured the profession and authorities of our Western states in their present epidemic of plague. Certain misfortunes come to a people due to geographical location. For instance, the South has its yellow fever and its disease-carrying mosquito, the Eastern seaports are constantly warring against the introduction of infections by way of European immigrants. But what seems to be the greatest scourge and difficulty of them all is presented in the states of California, Oregon and Washington. Since the development of our commerce with the Far Eastern countries and since the appearance of the United States as a world power there has been brought to the Western coast constant menace in the introduction of transmissable diseases A few years ago San Francisco alone had to deal with this problem and she attempted foolishly to keep the public in ignorance that the dreadful plague was really in their midst. For fear that the city's business and reputation might be hurt seriously, reports of existing cases were denied and even the state board of health insisted upon covering up the facts about the true condition. As a result attempts at disinfection and quarantine were only partially successful and

WHOLE NUMBER, 339

cases continued to spring up for several years. The earthquake and consequent fires destroyed a great many filthy and rat-breeding houses, especially in Chinatown, which helped to stay the disease for awhile. This fall and winter the bubonic plague has again appeared there and other places on the coast in greater numbers than for the whole previous period. All the seaports in the Western coast are in constant danger of admitting the disease either in an active case or through the coming ashore of infected rats, so these cities and their immediate surrounding territory have to fight this Not pest as they never fought before. only the coast, but the whole country is in danger of the disease appearing in persons who have come through the infected ports.

The problem is one that will require the assistance of the whole country. The hygienic and medical welfare of this nation has grown to such great proportions that we need a bureau of health with a representative in the president's cabinet. In addition to that, some interstate cooperation should be given, for this is in a measure the concern of every state in the country. California and her neighbors will have to make a continuous and open fight against all disease-carrying pests and we should all be willing to at least stand the inconvenience of a care

ful quarantine in coming through their ports, of submitting our merchandise and baggage to disinfection, and of lending our efforts toward the establishment of a commission that will assist in eradicating this menace to their health and business. F. C. N.

TREATMENT AND DIAGNOSIS. It is unfortunate that too often men

who are busily engaged in the practice of their profession are inclined to base their diagnosis, and therefore their treatment, upon the description of the subjective symptoms which is given them by the patient without controlling their diagnosis and treatment by a careful investigation of objective symptoms which can only be obtained through careful physical examination or the analyses of the various secretions. The result is that not infrequently cases which would ordinarily be treated with the greatest celerity are unnecessarily prolonged, and occasionally the carelessly made diagnosis subjects its maker to a conseder able degree of humiliation and mental distress. There can be no doubt that brilliant conclusions, drawn from a patient's description of his symptoms, is an attractive method of diagnosis, but there can be no doubt that in a given number of so-called "snap diagnoses" a very large percentage will be found to be entirely, or at least in part, erroneous. As illustrative of the evil of basing a diagnosis on one finding we may cite an instance in which the parents of a child were caused untold mental suffering by reason of the fact that during an attack of subacute gastrointestinal catarrh, of rather obscure origin, the urine was submitted for microscopical and bacteriological examination, and the report made that it contained tubercle bacilli. Ultimately, the child entirely recovered, and it was found that the so-called bacilli were smegma bacilli.

In an interesting address delivered by Mr. Howard Marsh before the Reading, England, Pathological Society and pub. lished in the British Medical Journal of December 7, 1907, entitled "The Scientific Use of Evidence in Surgical Prac

tice," he quotes a number of instances of the character just spoken of, and seizes the opportunity to protest against the reaching of conclusions without careful study of the case, even in instances in which the diagnosis seems to be evident at first sight. Thus, he states that he has repeatedly seen cases of synovitis of several months' duration in which a gonorrheal infection was flatly denied, in which micturition was reported to be natural, and in which no appreciable gleet was present, but in which. when a laboratory examination made, gonococci were found, and when a catheter was passed stricture was detected. Again, he cites instances of a septic throat or a carious tooth, an old sinus or a cutaneous boil having been the source of an infectious synovitis for which no cause was evident to a careless examiner.

was

He also quotes the case

of a great consultant, universally revered, who diagnosed a case as one of "intercostal rheumatism," and prescribed for it as such, only to be cast into the pool of humiliation by the patient saying, "By-the-bye, sir, they tell me I have got an aneurism of my abdominal aorta," a condition which was most manifest as soon as a physical examination was made. The late Dr. James Hutchinson, of Philadelphia, was wont to say that most of our difficulties in diagnosis depended upon a lack of careful investigation of the patient, and John Hunter remarked, "Don't think-go and see;" while Mr. Haldane has recently said in an address that we do not think enough. As a matter of fact, John Hunter's advice can be improved upon, changing the words so as to read "Do think, and go and see."

In this connection we may remark that too often physicians in examining a case ignore the negative signs and pin their faith only upon positive ones. Thus, for example, failing to find bronchial breathing or subcrepitant rales in a given area of a lung they conclude that no lesion is present, when the very absence of breath sounds in that part, or a great diminution in their intensity, may be quite as valuable in aiding in determin