cobbler's stitch manner, and of an inch from the free peritoneal margin. After ligating the arteries these flaps were brought together by Lembert's sutures, it requiring some twelve of them. The peritoneal cavity was cleaned, a glass drainage tube, going down into Douglas' cul-de-sac, was introduced and the abdominal wound closed with silk sutures.

There was little shock, the temperature never reaching above 101° F., except for about one hour, during the action of the first cathartic, when it reached 102° F.2

COMMENTS.

It will be seen from this report that I used Schroeder's intraperitoneal method of treating the pedicle, with my addition of inserting the elastic tube through the cervix to expand and resist contraction of the tissues at the seat of the ligatures. I should use the same method again, including drainage, not only because the results were good in this case, but because I believe where it can be done, it is the ideal method. Kieth and Bantock admit that this is the true method, at the same time they get the best per cent. by fastening the pedicle outside. Schroeder, I believe, at the time of his death, had some unpublished statistics, showing a lesser mortality by his intra-peritoneal mode. Formerly the submucous fibroids with pedicle, were the only ones admitting of radical cure by surgical means. Now we make an abdominal incision and remove the subserous variety by enucleation, or by hysterectomy, in cases where the exigencies demand it.

I admitted before this operation that I did not know whether I had to deal with a cyst or a myoma. Mr. Tait says the differ- . ential diagnosis is extremely difficult. In a conversation with Dr. John Homans, at his private hospital in Boston, on the 2d day of this present month, he said to me: "It can not be done." I fully agree with his opinion as expressed, especially when, as in my case, the uterus could be well defined by vaginal and rectal exploration, the soft myoma enabling the sound to move the uterus without any perceptible movements of the abdominal tumor.

"Tumor was exhibited to Marion County Medical Society.

PRACTICAL DEDUCTIONS AS A TEXT FOR WHICH THIS CASE

WAS REPORTED.

This case teaches these lessons: That exploratory incision is warranted when the diagnosis can not be clearly made out (and our most experienced abdominal surgeons admit we can never do it with certainty) provided he who does it is fully prepared to do any operation known to the surgery of the abdomen, and is able to care for his patient afterwards according to the most approved methods, to detail and provide the same surroundings for his patients as do those operators whose increased personal experience and success, has given them such a low rate of mortality that they unhesitatingly publish their death-roll with their successful operations.

After an experience yielded by seven or eight hundred cases, approximately, of laparotomy for various causes, extending over a period of twenty-three years, Dr. Thomas feels that he can say with truth that he has never once regretted opening the abdomen, and that he has in a dozen cases, at least, deeply regretted not having done so. He, at least, thinks it certain that in the future, explorative abdominal incisions will become the rule in all cases of the following conditions which do not yield to medical means, and concerning the etiology of which there is great doubt: 1, wounds and injuries of the abdominal viscera; 2, intestinal obstructions; 3, the presence of stones in the bladder or kidneys; 4, the accumulation of blood, pus, or serous fluid from any source; 5, the existence of a neoplasm in any part of the abdomen; 6, the occurrence of serious organic changes in certain of the viscera of the abdomen, such as the kidneys, the spleen, the uterus, the Fallopian tubes, or the ovaries; 7, ectopic gestation.*

This noted abdominal surgeon has completely cured a number of aggravated cases of ascites after tapping had been repeatedly resorted to, and all hope of recovery given up. He feels justified in assuming the position that in cases of ascites in the female, before the patient has been subjected to the usual practice of repeated tapping with its universally bad results, the most thorough investigation as to the existence of small neoplasms as pathological factors should be made; and if sigus of their existence be found,

Before New York City Medical Society.

exploratory incision should be made with the forlorn hope that relief might be obtained.

I can cite two cases of my own, where exploratory incision as a means of diagnosing abdominal tumors might have been the means of saving two valuable lives. A lady of Peru, Ind., under the care of Drs. Brenton and Higgins (at the time I saw her), had consulted two very eminent operators before she consulted me. Each insisted that the sound passed ten inches into the uterus, and that therefore it passed into the enormous tumor which distended her abdomen from pubes to ensiform cartilage, and hence nothing could be done. She had been tapped once, and three gallons of fluid drawn from her abdomen. During six years she sought the best advice with the view of an operation. When I saw her she was already poisoned by sepsis; pulse 140, temperature 103° F. I was asked to make an exploratory incision. I found a tumor weighing about twentytwo pounds, displacing the pelvic viscera, and in an advanced state of decomposition. It was subserous and pedunculated. The pedicle was small. When I seized the tumor with my hand my fingers pierced it, dragging away a rotten piece, pus dropping from it as I lifted it up. She lived only twenty-four hours. If an exploratory incision had been made even one year before, this life might have been saved, for the pedicle was small and the uterine cavity not deeper than four inches. The tumor was exhibited to the Marion County Medical Society, 1885.

Case number two, a lady from Hamilton county had been cared for by a physician of Noblesville. I was asked to see her, with Dr. H. S. Herr, of Westfield, Indiana. Her distended abdomen was very suggestive of ascites. A few days after I saw her she died. No operation was made. These facts of the case were determined by post-mortem. The cyst was found ruptured — probably six months before death, since the abdomen had been that long distended. No doubt was felt that had an exploratory incision been made in proper time, the patient would have had a fair chance of

recovery.

I cite these two cases from my own practice in confirmation of Prof. Thomas' views of exploratory incision.

Dr. R. S. Sutton, of Pittsburgh (the Lawson Tait of America), speaks in the following terms of exploratory incision :

"Make a clean cut down to the peritoneum, divide or tear the latter, after making a small opening in it, as one's fancy runs. Introduce the requisite number of fingers or the hand, turn out the intestines on a clean towel, look them over for wounds or obstructions, examine a tumor, or tubes, or ovaries, or uterus, or bladder, kidneys, or liver, or spleen. Having done this carefully, clean out the cavity with gentle sponging or irrigation, carefully return the viscera, carefully close the wound if all has been clean and the cavity of the peritoneum is left dry. I say, you have not done anything that will kill your patient, but you have cleared up the case, possibly saved a life.

"These measures must be observed if success will follow such practice. And when this practice obtains, fewer people will die, and fewer will be hanged for killing them with pistols, guns and dirks. People who die now for want of an ante-mortem examination will be spared the post-mortem, which rarely does the patient any good. Such scenes as a hospital staff turning away from a woman dying from the twisted pedicle of a large ovarian cyst will be no more. Such practice as is witnessed when a doctor sits by and gives opium until the post-mortem reveals the fact that an intestine was shot, or stabbed through, or that an obstruction killed the patient, will vanish."

He then discusses who should do the work in the following strong language:

"The best law any general practitioner can lay down for himself and his patient, in abdominal tumors, is this: If you can't do a radical operation, under proper precautions, do nothing. The patient should be sent to some one prepared for and capable of doing the work. In Europe and in Great Britain this rule prevails practically, and hence prominent operators get many cases, and it is from these men that the improvements in abdominal surgery have emanated. Simple bushwhacking in abdominal surgery is a very poor way to make a reputation. All such cases done in a lifetime will rarely exceed a dozen, and if this dozen comprise all the experience the operator gained up to the time of his demise, it has done humanity very little good. When the work in this country is put out to the men prepared to do it, and the cases are not bungled at the start, then we will have just as good results as are found abroad. When men who have not had special clinical training in abdominal surgery cease to do it, and act for the good of the

patient rather than for something else, then this branch of surgery will do well in this country. The present range of abdominal surgery is very extensive. The liver, gall bladder, spleen, kidneys, urinary bladder, intestines, ovaries, tubes and uterus, are all, under diseased conditions, successfully attacked."

Indiana women are as worthy of successful abdominal surgery as are those in any part of the world. Let us remember, then, that those who have placed laparotomy on a solid foundation were surgeons who had more or less abandoned the general practice of medicine, some of them at a great sacrifice, that they might secure that prime element of success in abdominal surgery-a large personal experience in the work. Booth would not think of playing Hamlet with new support each time. So, those who have published statistics, bad as well as good, demand that their patients shall have specially drilled attendants, whose increased personal experience in the work is a wonderful supplement to the skill and experience of the operator.

Mr. Tait, in speaking of the danger, care, results, and who should operate, says:

"What I fear, in fact what I already feel, is that the remarkable success which I have had, and of which Professor Byford speaks in such strong terms, is really leading astray those whose opportunities have not been as my own, into the belief that the work is easy, simple, easily acquired and free from risk. It is not so, and unless those who practice it, choose to follow me in the rigid precautions and immense care which I give, not only to the mere performance of the operation, but to the surroundings of my patients and to every detail in connection with them, they will not obtain, they must not expect, the success which I have had. I have said that I fear, in fact, I already feel, that this success of mine is leading people astray, and I want to urge in the name of humanity, as well as for the sake of the art we practice, that there should be less of the indiscriminate rushing into this kind of work which has already been deplored on both sides of the Atlantic.”*

From Journal American Medical Association.

Italics my own.