from anyone else. The probable explanation for my mortality in appendicitis being between that of Deaver, Ochsner and Murphy is that my statistics here are culled from eighty cases only, while theirs are culled from a larger number of cases. The statistics to which Dr. Freeman refers of Drs. Deaver and Ochsner, in the discussion at the recent meeting of the American Medical Society in Saratoga, were culled from 416 cases. I, fortunately, heard Dr. Deaver's paper, as well as the discussion which followed. Dr. Deaver's mortality, in all cases, I believe, was about 15 per cent. Dr. Ochsner's mortality, as I remember it, including all cases, was more than Dr. Freeman has mentioned. I think that it was not far from ten per cent., including all cases, and leaving out his general peritonitis cases that it was about four per cent. The paper and discussions were both interesting and instructive and I cannot help but believe that there is a great deal in the Ochsner method if we can properly carry it out. But there is a chance that we may blunder very seriously by passing the best time to operate and by letting the case go too long. Ochsner's method in the beginning of an attack is not different from that of other surgeons. Ochsner himself, at the American Medical Association at Saratoga, in the discussion of these papers, stated, without any modification whatever, that in all cases operation should be performed early, if possible, within the first twenty-four or forty-eight hours. He stated that in studying his cases he had observed that if he got his case early it nearly always got well. He observed also that if a case came in after it had been ill five or six days, that there is where he got his greatest mortality. He found that when cases had been ill ten or twelve days he could operate with much more safety. He then began to develop this method. I think Ochsner is very fair in his statistics because he includes every case of appendicitis that comes into his hospital, whether it is operated or not. If a patient dies without operation, he includes it in his mortality statistics. It is probable that we will be able to strike a happy medium between Deaver, who may be a little too radical and Ochsner, who to some appears ultra-conservative. In my case of

hysterectomy for epilepsy, this patient was a girl 22 years of age who had been afflicted with epilepsy for a number of years, and the attacks were very much more common and very much more severe at her menstrual periods. There was also a marked ante

flexion of the uterus with adhesions, and it was at the urgent request of the family and all concerned that the operation was performed. The girl was practically demented. Dr. Delehanty, who is with us, probably knows something of the case. She was in the County Hospital in Denver. The report that I have had from friends of the patient is that she has fewer attacks since the operation and that they have not been so severe. I operated more at the request of the parents, in fact, entirely at their request, and as an experimental operation. I know very little about the value of these operations in such cases, but in a case where there is nothing else, apparently, that can be done, it seems to be quite a justifiable thing to do.

DR. FREEMAN-Mr. President: Dr. Perkins evidently misunderstood me. I am a very strong advocate of early operation in appendicitis, before the formation of pus and before the appendix ruptures.

DR. PERKINS-No, I did not misunderstand you. You must have misunderstood me. I know that you advocate early operation and that is also the generally accepted opinions of surgeons. It is only in the delayed cases that Ochsner follows the waiting method.

SEPTICEMIA AND THE CURETTE,

BY H. PLYMPTON, M. D.

To attempt to break up an old established custom in any line of life is at best, a thankless job, and one likely to call down harsh criticism upon the head of the daring iconoclast.

To attempt to uproot old prejudices existing in favor of a certain line of practice in surgery, and diametrically oppose such practice, is to invite from some, adverse criticism of the harshest kind. The only recompense for this is a logical refutation of, or concurrence in the argument advanced on the part of other members of the profession.

This latter is what I hope for, and if I provoke a discussion, or start a line of thought in the minds of half of the readers of this article, I shall have achieved all I started out to do.

Curetting the uterus to remove fragments of after-birth or other debris has been taught in our medical schools from time immemorial, and it is firmly fixed in the receptive and retentive

mind of every medical student that the first move following any such abnormal uterine condition, is to cleanse the uterus by means of the curette.

That the organ should be thoroughly and aseptically cleansed admits of no argument, but that work should be done with the curette, I deny most emphatically.

The majority of cases of death following the decomposition of foetus or placenta in utero, are caused by the use of the curette, and I hold that septicemia may be avoided if a more rational procedure be resorted to.

The condition of the uterus containing septic matter is one of great congestion; the thickened walls being coated internally and over the os with a thick, brown, tenacious mucus.

The congestion is active, and therefore the more dangerous in the event of the admission of septic matter into the circulation. If the curette is used, denuding the walls of their protective covering, an immediate vaccination takes place with a septic virus, septicemia following in an incredibly short space of time (chemical metamorphosis is marvelously rapid in the circulatory system) and death quickly ensues.

If without using the curette, we can remove the septic matter from the uterus without disturbing the mucus covering, and enable the uterus of itself to expel the coating, we shall have taken a long step forward in the treatment of this class of uterine cases. The uterus, by reason of its congestion, may be made to perform a self-cleansing act by exciting the exudation of the serum of the blood into its cavity, thereby washing itself out,and expelling all septic matter instead of absorbing it.

This process of exosmosis is induced by a properly combined alkaline solution at a temperature above 100 degrees and a strict avoidance of Bi-Chloride, Carbolic Acid, Formaldehyde, or any antiseptic of an acid reaction or astringent nature, which would coagulate the fibrin and albumen of the blood.

My method of procedure is as follows:

First, the gentle removal of whatever fragments are lying in the uterine cavity, by means of forceps, care being taken not to tear from the walls any adherent piece.

Second, the gentle flushing of the uterine cavity with the alkaline solution (110 degrees), the reservoir containing the fluid being not more than two feet above the level of the hips.

If the flushing could be continuously administered for a few

hours (say two or three), the conditions would be more speedily reduced to normal, but the discomfort of the position of the patient (on a douche pan) prevents this, and a flushing once every two hours with one quart of solution is about the limit of treatment.

For flushing the uterus, I use a small dilating uterine douche, and as there is plenty of room for the escape of fluid and fragments, there is no danger of fallopian colic or salpingitis.

The first flushing is frequently followed by contractile pains and expulsion of any previously adherent pieces, together with much of the mucus.

A tablet of Ext. Cannabis Indica, gr. 4

Ext. Ergotin, gr. 1⁄2

every hour till desired effect is produced will contract uterus and alleviate pain.

The bowels should be moved freely, both by enema and catharsis.

During the interval between douches, the patient should be kept on her back with the hips sufficiently raised to permit the retention in the vagina of as much of the alkaline solution as it will hold.

The rapidity with which this treatment will reduce temperature, relieve pain, stop vomiting and remove offensive odor is marvelous to one who has not tried it. Sometimes two flushings are sufficient to cleanse the uterus thoroughly; vaginal douches being all that are needed subsequently to complete the work.

Uterine congestion is speedily relieved, and the uterine discharge changes from brown, thick, bad smelling mucus, to a thin, transparent one, accompanied or followed by more or less of a flow of blood.

A reduction in the frequency of the flushings is desirable as soon as a tendency to return to normal conditions begins to be observed, as it frequently will within twenty-four hours. Then simple vaginal douches every three hours with an occasional uterine flushings if symptoms indicate it.

The action of exosmosis (and endosmosis, for there is every reason to believe in the absorption of some of the fluid), is what is desired to relieve the existing congestion, as in a bronchitis, pneumonia, congestion of kidney, congestion of any mucous membrane, etc., and is the most rational means of restoring to normal condition.

I do not wish to be understood as decrying the use of that most valuable instrument, the curette, but only the abuse of it to-wit its employment under such conditions as make it practically a sharp weapon loaded with septic matter, dangerous beyond the poisoned arrow of the Malay, or the fang of the Cobra, and utterly opposed to our modern ideas of antisepsis.

2 Macon street, Brooklyn, N. Y.

SURGICAL REMARKS REGARDING APPENDICITIS-REPORT OF CASES ON VIGINAL OVARIOTOMY-OSTEOMYELITIS OF THE TIBIA -COMPLETE RECTAL FISTULA

AND APPENDICITIS.

By HARLAN TRASK, M.D.,

Surgeon-in-Chief Electro Thermatorium and Surgical Clinic, Colorado Springs, Colo.

A few suggestions for operations: Avoid iodoform; avoid large needles and tight stitches; remember that a proper technique is very essential to success; clean surgery lessens mortality and morbidity. Colonic lavage is very beneficial in all abdominal congestions. Have the rectum as nearly aseptic as possible. If the adhesions have been extensive, before closing the abdominal wound, fill the abdominal cavity with normal salt solution. Before removing the patient from the operating table, flush the colon with a quart of normal salt solution through a high enema tube. Slight rise of temperature even if no actual sepsis rises, warns us that we have been erring in some way, and our methods as well as our materials, should be thoroughly overhauled.

To properly guard the peritoneal cavity with sterilized gauze is of the utmost importance.

Many of the clinical ailments of the pelvic and abdominal organs are caused by intestinal auto-intoxications.

There are many more fecal impactions than are supposed, and the proper use of high enemas has saved many lives without resorting to operative interferences.

The following conditions may contribute to the lack of success in the treatment of these diseases: Failure to live within the reach of a good surgeon; failure to send for a good surgeon soon enough; failure of a physician to diagnose the disease before