complications have set in; failure of surgeon to be thoroughly aseptic; slow operations which invariably cause shock; failure to employ the proper technique, which includes the best methods to prevent infection.

Whenever a patient dies we should ask ourselves several questions as to the cause of the death.

A great many deaths are caused by the operation being done too late or being done by a dabbler in surgery.

In either case surgery is not to blame.

The physician who claims to be favored by all his cases of appendicitis recovering without surgical aid, and who cries much against operations, is a dangerous man that should be disciplined.

This can be done by educating the public to the fact that his experience is necessarily limited, or that he handles the truth carelessly. A physician who never calls on a surgeon for assistance except for an operation in the last resort, should be held up to the public as a dangerous man.

All honor and practical appreciation should be given the physician who knows clinical pathology.

He is the man who will recognize the ominous signs of beginning danger and call to his assistance the aid of a good surgeon. Once in a while in operating upon a case of appendicitis in the latter stages of the acute form, we will have a "facer" when a patient dies of shock following one of our heroic efforts to save life. Deaths of this kind remind us of our limitations in such a forcible manner that we are made to feel the responsibility of endangering human life, even when that life is beyond hope.

I remember at this moment some sleepless nights spent in reviewing a fatal operation, struggling in vain to find in what detail of the work I might have acted differently, and perhaps saved a few drops of impoverished blood. It might have been better if no morphine had been injected before the anaesthetic had been given.

These fantastic ideas course through one's brains, keeping away slumber while the body is tossed from side to side.

The problem is still unsolved and sleep finally comes to our rescue. A few nights of this kind will dampen the ardor of the most enthusiastic operator, and unless nature has endowed him for the work and given him strength and such nerves and organs of sense that will enable him to stand the ordeals of hard work

in the day time and restless nights now and then, he will abandon surgery and devote himself to some other work in the profession.

VAGINAL OVARIOTOMY.

Mrs. F.-22 years of age, complained of severe bearing down pains for the past four years, menstruation regular but painful. On examination a movable tumor the size of a large orange was felt through the posterior fornix. The case was diagnosed as a left-sided ovarian cyst. The patient being placed in dorsal position with the hips well elevated, with scissors and dissecting forceps a transverse incision about one inch in length is made through the vaginal mucous membrane behind the cervix, the connective tissue is snipped through and the peritoneum opened with scissors and the tumor pulled down through the incision, allowing the pedicle to be ligated in the usual manner. The wound is completely closed with silver catgut sutures. patient received practically regular diet from the day of the operation and was out of bed on the eighth day.

OSTEOMYELITIS OF THE TIBIA.

This

Mrs. B.-Age 30. This patient has a history of injuring her leg four years ago; since that time she has suffered constantly; the pains are more severe at night. This is a simple or circumscribed osteomyelitis. There was a sinus on the inner side of the right knee leading down to the abscess cavity within the tibia. An incision was made through the sinus, which was opened down to the bone, the walls of the sinus were curetted, the bony walls of the cavity were cut away with a chisel and wooden mallet, the floor was gouged away and the walls curetted. This patient was discharged the ninth day with a healthy granulating wound.

COMPLETE RECTAL FISTULA.

Mr. V.—Age 32, operation, chloroform anaesthesia, patient in dorsal position, thighs flexed. The right ischiorectal region was dense and firm from the presence of cicatricial tissue. A grooved

director was passed along the sinus from without inward, the inner end of the director was brought down through the anus and the sinus tract was laid open with a curved bistoury, the second sinus was opened into the first incision, the wound was packed with iodoform gauze and a perineal bandage applied. Patient discharged on the eighth day.

APPENDICITIS.

Ella K.-Age 7 years, has complained of cramps in the stomach since she was five years of age. She has complained of severe attacks of colic with abdominal symptoms referrable to the right iliac region, accompanied with pain, tenderness and vomiting. There had been several attacks lasting from a few days to one or two weeks. Examination; well developed child, with pink face, lying on the back with knees drawn up; very compressible pulse, of a rather poor quality; tongue has a thick white coating; respiration costal and tight; abdominal movement slight; abdomen symmetrically distended; child protects right iliac region with hands; dullness in left flank; abdominal symptoms limited to right iliac fossa; palpation very difficult; there seems, however, to be a mass in the iliac fossa; temperature 105, pulse 170; child alsɔ has a severe attack of whooping cough. Operation under chloroform anaesthesia, laparotomy for evacuation of appendicular abscess. The tumor was found to occupy the whole right iliac region; the incision was made over the most prominent part of the tumor, through the outer border of the rectus muscle, and subsequently enlarged. The abscess was evacuated and contained over one-half pint of flocculent pus. The seat of the operation was thoroughly irrigated with peroxide of hydrogen filled with a normal salt solution and drainage applied. The temperature dropped within two hours to 99 degrees. In this case we got beautiful result with an intracellular transfusion of normal salt. solution in the gluteal region. This child has made a perfect re

covery.

THE UTILITY OF THE GENITAL VASCULAR CIRCLE OR CIRCLE OF AUTHOR.

By BYRON ROBINSON, B.S., M D.

Chicago.

The greatness of anything depends on its usefulness to man. Definition. The genital vascular circle consists of two segments -I, a spiral segment which is the arteria uterina ovarica 2, a straight segment the abdominal aorta, from the origin of the ovarian segment, the common and internal iliac arteries.

The spiral segment of the genital vascular circle accommo

Fig. 1. 1, 2, 3, the spiral segment of the genital vascular circle, the left side has no rami laterales genitalis. 4, 5, 6 the straight segment of the circle. 9- notes rami laterales uteri. 10 notes rami laterales oviducts. 15 notes rami laterales ovarii. 11- cervico vaginal artery. 12- ureter dorsal to uterine artery. Here it can be noted that the uterus oviducts andovary could be removed by severing the rami laterales genitalis only (9, 10, 15). The authors operation (endometrectomy and partial myomectomy) incises the uterus in the line 14 after which the lateral segment of the uterus is sutured dorso-ventral.

dates the rapid changes of position and volume of the uterus. It shows that the internal genitals are supplied by a vascular circle similar to that of the Willis circle (in the brain). The uterus, oviduct and ovary may be extirpated per vaginum without severing any segment of the utero-ovarian vascular circle, as advocated by Dr. E. H. Pratt, of Chicago (and the author also). The rami laterales to uterus and oviduct and ovary will need severing, but may be arrested by small pressure forceps, without a ligature. Mobility and distensibility of the spiral segment of the uteroovarian vascular circle enables the gynecologist to draw the uterus oviduct and ovary into the vagina with traction forceps, where the organs may be inspected, palpated and ligatures may be applied at leisure. One of the great principles of vaginal extirpation of the genitals rests on the anatomic fact that the spiral segment of the utero-ovarian vascular circle will yield and elongate sufficient to draw the uterus oviduct and ovary into the vagina for inspection and palpitation for repair and removal or for application of ligatures.

Fig. 2 shows the circle of Byron Robinson. It illustrates the utero-ovaran vascular circle with the fundus of the uterus drawn distalward. 1, the abdominal aorta; 2, common iliac; 3, internal artery.