operation, because it is a mutilating operation, and has, according to statistics, a higher mortality than the conservative section. This opposition, however, has been losing ground within the past few years. The reason for the high mortality is better understood. It is acknowledged that the statistics give a wrong view of the value of this operation. Those who are guided by these figures alone are misled. A study of the cases shows that many women delivered by the Porro operation were previously infected and in a hopeless condition. Quite a number of cases were complicated with fibroid tumors or malignant growths. In short, this operation has often been performed under circumstances when any other procedure was out of the question, as it would almost surely have resulted in death.

Recent statistics, published at Paris and extending over a period of four or five years up to 1896, show that both operations have given more satisfactory results. They give a mortality of 16 per cent. for the conservative Cesarean section and of but 10 per cent. for the Porro operation.

DR. CHARLES N. PALMER, of Lockport, N. Y. (by invitation).Some years ago I had an experience with a case of rupture of the uterus which was quite interesting. It was before the days of antiseptics, and, inasmuch as I have saved 100 per cent. of my cases of rupture of the uterus (that being the only one), I think it is worth while to report it. This patient recovered, possibly in spite of me, certainly in spite of the rupture. I was called to see a woman who had been in labor for thirty-six hours; she had been under the care of a midwife, and on arriving at the house I found the right arm and shoulder presenting. The traction which had been made had so forced the body of the fetus into the pelvic cavity that is was with the utmost difficulty that it could be pushed up in order to perform version. I was taken into the country, not knowing that the case was going to be other than a normal one. I was informed by the husband, who came after me, that his wife was in labor, that "everything was all right," and I went entirely unprepared for any such emergency. When I had found what the trouble was, I said to him: "You must make your horse go as fast as you can, and get medical assistance quickly." The pains were tremendous. They were exceedingly severe, so much so that I anticipated rupture of the uterus. I had no chloroform, or any one to administer it. I finally succeeded, after a good deal of effort, in pressing up the impacted fetus, so that I could introduce my hand into the uterine cavity, which I succeeded in doing. When I reached the vicinity of the fundus I found my hand was in the abdominal cavity. I felt the uterine walls, which were muscular in character; at

first I thought I was passing my hand outside of the placenta, but it was a mistaken sensation. I could feel the intestines also. I delivered a child twelve or thirteen pounds in weight which had been dead for some time, death being due undoubtedly to the manipulations made by the so-called midwife. Immediately after the delivery of the child and placenta there was every symptom of a severe type of strangulated hernia. In re-introducing my hand into the cavity of the uterus I found a mass of intestines as large as my two fists protruding into the uterus. By careful manipulation I succeeded in reducing them, holding the back of my hand against the uterine tear and, with external manipulation, getting up uterine contraction, I prevented the return of the intestines. In the mean time, I gave a large dose of ergot, and the uterine contractions still continued. About the time that the other doctor arrived there was again relaxation of the uterine. walls, with a repetition of the symptoms of strangulated hernia. I said to the doctor," Introduce your hand, and tell me what you find." He said, "My God! it's the guts." I said, "You are right; put them back, and hold them back until the operation is closed by uterine contraction." This he did, and the contraction becoming permanent no further displacement of the abdominal viscera occurred. Following, there was considerable peritonitis, for which she was treated by opiates in large doses, which was the usual practice at that time, and recovered, and has since had children without any trouble. (Here Dr. Palmer demonstrated the nature of the uterine tear on the blackboard.) It was in three directions from a given point, thus producing a large opening, without dividing any set of muscular fibres running in one direction to a sufficient extent to interfere with complete closure of the wound by general contraction of the organ. This accidental opening may possibly suggest the propriety of making a similar artificial incision when section is required, as securing better coaptation, and preventing, or nearly so, any tension on the sutures of approximation. Will some one try it and report?

DR. BRANHAM (closing the discussion).-I have only a few words to say in reply to the remarks that have been made. Dr. Hall's criticism was that in my first case a Porro operation would have been preferable to Cesarean section. Probably that is true. It is well to state here, however, that this patient did not have any forceps interference, but she was examined by a woman who was not a trained midwife, and sepsis may have occurred from this source. Outside of that the case was apparently favorable for Cesarean section. I will say, however, that if I should have such a case in the future, I would do a Porro rather than a Cesarean section, risking the chance of infection.

I think the doctor's criticism is justifiable, and I made up my mind on that point before.

Dr. Blume speaks along the same line. I am not thoroughly familiar with the statistics of the Porro operation, but I am sure he puts the mortality too low.

If

Dr. Palmer says that in his case he waited for contractions; he did not drain or wash out the uterine cavity. His patient got well. This was conservative surgery. A good many careful observers and great authorities recommend drainage, and there are some statistics favorable to this method. There is no question but that surgeons have known of patients who have died from rupture of the uterus by the conservative method, or by drainage, which is a conservative method. There is no reason why physicians should not report these cases. they have any successful cases to report, they are reported; but the unsuccessful ones are not always placed on record. When an operation is performed and the case terminates successfully, it is reported most generally. If a man has a case of conservative surgery and it gets well, he reports it; consequently, I have no doubt but that a large proportion of the cases of rupture of the uterus which occur are not treated at all surgically; they are treated by simply waiting, nearly all die and are never reported, and that is why there are favorable results from this method.

EXHIBITION OF SPECIMENS.

BY LEWIS S. McMURTRY, M.D.,

LOUISVILLE.

OVARIAN CYST AND CYSTIC OVARY UPON THE OPPOSITE SIDE.

THE first specimen I present is from a case of small ovarian cyst, with cystic ovary upon the opposite side. You will notice the vermiform appendix. The case is interesting on account of the relations of the appendiculo-ovarian ligament and of the blood supply of the appendix in women, making it more vascular than in man. It is interesting, furthermore, as showing how the appendix can complicate cases of inflammatory disease of the right ovary and Fallopian tube.

FIBROMA OF THE UTERUS COMPLICATED BY PREGNANCY.

The next specimen is one of fibroma of the uterus complicated by pregnancy. You will see from the photograph (Fig. 1) the condition of the tumor when it was removed from the pelvis. In Fig. 2 the uterine cavity has been opened, and you see the fetus. There is nothing of special interest in the clinical history of the case. The diagnosis was readily made. The tumor occupied the entire pelvis, with the impregnated uterus above so that it was impossible for the woman to have gone on to full term and labor.

TUMORS OF THE RIGHT AND LEFT OVARIES.

Here is a specimen of exceptional interest (Fig. 3), showing tumors of both the right and left ovaries. I show you photographs of the anterior and posterior aspect of these tumors. The woman had lost about forty pounds in six months before the operation. The pelvic symptoms were not very aggressive, although the mass could be made out by vaginal examination, when the tumors were enu

cleated. Hemorrhage was excessive, and, as there was a tendency on the part of the tumors to bleed, it created a suspicion of their being sarcomatous in character. Sarcoma of the ovary is more common than fibroma of the ovary. I sent sections of the tumor to one of our leading pathologists, and he said they were fibromata, and that he was unable to discover any evidence of sarcoma. Two months after the woman left the hospital, having recovered from the operation, she had an accession of symptoms about the pelvis, with effusion of serum into the peritoneum, and died with active general peritonitis and emaciation, and I am satisfied, from the clinical history, that the tumors were malignant. This case illustrates how often there will be a difference in diagnosis between surgeon and pathologist, the latter being deprived of the knowledge furnished by the clinical course.

SARCOMA OF THE ABDOMINAL WALL.

Here is a specimen of a large sarcoma of the abdominal wall, occurring in a woman fifty-five years of age. The operation was a very difficult one, and the dissection was extended down to the peritoneum; the place from which the tumor was removed could not be closed over; it had to heal by granulation. The woman recovered, and continues well four months after operation.

EXTRA-UTERINE PREGNANCY.

Here is a beautiful specimen of extra-uterine pregnancy. I operated in this case the day before leaving home. The history of the case is interesting, in that the woman had never before conceived, and she has a history of peritonitis and salpingitis beginning soon after marriage. Such a history very commonly attaches to these cases.