to pass before opening the bowel itself, so as to shut off the abdominal cavity. The second night following the operation the vomiting became more severe and was fecal in character, and the following morning she was in a state of fearful exhaustion. The bowel was quickly opened without anaesthetic, and almost at once there was a free escape of quantities of gas and soft fecal matter of vilest character, which had evidently been stored up a long, long time. Under the eye the distention of the bowel began to be relieved, and almost immediately her condition showed improvement. From that moment there was no more vomiting great quantities of gas and fecal matter were discharged, she began to take nourishment, and her condition rapidly improved until she was entirely comfortable. She was discharged at the end of thirty-two days and returned home.

These cases are hopeless, but I know of none where such prompt and efficient relief is given more promptly and efficiently than in these by some form of colostomy. This case above illustrates perfectly how desperate they are, and yet how prompt is the relief; and I have known a number of such cases to live in entire comfort for many months after the operation.

Mrs. E. R. Age, 37.

One week before this patient entered the hospital an abortion was procured by the use of a linen catheter. She flowed profusely for several days, vomited some, and had several chills; and a physician was consulted for the first time the day she entered the Hospital. On the morning of that day he curretted her, which was the proper thing to do. In the course of the curretting it was found that the sound passed without resistance its whole length into and through the uterine cavity, and the hemorrhage was increased. It was immediately surmised that the uterus had been perforated, and it was because of this that she was at once brought to the Hospital. When first seen by us on her arrival there was nothing characteristic. The only noticeable symptom was a very profuse flow of fresh blood from the vagina. I determined to make an immediate abdominal section, which was done; and a remarkably interesting and unusual condition was discovered. The abdomen was partly filled with freshly effused blood which could be seen slowly oozing from a slit in the anterior wall of the uterus, which was sufficiently large to admit a finger. The slit-like opening was irregular in outline but with definite margins, as if it had been incised. The uterus was as large as a three months' pregnant uterus, and was different from anything I have ever seen. A finger was introduced through the opening in the anterior wall, and the cavity of the uterus thus explored. The uterus itself was very soft and flaccid. The exploring finger found portions of the placenta attached to the fundus and anterior wall in the vicinity of the right cornu. The walls of the uterus were of irregular

thickness. There were wave-like depressions as felt from the outside, at the bottom of one of which was the perforation. The uterus was curretted through this perforation by means of a sharp currette on a flexible stem which was bent in such a manner that it could be introduced through this opening and reach the fundus. The remains of the placenta were so firmly attached that considerable force was necessary to separate them, and as this separation took place it was found that at the seat of attachment of this portion of the placenta was another depression in the substance of the uterus, at the bottom of which the wall was very thin and lacking in integrity. Had I not had the uterus in hand and been able to support it at the point of curretting with the hand outside, I do not see how this attached placental remains could have been separated without again perforating the uterus. It took some time. and the utmost care to succeed even under these conditions. After the placenta was all removed, the changes which took place in the uterus could be seen. It slowly but perceptibly became firm and smaller in size by contraction, and in a very short time the whole character of the uterus had changed; and it was so well contracted that all oozing from the injury in its anterior wall had ceased spontaneously. This point of injury was then sutured with catgut, a pus tube of the left side removed, together with the appendix, and the abdomen closed. The subsequent course was entirely satisfactory surgically. On the seventh day she had a chill in the afternoon which did not affect the pulse, and for several days thereafter had a diarrhoea which yielded, however, readily to treatment and proved to be without incident, and her recovery was satisfactory in every way.

Mrs. G. C. Age, 42.

This case was a very remarkable one. The tumor was very prominent and apparently extended from the pelvis (into which it had crowded a somewhat enlarged and retroverted uterus) up to the border of the ribs. It fluctuated. Through a median incision the tumor presented every appearance of an ovarian cyst; a finger in the pelvis, however, demonstrated that the growth sprang neither from the uterus nor from the ovaries. Examination of the gall bladder showed it to be normal, and the growth apparently had its origin outside of the ascending colon. It lay behind the peritoneum, which covered it, the latter being much attenuated. The ascending colon was pushed toward the median line. The peritoneum was split and readily separated from the tumor, which was finally delivered through an incision extending to the umbilicus. The most painstaking care in its removal discovered no pedicle, and it finally came away as a large, oblong, thin-walled cyst, weighing 61-4 pounds. After it was removed the right kidney was discovered in its proper position and normal in size upon palpation, the peritoneum collapsed, and the in

cision into it was sutured. A very much elongated and irritated appendix was removed, and the wound closed.

T. M. Age, 5.

This patient while on his tricycle collided with a wagon and was thrown under the rear wheel, one of which evidently attempted. to pass over his head. It must have squeezed the head to one side, as one displaces a cherry pit between thumb and finger, since it could not have gone square over the head without killing the child. It caused a very seriously lacerated wound, laying open and lifting the scalp from the top of the head and separating the temple muscle from its fossa, with a very considerable actual destruction of the scalp. The wound was ground full of mud and dirt, and of course the hemorrhage was something considerable. Because of my absence from town Dr. Geo. H. Earl gave the first attention, and wherever the tissues could be brought together and sutured. they healed by first intention. He anaesthetized and carefully and efficiently cleansed the wound and then sutured it. There was, however, such a loss of tissue that six weeks later a skin-grafting was resorted to, and the result has been remarkably satisfactory.

In the recent cases of skin-grafting which have gone through my hands, I have found a modification of the Tiersch method as carried out according to the usual methods which have been familiar to me, has been most successful. After the site to which the graft is to be applied is prepared, the grafts are cut in the usual way. Instead, however, of passing them into or through the salt solution, they are immediately transferred to the place to be covered and arranged in the position where they are to be left. In every case where this has been done, the results have been remarkably fine. The grafts have united immediately, there has been very little discharge, and the renewal of integument has literally resulted in a new skin.

Miss H. M. L. Age, 20.

Well until the age of fourteen, when she felt the premonitory symptoms of menstruation but there was no flow. About the 27th or 28th of each month she has headache and bearing down feelings in the lower abdomen, with pain in this region. Very frequent urination, at times urination involuntary. Bloats; no nausea; bowels constipated. Headache was somewhat relieved by the use of glasses. At the time of attack she has very severe backache, but not at other times, but never has been able to walk freely.

Examination showed that the external parts were absolutely normal, but there was no entrance to the vagina. At first, apparently, there was no vagina, simply a smooth protrusion between the labia. This gave a sensation of bogginess upon palpation. Examination through the rectum showed a fluctuation of the vagina with a solid body above, which was taken to be the

uterus, although it could not be properly outlined. The labia were separated and an incision was made into the protrusion, when there gushed out a thick, dark, tarry, sticky mass which was plainly confined blood. There was about three pints of this. The vagina had been distended by it for so long that it was a great cavity when fully evacuated, the walls of which were much thickened and irritated. The uterus was normal in size and position, as were the ovaries, and the whole trouble had been caused by an imperfect hymen which had become much thickened by constant irritation. This was freely removed, and with daily douching the parts affected almost immediately recovered themselves.

E. C. Age 8.

In January, 1904, had an attack of rheumatic fever lasting two weeks, affecting the left leg to the knee. As a result of this, several abscesses formed which were opened and have never healed. When first seen by me (March 30, 1905), there were sinuses, two above and one below. through which necrosed bone could be felt. The shaft of the tibia was also much broadened and thickened. These sinuses led down into the tibia itself, and through them probes (one above and two below), could be brought into contact. The leg over the tibia throughout the whole length of the shaft was very sensitive to touch. A diagnosis of osteo-myelitis was made. and two days later the leg was opened and the bone freely excised and thoroughly cleared out. He was in the hospital two months, and he left apparently cured and was about and active all the

summer.

The following January the leg began to be painful again, and on January 30 it was found to be red and swollen and tender at the lower part of the shaft, just above the ankle joint. This was immediately opened and trephined and thoroughly cleared out. after which it healed without any complications and has remained perfectly well.

The following comprises a group, small, to be sure, of cases which have proved very interesting to all concerned.

I was asked to see A. A., age nine, because of a bad knee, and found a very anaemic and puny child with a leg so badly affected that it was about to be amputated at the upper third of the thigh. The child was pallid to a degree and looked badly nourished. The limb from the junction of upper and middle thirds of the thigh down to the lower third of the leg was an indescribable mass of diseased tissue, apparently tubercular. The knee had already been excised for tuberculosis of the joint and the tissues were enormously proliferate and distorted and profusely secreting foul pus. My first impulse was to say, of course, the leg must come off, but when I looked beyond the leg to a perfectly-formed and beautiful and well-nourished foot and ankle; I hesitated and reasoned out that there must be good blood and nerve supply

intact to keep the foot in such perfect condition, that the leg could be amputated at any time, but that nothing in the world could replace this foot and leg if it could be saved. The saving of it, of course, meaning that the tubercular condition could be gotten rid of and ankylosis at the joint be secured.

The whole matter was talked out with the parents, who were remarkably intelligent about it, and it was explained that if benefit followed, it would require months and months of patience. They left the matter to me, and I brought the child to the Hospital.

The leg was opened wherever a pocket could be found and thoroughly cleared out, and at first there seemed little or no response, but whenever there was a tendency to pocketing or any lack of free drainage, immediately an opening was made and drainage established with iodoform gauze. The child began to improve very quickly. Regular hours with plenty of simple food, simply cooked, resulted in benefit. He was kept out of doors constantly, weather permitting, and later slept in a room, which was partly an out-door room. After improvement in his general condition began it was continually cumulative, and the appearance of the leg improved constantly. At present the leg is practically healed. One small superficial sinus still remains open, but all others have closed. During all this time the leg has developed with the other one, until the amount of shortening at present is no greater than when he first came under our care, nearly eighteen months ago, although in the meantime he has very markedly developed in all ways. He presents now the appearance of rugged health, with the exception of this leg, upon which he is now beginning to walk. He has been away from the hospital for several months, still wears the leg in a splint and goes about with one crutch, and ankylosis has taken place. The result is assured as a permanent cure.

Miss G. L. D. Age 26.

In December, 1904, she caught her foot in the braid of a skirt and fell and hurt her left foot, but was able to walk home. It swelled and was tender, but she kept about upon it for the following six months. At that time a plaster cast was put on which she wore for six months more, after which she wore a leather support for over a year. Then the foot was opened pus found and the part curetted, since which time it has failed to heal. When first seen by me last May, the foot was much swollen, inflamed, and boggy all through the middle portions of it. It was opened. on either side, thoroughly curetted and drained. the curretting removing a considerable portion of bone. This patient immediately showed improvement, not only locally, but in her general health, and in the following weeks there was a marked improvement in every way. The foot went a variable course. Whenever it became irritated at any point this was opened and relieved, and no pus was allowed to form anywhere under pressure. The result