The Medico-Legal Aspect of 
Abdominal Section. 
Read in the Section of Medical Jurisprudence at the Forty-first An- 
nual Meeting of the American Medical Association, held in 
Nashville, Tenn., May, iSgo. 
“ She Thought it was Her 
Change of Life.” 
Read by Title in the Section of Obstetrics and Gynecology, at the Forty- 
first Annual Meeting of the American Medical Association, at 
Nashville, Tenn.,June, iSyo. 
BY 
A. VANDERVEER, M.D., 
OJi-jrtSSNY; N. Y. 
PROFESSOR DIDACTIC, ABDOMINAL AND CLINICAL SURGERY 
ALBANY MEDICAL COLLEGE. 
Reprinted irom the “Journal of the American Medical 
Association,” July 5 and July 12, 1890. 
CHICAGO : 
Printed at the Office of the Association. 
1890. THE MEDICO-LEGAE ASPECT OF 
ABDOMINAL SECTION. 
A year ago I had the pleasure of presenting to 
the Section on Obstetrics and Diseases of Women 
and Children, American Medical Association, a 
paper on “Concealed Pregnancy, and its Rela- 
tion to Abdominal Surgery.” In the prepara- 
tion of that paper considerable time was devoted 
to the compiling of a table of cases wherein ab- 
dominal section revealed an undiagnosticated 
pregnancy. This table is measurably complete, 
and journals, by extract and summaries, have 
given a wide circulation to the paper and the 
table. While that table was in preparation, from 
letters and other sources, my attention was called 
to the medico-legal aspect of abdominal surgery, 
in its general relations, and to the probable testi- 
mony of expert witnesses in the cases where an 
action for malpractice is brought. For this, and 
the other reason that two American surgeons 
have already been compelled to plead to an in- 
dictment of manslaughter, it seems to me profit- 
able to join this paper rather as a supplement to 
the one of last year by considering certain medi- 
co-legal points of abdominal surgery. A letter from 
a very eminent American surgeon in relation to one 
of these cases, says, “For my part I do not see how 
the error occurred,” and I have numerous other 
letters stating that we ought never to be unable to 2 
diagnosticate pregnancy, especially after the 
fourth month. Testimony such as this would 
have been very dangerous to such as Professor 
Freund, Karstrom, Wm. Varian, Professor Czerny, 
Professor Byford and others equally as compe- 
tent, had they been placed on trial for malprac- 
tice. 
We all may at any moment be placed upon our 
defense by clamor of the public press, which 
seldom, very seldom, gets down on the right side 
of any medical question. Dr. Mary A. Dixon 
Jones is a conspicuous example of newspaper 
persecution, which happily she overwhelmed. 
Designing attorneys, with prospects of good fees, 
may urge unwilling people into litigation, or ava- 
ricious relatives may, failing in levying black- 
mail, institute an action. Motives no different 
from these give rise to nine-tenths of all actions 
for malpractice. 
In case of the death of the patient the surgeon 
may be proceeded against, criminally, by an in- 
dictment for manslaughter, and civilly, by an action 
for damages. One action criminal, is no bar to 
another civil, for damages, nor can the result in 
one prejudice the result in the other. If the sur- 
geon be proceeded against by an indictment, in 
my own State, New York, the indictment is 
drawn under the provisions of the Penal Code, 
Section 195, viz.: “A person who, by an action 
of negligence or misconduct, in a business or em- 
ployment in which he is engaged, or by any un- 
lawful negligence or reckless act, occasions the 
death of a human being, is guilty of man- 
slaughter in the second degree.” 
In States where no statutory provisions have 
been enacted, the indictment is drawn at com- 
mon law. At common law, ‘‘If a physician or 
surgeon or any person assuming to be such, by 3 
his gross negligence, or gross ignorance, or by 
his rashness or want of proper caution, causes 
the death of his patient, it is manslaughter.” 
(Field’s Medico-Legal Guide.) 
As the statutory provision is drawn from the 
common law and depends for its interpretation 
on the interpretation of the common law, we can 
find no clearer demonstration than that of Lord 
Ellinborough (Rex vs. Williamson, 3 C. & P. 
635), in his charge to the jury. He says, “To 
substantiate the charge of manslaughter the de- 
fendant must have been guilty of criminal mis- 
conduct arising, either from the grossest ignor- 
ance or the most criminal intention. One or the 
other of these is necessary to make him guilty of 
that criminal negligence and misconduct which 
was essential to make out a case of manslaughter. 
It does not appear that there was any want of 
attention on his part and from the evidence of 
the witnesses, on his behalf, he possessed some 
degree of skill.” (The defendant in this case 
had forcibly torn away a prolapsed uterus, fol- 
lowing delivery). ‘‘I think the defendant could 
not possibly commit such mistakes in the exer- 
cise of his unclouded faculties, and I own that it 
appears to me if you find the defendant guilty of 
manslaughter, it will tend to encompass a most 
important and anxious profession with such 
dangers as will deter reflecting men from entering 
into it.” (The verdict not guilty was entered in 
this case). So far as I am able to learn, charges 
to juries have been uniformly that gross neglect 
or gross ignorance, or both, must be shown on 
the part of the prosecution beyond a reasonable 
doubt before conviction can be had. Then, as 
has already been shown, the prosecution must 
stand or fall upon the proof of gross neglience or 
gross ignorance, one or both, or in other words, 4 
criminal misconduct. Gross ignorance and gross 
negligence are both questions of fact, and must 
be passed upon by a jury. In consequence, 
the standard of care and skill form that, and 
other facts and conditions, must be a variable 
one. But they are not questions of fact 
purely. It is the duty of the court to charge 
the jury with reference to degrees of care and 
skill by definition and illustration. It has been 
maintained that it is impossible to make precise 
distinctions between negligence and gross negli- 
gence. Mr. Justice Bradley (U. S. S. C. Reports,) 
says, “In deciding the question of negligence 
where there is any conflicting testimony, and 
ordinarily where there is not, all the facts and 
circumstances should be submitted to the jury 
with instructions to the jury that in deciding 
whether there was ordinary care or gross negli- 
gence, they are to consider the position of the 
party, his business, his duties and responsibili- 
ties, and that the same act which under some cir- 
cumstances would not show any degree of negli- 
gence might under others, show want of ordi- 
nary care ; and under still other circumstances 
might show gross negligence, and this should be 
settled by the jury as a question of fact, and not 
by the court as a question of law.” 
Gross ignorance is open to the same objection 
that gross negligence is, viz.: of being relative. 
That which under some circumstances would be 
ordinary skill, in other circumstances would be 
ignorance, and, in still other circumstances, would 
be gross ignorance. The very favorable rule of 
law has been laid down that, “The least amount 
of skill therefore, with which a fair proportion of 
the practitioners of a given locality are endowed, 
is taken as a criterion by which to judge the 
physician’s ability or skill.” (Bouvier’s Inst. 5 
1004-5O ‘ ‘The surgeon must adopt the means and 
apply the skill well settled by the highest lights 
of his profession. He must possess and practi- 
cally exercise that degree and amount of skill, 
knowledge and science which the leading author- 
ities have pronounced as the result of their re- 
searches and experience up to the time, or within 
a reasonable time before the issue or question to 
be determined is made.” (Elwell on Malp., 55.) 
Again surgeons residing in the large cities with 
hospitals and other superior advantages, will be 
required to possess greater skill than those living 
in localities remote from such advantages, and 
there seems to be a concensus of judicial opinion 
that unless specifically contracted for, the sur- 
geon is only bound to exercise the ordinary csfre 
and skill. 
By way of illustration let me present a single 
case the kind of which is not likely to occur 
again. Surgeon A. is called to a case of abdom- 
inal tumor. By examination he finds that the 
patient is thirty-six years, married twenty years, 
no children. The tumor has been growing eight 
months. Patient has never menstruated regu- 
larly, often not flowing for five or six months, 
and now has not menstruated for eight months. 
She has vomited and been constipated at intervals, 
has felt no quickening and does not believe her- 
self pregnant. Vaginal examination reveals a 
cervix high up, somewhat enlarged, os uteri not 
patulous or particularly enlarged, unable to make 
out body of uterus. Upon abdominal examina- 
tion a distinctly fluctuating tumor is made out 
located centrally and evidently from the physi- 
cal signs contains fluid within a cyst. The diag- 
nosis of ovarian cyst is made, and an operation 
proceeded with. Upon opening the abdomen the 
tumor appears. The walls are thin and not of 6 
unusual appearance ; the trocar is introduced and 
six quarts of fluid withdrawn, after which the 
operator finds he has tapped a pregnant uterus. 
He completes the operation by a Caesarian section, 
and in five days the woman dies of septicaemia. 
Surgeon A. is indicted for manslaughter, the 
indictment averring that he through gross igno- 
rance, by gross negligence, by rashness or want 
of proper caution, caused the death of his patient. 
The indictment is drawn under the provisions of 
the common law of the State in which he resides. 
Surgeon A. pleads not guilty, and the trial is 
proceeded wfith. The prosecution prove the facts 
as have been heretofore stated, and call expert 
witnesses to prove gross ignorance, gross negli- 
gence, want of caution or rashness. The only 
way they can demonstrate the facts so essential 
for conviction, is by expert testimony. The 
chief question involved and presented with earn- 
estness : Was there sufficient symptoms of preg- 
nacy present to arouse the suspicion of preg- 
nancy, and did the defendant exercise sufficient 
care and skill in making his diagnosis ? The 
opinion of the witnesses for the prosecution is 
that sufficient symptoms, amenorrhoea, vomiting 
and the presence of a tumor was sufficient evi- 
dence of pregnancy to require a most searching 
examination before pregnancy could be excluded, 
and that the defendant was negligent and un- 
skilled in his examination. It is shown that he 
did not examine the breasts for the changes that 
occur in pregnancy, that he did not inspect the 
vagina for the change in color (wrine leaf), he did 
not seek to illicit ballottement, that he did not lay 
sufficient stress upon these and other symptoms 
as to the probabilities of pregnancy, and that a 
proper explanation of the possibilities of her con- 
dition was not made to the patient and to her 7 
friends, previous to the operation. That no sug- 
gestion was made by the operator as to the neces- 
sity of exploratory incision, if at all in doubt as 
to the diagnosis. 
The defendant showed by competent witnesses 
that he had exercised the average care and skill 
in examining the patient, that he had not acted 
with undue haste or rashness, and that he was hon- 
est in his belief that the case was one of ovarian 
cyst. He admitted having committed an error 
of judgment, which he ’ believed was liable to 
occur in the hands of surgeons of good reputa- 
tion under existing circumstances. The case 
was ably tried and the jury brought in a verdict 
of guilty. It was carried to the next court, and 
there the court on argument overruled the ver- 
dict, presenting some very strong points on the 
subject, part of the line of argument being that 
the surgeon was shown to have been a man of 
great experience, of large practice, a man who 
stood extremely well with his professional breth- 
ren, who had for years maintained a high reputa- 
tion, very far above the average. That the verdict 
rendered by the jury was not for the public good 
and that the conviction ought not to stand. No 
further attempt was made by the prosecution. 
Another case which illustrates ninety-nine per 
cent, of the cases of concealed pregnancy, where 
an operation has been done, is surely not so easy 
of diagnosis, being that of Surgeon B., having a 
patient aged fifty, married many years, always 
sterile. Fibroid had existed for twenty years or 
more, pregnancy not suspected. A hyste- 
rectomy was done for the removal of the fibroid, 
and when the uterus was opened, to his own and 
everybody’s surprise, the surgeon brought out a 
buxom foetus which seemed also very much sur- 
prised, for it immediately began to cry. It 8 
proved to be at least eight months old and all 
right. There was also a very large fibroid which 
was very vascular. Unfortunately the patient 
died soon after. Surgeon B. was tried for man- 
slaughter and acquitted. 
Perhaps one of the most unpleasant cases of 
malignant persecution is the case of Surgeon C., 
where after careful explanation to the patient of 
the physiological change that would take place, 
and her condition after the operation, it was 
finally decided to remove the uterine appendages. 
The operation was done, the patient recovered, 
and some months afterward a suit was brought 
against Surgeon C. for wilful mutilation. It was 
shown that all proper explanation had been made 
to the patient and to her friends, that the opera- 
tion had been skillfully done, and the patient 
made a good and speedy recovery, and yet the 
jury disagreed. A second trial took place some 
time after and the surgeon was acquitted, yet he 
had been to great expense in his defense and had 
lost much valuable time, but the laws of his State 
afforded him no redress whatever. I might cite 
other cases, but can say earnestly, and for the 
comfort of the honest and well-meaning surgeon, 
that I have not been able to find a case where 
conviction has occurred and the higher courts 
have sustained the verdict. A careful study of 
the rulings of the courts and charges made by 
judges to juries in such cases, brings up promi- 
nently the fact that the law recognizes no one 
school of medicine. The doctor must practice 
the necessary skill in the diagnosis of his cases 
and he must exercise the average degree of ability 
in the doing of the operation, and that he is not 
supposed to do more than is required of the 
person possessing an average amount of skill. 
Another point that seems to have been pre- 9 
sented with considerable force by some of the 
rulings, is contributory negligence on the part 
of plaintiffs. In several operations it was shown 
that the plaintiff wilfully withheld from the 
surgeon certain symptoms, and that she purposely 
misled him by making statements of conditions 
that did not really exist. This would have 
been the case had Drs. Prince and Varian’s 
cases been presented for trial. Beyond a doubt 
on these points alone plaintiffs would have been 
ruled out of court. 
Referring once more to the case of Dr. Jones, 
which has been so recently before the profession, 
she says in answer to a letter of mine that “She 
is glad to know that the subject of the medico- 
legal aspect of abdominal section is to come up 
for discussion at this meeting,” and states as fol- 
lows : “There is a necessity to look into these 
subjects. Under the existing laws of the State 
of New York, a surgeon has no protection. If, 
in his efforts to relieve the sick and suffering, he 
decides to do abdominal section, or indeed to per- 
form any surgical operation, and if, notwithstand- 
ing his best directed efforts, the patient should 
die, he is liable to, or may have a suit for mal- 
practice or an indictment for manslaughter in the 
second degree. If the patient lives and does well 
there may still be a suit for malpractice. The 
surgeon may spend his strength, his time and 
give his best efforts to relieve the suffering poor, 
yet under the law, and b}' the law, these same 
persons, for whom he has labored, may turn and 
rend him and use every effort for his destruction, 
personal and professional. Malice at any time 
may so construe the law that at any unexpected 
moment the surgeon or physician may find him- 
self in the most serious and unpleasant difficul- 
ties. Thus it is simply dangerous to practice 10 
medicine and surgery in the State of New York. 
A distinguished lawyer said to me the other day, 
that however well prepared he might be, yet he 
would not, as the law at present stands, dare to 
practice medicine, and he thought he had about 
as much courage as most people. 
Section 200 of the Penal Code, says: 
Liability of Physicians.—A physician or surgeon who 
being in a state of intoxication administers a poisonous 
drug or does any other act as a physician or surgeon to 
another person which produces the death of the latter is 
guilty of manslaughter in the second degree. 
But according to Judge Bartlett’s ruling, “Phy- 
sicians are also liable under Section 193 of the 
Penal Code in connection with the proceeding 
provisions.” Subdivision 3 of Section 193 says : 
“By any act of procurement or culpable negli- 
gence.” This comprehends a great deal and can 
be made to mean anything. A physician or sur- 
geon though he may have the best preparation, 
yet by any act of procurement as administration 
of medicine or surgical operation, if the patient 
dies he may be found guilty of culpable negli- 
gence. There will always be found physicians 
who would have used different procedures, or 
advised another course as preferable. 
If a surgeon for the welfare of a patient deems 
it best for him or her to perform abdominal sec- 
tion and death ensues, malice can, under subdi- 
vision 3 of Section 193, have him indicted for 
manslaughter in the second degree. 
If a surgeon neglects to perform abdominal 
section, when in the estimation of another it 
should have been performed, and the patient dies 
in consequence of the pelvic conditions, that sur- 
geon under Subdivision 3 of Section 193, of the 
Penal Code, can be found guilty of culpable neg- 11 
lect, and indicted for manslaughter in the second 
degree. 
Judge Bartlett says further : “If a person 
assumes a certain amount of skill, and does not 
develop that amount of skill, his act is guilty 
of culpable negligence.” How largely malice or 
blackmail may misjudge this skill and use the 
law for direct persecution, or as the New York 
Medical Journal puts it, for “Roasting Physi- 
cians.” 
Notwithstanding the strong points she presents, 
I am of the opinion that the courts have ruled in 
justice to all concerned in these cases. It is 
necessary that the public have proper protection, 
that while we must advance in our profession only 
by experience and accumulated skill in the doing of 
untried operations, yet in their performance great 
caution and the careful study of cases becomes 
a necessity. It will be observed that, while it 
has been a great hardship and required much 
resolution for the surgeons who have been 
attacked to defend themselves, yet they have in 
the end triumphed. 
What I would like to see as the result of this 
discussion is, the betterment of our laws in this, 
that surgeons may have better protection in the 
recovery for loss of time, for expenses they have 
been put to, when it is proven that the case was 
urged by some disreputable lawyer, or by those 
personally malignant, within or without the pro- 
fession. 
My conclusions would then be : 
1. That we should exercise the greatest care in 
the examination of our cases of doubtful diag- 
nosis. 
2. That when in doubt we should lay great stress 
upon the necessity of an exploratory incision, 12 
and make a very proper explanation of what this 
means to the patient and friends. 
3. That in the cases thus far brought to trial, 
we have reason to believe that the judges in their 
rulings have treated our profession with great 
fairness, the strong points being, that the public 
good is not subserved by undue and wilful perse- 
cution of the surgeon who has shown the proper 
amount of intelligence in his profession. 
4. That we should seek still to have the law so 
made in our favor as. to eliminate the cases of 
wilful prosecution. 
5. That in the careful study of these cases we 
have presented the lamentable condition of expert 
testimony. Men absolutely ignorant upon the sub- 
ject, men who have never done an operation of 
any merit in surgery, being allowed to come upon 
the witness stand and testify as experts. “SHK THOUGHT IT WAS HER CHANGE 
OF LIFE.” 
REPORTING CASES OF UTERINE POLYPI, UTERINE CANCER, 
INVERSION OF UTERUS AND SUB-PERITONEAL FIBROID. 
The object of this paper is to concentrate upon 
certain cases that occur in our consultation prac- 
tice, and in the practice of the overworked gen- 
eral practitioner, a closer and more positive ex- 
amination for the purpose of a correct diagnosis. 
I will proceed at once to the report of a case that 
will help to illustrate what I have in mind. 
Miss M., aet. 47, a well-to-do maiden lady re- 
siding in a small country town, had been in good 
health, regular in her menstruation up to the age 
of 44, when she began to flow more excessively 
at her menstrual periods, and soon thereafter de- 
veloped a condition of both menorrhagia and 
metrorrhagia. After this condition had lasted 
for a year, and when she was quite anaemic, some- 
what exhausted and losing in flesh, she consulted 
her family physician, Dr. B., who treated her for 
some time with tonics, rest and diet, with some 
little benefit, and yet not much improvement as 
to the excessive flowing. He suggested making 
a careful examination as to her condition, but this 
she positively refused to have done, saying that 
“she believed it to be only her change of life.” 
He treated her for another year, at the end of 
which time she was confined to her bed, and yet 
refused to have any local treatment. When she 14 
had suffered for nearly three years, and in a con- 
dition when there was much oedema of the ex- 
tremities, her lips colorless and a profound state 
of anaemia present, at the earnest solicitation of 
the members of her family, she finally yielded, 
and the doctor was permitted to make an exam- 
ination which confirmed his previous suspicions 
of a uterine fibroid. It presented in the form of 
a simple polypus projecting from the external os. 
Her condition was made known to her and an 
immediate operation urged. I was sent for on 
October io. 1887, and found her in such an ex- 
ceedingly feeble condition that I really feared she 
might die from the additional slight shock of the 
operation. She, however, was very willing to 
have done what seemed to be best, was now en- 
tirely passive, knowing that she could live only 
a short time if not helped in some way. I found 
a large polypus filling the cavity of the vagina, 
and attached by a moderately-sized pedicle to the 
internal os. Around it I was able to pass the 
chain of the ecraseur, and to remove it without 
any great trouble, not giving the patient an an- 
aesthetic, as I feared she would be unable to endure 
it. Cavity of the uterus was curetted thoroughly, 
washed out with a weak solution of bichloride and 
packed with iodoform gauze. This was removed 
at the end of forty-eight hours and afterwards 
vaginal douches made use of containing boracic 
acid in solution. This patient ultimately made 
a complete recovery, although her convalescence 
was somewhat slow in consequence of her ex- 
ceedingly weak and exhausted condition. 
I present this as a case familiar to many of us, 
illustrating a class of cases where procrastination 
on the part of the practitioner, absolute indiffer- 
ence and stubbornness on the part of the patient 
often costs the latter her life. Women seem to 15 
have in their mind the idea that they must expect 
all sorts of conditions to present at the time of the 
menopause, and are too negligent, too frequently, 
in having their cases properly looked into. 
Belonging to another class of cases, which are 
far more sad, are the following: 
Mrs. B., set. 33, married, mother of three children, 
has always been in good health, family history 
good, youngest child 3 years of age, whom she 
nursed and weaned at the age of 14 months. Men- 
struated regularly after that until six months previ- 
ous to her admission into the Albany Hospital, Sep- 
tember, 1886. During that time her flowing had 
continued almost constantly. She suffered little 
pain, but was much weakened, had emaciated 
somewhat, and continued attending to her house- 
hold duties, refusing all local treatment. Her 
family physician finally told her that he would 
have nothing more to do with her case, and that 
she must go to the hospital, where she came under 
my care. On making an examination, I found an 
epithelioma that embraced the entire cervix, ex- 
tending to the lateral walls of the vagina, to the 
under surface of the neck of the bladder, and ex- 
tending up along the lower portion of the urethra. 
It was absolutely impossible to do anything for 
her in the way of treatment or operation, and 
when she was informed of her true condition the 
sadness of the scene is but too well known to 
many of us. This illustrates a class of cases by 
far too numerous as they present in hospital prac- 
tice, and yet notwithstanding the time of life at 
which this patient complained, she too insisted 
that “she supposed it was her change of life, and 
that she would soon be all right.” 
Belonging to another class of cases are some 
such remarkable ones as I here report, where, 
having passed the menopause in a normal manner, 16 
the patient afterwards presents this condition of 
flowing and exhaustion, but still entertains the 
idea that it is simply a return of the menstrual 
flow, and which indicates another phase or condi- 
tion of change, and which the following cases 
illustrate somewhat: 
Mrs. Gory, aet. 65, married, native of Canada, 
mother of seven children, a strong and healthy 
woman all her life, passed her menopause with- 
out any unusual symptoms at the age of 49. At 
the end of three years, during which time she had 
been in good health, she began, as she supposed, 
her menstruation again. Did not pay very much 
attention to it at first, it came on at irregular in- 
tervals and continued so, at times flowing very 
severely. During March and April, 1889, she 
visited Chicago, when, flowing very severely, and 
being under the care of the physician of the fam- 
ily where she was stopping, after examination she 
was told by him that she had a uterine polypus, 
and that he would operate upon her by dilating 
the womb and removing it. She did not like to 
be operated upon away from home, was fearful of 
the effect of an anaesthetic, and returned to her 
family. Her flowing continued at intervals with 
more than usual severity, accompanied with very 
much pain at times. She described her pain as 
being of an expulsive character, not unlike that 
of childbearing, as she stated. The pain during 
July and August was unusually severe, and she 
realized that something was projecting from the 
vaginal orifice. About August 15, 1889, this be- 
came very prominent and somewhat offensive. 
She had been treated by her local physician, who 
failed to make any diagnosis of the case. On 
August 23, Dr. Turner, of Crown Point, N. Y., 
was called to see her and was somewhat startled 
on entering the room, to notice the very marked 17 
odor of gangrene that presented. On examina- 
tion he found a mass protruding from the vulva, 
the exact character of which he was unable to 
diagnosticate. I was telegraphed for, but did 
not see her until August 26, 1889. I then found 
the mass protruding as seen in the accompanying 
specimen. After a thorough and careful exami- 
nation, I reached the conclusion that she had 
been suffering from uterine polypus, which had 
gradually extruded itself from the cavity, bring- 
ing down the fundus of the uterus, and causing 
inversion of the same. I could feel the lips of 
the external os well up in the vagina. Taking 
all things into consideration, her age, and the 
nasty gangrenous condition of the presenting 
mass, I concluded that it was not wise to dissect 
off the polypus, and reinvert or return the uterus, 
but to throw around that portion of .the fundus 
that could be easily reached, the chain of the 
ecraseur, and remove the mass in that manner. 
She bore the operation without taking an anaes- 
thetic, the haemorrhage was not at all severe, the 
parts were thoroughly douched with a bichloride 
solution and the cavity of the vagina packed with 
strips of iodoform gauze. These were removed 
at the end of the second day, and afterward the 
vaginal douche of boracic acid solution was con- 
tinued daily. The specimen, as you will observe, 
contains the right horn of the uterus and Fallo- 
pian tube, the ecraseur having reached well above 
the sloughing mass. She made a good recovery, 
and is now in excellent health. 
The next is a case quite as remarkable in many 
respects. 
Mrs. B., aet. 72, married, mother of three chil- 
dren, her husband a physician, but who had been 
in a very sad condition of nervous prostration for 
a period of ten or fifteen years. Mrs. B. had al- 18 
ways enjoyed good health, but at the time of her 
menopause flowed very severely and irregularly. 
Supposed that she had ceased to flow at the age 
of 53, and was in fair health for a few years, but 
feeling some distress later on consulted the late 
Dr. Goldsmith, of Rutland, Vt., who told her 
that “she had a falling of the womb,” and fitted 
her with a glass pessary which she wore without 
removing for fifteen years. She could then retain 
it no longer and suffered much for the following 
year. Later she consulted another physician and 
an attempt was made to have her wear, first a 
Babcock external supporter with stem pessary, 
and later a Macintosh, all of which were some 
what useless. She suffered a right hemiplegia two 
years ago, when 70, from which she made a good 
recovery. Six months ago she noticed, as she 
supposed, an entire prolapse of the uterus which 
she could press back with much difficulty, and 
which she continued to do until about two months 
ago, when she was unable to do it. It now re- 
mained out, she was confined to her bed, gradu- 
ally growing worse, but her husband not in a 
condition of mind to recognize the serious state 
of her health. Her son, a very competent phy- 
sician, she did not consult, although he saw her 
daily until about January 28, 1890, when, noticing 
her condition, the odor of the room, etc., he made 
careful inquiry of his sister, and then for the first 
time, learned of the serious condition she was in. 
He immediately sent for one of his neighboring 
physicians, who made an examination, but was 
unable to state positively what he believed to be 
the real trouble. February 1, 1890, the doctor 
called at my office, desiring me to see his mother 
at once. I did so the |following day, and found 
a sloughing fibroid protruding from the vulva, 
presentingthe most offensive odor possible. The 19 
room had been kept thoroughly ventilated, but 
the odor was almost unbearable, and the patient 
seemed much distressed and in a very anxious 
condition of mind. She stated that she supposed 
for a long time that her flow had returned, and 
that she did not think there could be anything 
seriously wrong until the mass protruded from 
the vulva. The fibroid had its attachment to the 
anterior wall of the uterus, and very curiously 
rested between the cervix and posterior wall of 
the bladder. By passing the catheter into the 
latter viscus I obtained a very correct idea of the 
surroundings and concluded to remove it with 
the chain ecraseur, which I did with little trouble. 
After removal the uterus returned kindly to its 
position. She made an uninterrupted recovery 
and is again able to care for her invalid husband. 
The point that I wish to present is this, that 
these cases are to be found all over the country, 
and that in some way, and in some manner we 
should indicate to our patients the importance of 
their yielding to a more prompt examination, 
when such histories present as are here given. 
Our young women should be taught in our 
schools, academies and colleges more on the sub- 
ject of menstruation. They should know more 
about their reproductive organs from chaste, moral 
and intelligent teachers. Mothers should know 
more of the functions of their own individual or- 
gans, and learn to teach their daughters. 
Finally, the profession should exercise more 
care in impressing upon young wives and moth- 
el’s the knowledge that in so many cases they so 
sadly need, and not assume the care of patients 
wTho are so unwilling to have the necessary exam- 
ination made.