CATGUT FOR LIGATION OF THE PEDICLE. BY Archibald McLaren, M. D., ST. PAUL, MINN. REPRINTED FROM THE American Gynecological and Obstetrical Journal for June, 1895. [Reprinted from the American Gynaecological and Obstetrical Journal for June, 1895.] CATGUT FOR LIGATION OF THE PEDICLE * By Archibald McLaren, M. D., St. Paul, Minn. We must all admit that on account of its absorbable properties catgut is an ideal ligature and suture material. The difficulty, how- ever, of rendering it sterile has led to a very limited use of this ma- terial by more careful surgeons. Most of us have in the past used catgut which we had sterilized according to different methods, trust- ing that at last the problem had been solved, but only to be again dis- appointed. The best results have been procured probably by using catgut which was first soaked in ether to dissolve the fat, then boiled in alcohol and later soaked in a 1-500 bichloride solution in alcohol. But even when this method was used we had to agree with Hunter Robb when, in his late article on gynaecological technique, he says : " Catgut would be an almost ideal material for sutures, but unfortu- nately we have as yet no thoroughly reliable method of rendering it sterile." With many others I had entirely given up the use of catgut for silk until eighteen months ago, when Dr. Edward Boeckman, of St Paul, presented to the St. Paul Medical Society his combination steam and dry sterilizer and described his method for the dry sterilization of catgut, showing at the same time a long series of bouillon and agar-agar cultures of catgut both before and after sterilization. By Dr. Boeckman's method the catgut is cut into desirable lengths wrapped in waxed paper, then sealed in small envelopes, raised in the sterilizer to a temperature a little above 284° F. and kept at that temperature for four hours. All ordinary pus germs are killed at a lower degree of temperature, but the spore-bearing germs, particularly anthrax, so common in the intestine of the sheep, from which catgut is manufactured, are only killed by this high and protracted degree of heat. That catgut prepared in this way is sterile has been proved by innumerable culture tests as well as by the personal experience of all my friends who have used it. Among the minor points in favor of this method are its economy and the convenience with which it may be carried ; a few of these small envelopes may be placed in the pocket- book, always ready for any surgical emergency. * Read before the American Gynaecological Society, May 284, / Co Copyright, 1895, by J. D. Emmet and A. H. Buckmaster. 2 Archibald McLaren, M. D. Dr. C. A. Johnston, of Grand Rapids, Mich., describes in the April number of the American Journal of Obstetrics a method used by Krdnig, of Leipsic, which is based upon what seems to me sound bacteriological principles. He boils his catgut in cumol, a coal-tar oil, the boiling point of which is 170° Centigrade. Theoretically, I should say that this method would render catgut sterile, and Dr. Johnston reports that the catgut so prepared is serviceable and followed by none of the ordinary bad results of silk. Even if this method pro- duces catgut which is absolutely sterile, I should still prefer the gut prepared by dry sterilization, if for nothing else on account of the greater ease and convenience in carrying as well as the greater danger of infection of the catgut which is kept in any liquid preparation. My experience with the various ligature bottles for carrying cat- gut and silk in liquids has been very unsatisfactory; they all leak and the ligatures become infected, even though they were originally sterile. Turning our attention now to pedicle ligatures, one objection to a non- absorbable material, such as silk, is that even though the silk may be perfectly sterile before it is put into the abdomen it is at times impos- sible to prevent its becoming infected, as, for instance, when remov- ing a pus tube or a suppurating ovary, or occasionally when using it for an intestinal suture. As drainage is usually used in such cases, little harm results ; the sinus is delayed in closing, however, until the last ligature loosens and comes away, and even then a chronic sinus may continue to discharge until it is opened and the granulation is removed. This happened to me recently, and it was found necessary to perform such an operation eighteen months after the removal of an appendix. A long sinus led down to the peritonaeum, not through it and still continued to discharge months after the last particle of silk had come away, a continuous silk suture having been used to bring the edges of the peritonaeum together. Dr. Polk, in his very excellent article on pelvic inflammations in Keating & Coe, advises against the ligation of the tubes even in radical removal of the appendages, because, as he says, " the ligature is so often infected through the stump of the tube that in place of being innocuous they become a source of irritation and inflammation, lead- ing to many vexatious symptoms " even when " the ligature be applied .at the cornu, as the writer has found to his cost." In the preceding paragraph Dr. Polk advises the use of either silk or catgut for the ligation of the ovarian vessels and the mesosalpinx. I will venture .to say that Dr. Polk has probably had much more trouble of this na- ture when silk has been used than when catgut ligatures were em- Catgut for Ligation of the Pedicle. 3 ployed. It seems more reasonable to believe that the source of infec- tion was the suppurative disease for which the operation was performed rather than a later infection from the stump of the tube. I most heartily agree with Dr. Polk's principle of conservative surgery of the appendages, but I do not understand that this is in the line of that con- servatism but is only applied to the removal of inflamed or purulent tubes. I can not see why the ligature should not be safer from in- fection from the stump of the tube when the stump is tightly con- stricted. The mucous lining of the tube is always surgically unclean, or is supposed to be, and should therefore be at once seared over with a Paquelin cautery, as is the custom, I believe, with almost all surgeons. Dr. Polk's theoiy in this regard, however, is not nearly so far-fetched as that of the Chicago surgeon, who ascribes the suppura- tion about the ligature and long-standing sinuses to the effects of the gonococcus in contra-distinction to other pus germs. This seems to me to be a serious relapse into the Noeggerathian darkness of bacterio- logical pathology. To illustrate the trouble which at times follows the use of silk I will report a few cases which may prove of interest : Case I.-Last winter Dr. Charles McBurney reported to me a case in which he had recently opened a pelvic abscess and evacuated a large quantity of pus and removed a silk pedicle ligature. This case had been operated upon several months before by another New York surgeon who had removed the appendages. Case II.-In June, 1893, Dr. C. A. Wheaton, of St. Paul, removed a suppurating ovary from Miss R., aged thirty years, at St. Luke's Hospital. On July 6, 1893, in Dr. Wheaton's absence I opened a large pelvic abscess, in this case through the vagina, removing the silk pedicle ligature at the same time, and introduced a rubber drainage- tube, after which she promptly recovered.* In regard to the cleanli- ness of the silk used in this last, as well as the succeeding, cases which I shall report, I will say that I have every reason to think that it was absolutely sterile. It was either first boiled for several hours, then immersed in a 1 to-500 bichloride solution, and again boiled for at least half an hour in the instrument-tray just preceding the operation; or in the later cases it was prepared by the Johns Hopkins formula, of sterilization in live steam for half an hour on three successive days and then preserved in sterilized alcohol. Case IILf-Mrs. W. T. L., St. Paul; consultant, Dr. P. E. Jones, of Red Wing, Minn. Operated upon for pyosalpinx, combined with an *Case No. gg, Northwestern Lancet, May I, 1895. f Case No. 114, Ibid. 4 Archibald McLaren, M. D. ovary of the right side containing two pints of clear serous fluid, at St. Joseph's Hospital in St. Paul, on August 13, 1891. Mrs. L. recovered and left the hospital in a little over three weeks, but she was far from cured and was only able to be out of bed for a few days at a time. Examination several months after the operation showed a tender, fixed uterus with an inflammatory mass about the right uterine cornu about the size of a lemon and resembling a pyosalpinx. On November 7, 1893, over two years after the first operation, I again opened the ab- domen and discovered an abscess cavity at the right uterine horn, containing one ounce of pus and the pedicle ligature floating loose in the pus. The abscess cavity was sponged out and drained with a strip of gauze ; the sinus soon closed and in six weeks she was perfectly well for the first time in nearly three years. Case IV.*-On October 28, 1893, I operated upon Mrs. H. H. T. for Dr. Ogden, of St. Paul, and removed a multinodular fibroid uterus by supravaginal amputation, after Baer's method, enucleating from the left broad ligament a large subperitoneal fibroid ; on account of the oozing from the large cavity in the left broad ligament I used a gauze drain. Three months after the operation, the patient having in the meantime suffered a great.deal of pain, an abscess opened into the vagina, just at the left of the cervical stump, and discharged several ounces of pus and the silk ligatures used on that side. After this she promptly recovered. Case V.f-On September 14, 1893, I operated upon Mrs. C. H. S. for Dr. John Rogers, of St. Paul. Supravaginal amputation of a very large multinodular fibroid uterus. One year after this operation I saw her again with Dr. DeWitt. She gave at that time symptoms of in- testinal obstruction. As the symptoms soon subsided, we were of the opinion that the trouble had been fcecal impaction. She lost flesh, however, complained of a great deal of pain and could not work. About six weeks ago I sent her to the City Hospital and on May 5th discovered a small abscess pointing into the vagina just at the left of the cervical stump. From this abscess I removed two silk ligatures ; as her temperature did not abate, I later made an exploratory cceliotomy and discovered a second small abscess at the summit of the left broad ligament at the site of the ligature, which was applied to the ovarian vessels, just outside of the appendages. No silk was found in this abscess, however; it probably escaped observation in the pus, when the abscess was opened. Her temperature now dropped to normal, *Case No. 108, Northwestern Lancet, May i, 1895. f Case No. 140, Ibid. Catgut for Ligation of the Pedicle. 5 and I trust that she will soon be entirely cured. In this last case, at the time of the original operation, no drainage was used, and the case did well for nearly a year. In both this and the preceding case the ligatures could not have been infected from the tube in the manner which Dr. Polk describes, because both appendages were removed with the uterus, the ovarian vessels being ligated just outside of the ovary and tube. Case VI.*-Mrs. Van D. For Dr. Sutherland of Morris, Minn., I removed a simple ovarian cyst, at St. Joseph's Hospital, on October 25, 1892. One year after the operation, so Dr. Sutherland informed me, this patient had an attack of pelvic inflammation ; this was re- lieved by the discharge from the rectum of a quantity of pus, contain- ing blood and silk ligatures. She promptly recovered and was entirely cured at the time of the last report. Case VII.f-Mrs. S. Operated upon for Dr. Camp, of Brainard, Minn., June 3, 1892. Vaginal hysterectomy for carcinoma uteri. During the next six months or more Mrs. S. was very much distressed by suppuration about the silk, which had been used to control the haemorrhage from the broad ligaments at the time of the operation ; she was eventually entirely relieved of this trouble by the discharge of all the silk ligatures. The last case of this nature which I have to report followed the use of a catgut pedicle ligature, but it was not properly sterilized ; this was the first case in which I used catgut and the sterilization was attempted in a sterilizer surrounded by a water jacket in which it was only possible to get a maximum temperature of 210°. Case VIII.-Mrs. J. M. D. Operated upon for, Dr. Jeannette McLaren, of St. Paul, at St. Joseph's Hospital, May 18, 1894, in which I removed a small multilocular ovarian cyst. Two months later I opened a small abscess at the left uterine horn, when she promptly recovered and is now perfectly well. The closure of peritoneal fistulae is sometimes very slow, following the use of silk, as, for example, in the case of Mrs. C., from whom I removed a very large kidney for Dr. P. Ritchie, of St. Paul, on April 14, 1893. Her operation was done through the anterior incision ; the kidney ruptured during enucleation, flooding the abdominal cavity with pus. Mrs. C. Is now very well, having gained over thirty pounds in weight, but is mentally very much distressed over the continued discharge of a small fistula left in the track of the gauze drain ; two silk ligatures have already come away. • *Case No. 89, Northwestern Lancet, May I, 1895. fCase No. 136, Ibid. 6 Archibald McLaren, M. D. Again, Mrs. F., operated upon April 29, 1894, for Dr. A. Sweeney, of St. Paul, for double pyosalpinx. The operation was followed by irrigation and gauze drainage. Two silk ligatures have already come away, but the sinus still continues to discharge. That there should be no question as to the honesty of my statistics, I reported to the St. Paul Medical Society, six weeks ago, where the cases and the consul- tants are known, a list of my abdominal work during the past two years, in an article entitled One Hundred and Twenty-five Consecu- tive Abdominal Operations. Most of the cases which I have already cited are in that article, and I have given them the corresponding numbers of that table. In the last sixty cases of that list I used catgut ligatures only and, in each case, a continuous catgut suture to bring together the peritoneal edges of the abdominal wcund. I will submit for publication a list of seventy-three consecutive abdominal operations, in which catgut only has been used. My conclusions from my experience of the past year have been very satisfactory. There have been no deaths that could in any way be ascribed to catgut ; mural abscesses, which, during the use of silk for pedicle ligatures and continuous suture of the peri- tonaeum, were not uncommon, even in non-suppurative operations, have entirely disappeared in this class of cases. The suppurations which so often complicate drainage cases still occur with the use of catgut, but they are of much shorter duration, though I now use two buried sutures where I formerly used but one ; fistulas have closed much more quickly, and the ultimate comfort of the patients has been very much better. I certainly have seen very few cases in which vaginal hysterectomy for pelvic suppuration could have im- proved upon either the immediate or the secondary results. Looking at this list of cases, there are six deaths in seventy-three cases. One died on the tenth day from pneumonia-pelvis dry and clean. One died on the tenth day from the persistent vomiting of a chronic gas- tritis ; no haemorrhage; no peritonitis. One died three months after the removal of a suppurating ovary, from the' effects of a vesico-ab- dominal fistula. Two died from shock-one in six and one in twenty- four hours. For operations done to relieve deep pelvic collections of pus, which could not be reached through the vagina, one died of septic peritonitis, from the rupture, during the removal of an extra- uterine gestation sac containing a necrotic foetus and placenta. In every fatal case the pelvis was carefully examined to make certain that haemorrhage or sepsis about the ligature had not occurred, and in not one case was such a condition found. Catgut for Ligation of the Pedicle. Number of coeliotomy and date. Name. <u tuO Ch. M. Disease. Operation. Drain- age. Results. 140 May 18, 1894. Mrs. J. M. D. Dr. J. McLaren. St. Joseph's Hos- pital. 25 1 Multilocular ovarian cyst as large as Florida orange. Ovariotomy. Pedicle ligated with catgut, 2100 sterilized. Dr. J. McLaren. Curettement. No. Recovered. No. 147. 141 May 22, 1894. Mrs. L. Dr. H. Bissell. St. Luke's Hos- pital. 37 6 2 Retroflexion. Laceration of cervix and perinasum. Coeliotomy. Ventro-fixation. Dr. Bissell performed trachelorrhaphy and perineorrhaphy. No. Recovered ; 6, 25, '94, very much improved. 142 June 21, i894- Miss M. O. Dr. E. Strain, Minot, N. D. St. Luke's Hos- pital. 36 1 Carcinoma of cervix. Ery- sipelas toxines injected by Dr. DeWitt for past month. Vaginal hysterectomy. Heavy catgut ligature, 280° steriliza- tion. No. Recovered: no report. M3 June 22, 1894. Mrs. S. Dr. J, McLaren. St. Luke's. 1 2 Retroflexion : adherent ; endometritis. Ovariotomy. Left tubo-ovarian cyst as large as a hen's egg. Right hydrosalpinx. Both removed. No. Recovered. 144 July 3> 1894. Mrs. A. D. Dr. A. O. Beal. St. Luke's. 30 2 Double hydrosalpinx. Both appendages very much dis- eased. Coeliotomy. Both appendages very densely adherent. Both re- moved. No. Recovered ; cured. * 145 July 7, 1894. Mrs. F. Dr. J. McLaren. St. Luke's Hos- pital. .... Multilocular ovarian cyst of right side. Left hydrosal- pinx. ' Coeliotomy. Both appendages strongly adherent. Removed. Broad ligament badly torn. Gauze. Recovered ; 3, 1, '95, sinus closed ; cured. 146 July 10, 1894. Mrs. E. L. F. Dr. J. McLaren. St. Luke's Hos- pital. 50 4 Profound anaemia. Con- stant flowing. Several cu- rettings. Abdominal hysterectomy. Baer's method. Uterus small. No. Recovered; very much improved. 7 * Ligatures of catgut, sterilized by dry heat of 284° Fahr., used on all cases after No. 145. 8 Archibald McLaren, M. D. Number of coeliotomy and date. Name. Age. Ch. M. Disease. Operation. Drain- age. Results. 147 Mrs. J. M. D. 25 I 2 Large inflammatory mass Coeliotomy. Small abscess about Gauze. Recovered ; cured. July 18, See No. 140. about left stump. Rising left horn of uterus. Opened and 1894. temperature and pulse. drained. 148 July 21, Mrs. B. 52 I Tubo-ovarian abscess. At Both appendages removed. Right abscess ruptured during enuclea- Gauze. Recovered ; xi, 15, '94, Dr. 1'. H. John- least 8 oz. of pus. Left hy- sinus closed ; cured. 1894. son. St. Joseph's drosalpinx. tion. Irrigation and drainage. Hospital. 149 Aug. 23, Half-breed In- 26 Right pyosalpinx and sup- purating ovarian tumor. Both appendages removed. Irri- gation and drainage. Glass. Recovered; very much dian. City Hos- improved. 1894- pital patient. Left appendage adherent. 150 Aug. 28, Mrs. F. W. 32 Intestinal fistula. Follow- Coeliotomy. Murphy button in small intestine. Suture of large Gauze. Recovered ; fecal mat- Dr. Moloy, St. ing laparotomy II, 29, '90, for double pyosalpinx, glass ter discharged from 1894. Cloud. St. Luke's Hospital. intestine; silk. Fsecal abscess behind sigmoid ; drained. fistula sixth day ; but- ton passed from bowel on fourteenth day ; un- improved. drainage. 151 Mrs. L. H. P. 30 I I False labor pains every Both appendages removed. Right No. Recovered ; no better Sept. 2, St. Luke's Flos- night. Erotic dreams con- ovary twice as large as normal. until both pudic nerves 1894. pital. Dr. F. J. stantly. Nearly insane. Has recently been curetted. were divided ; now Cressy. cured. 152 Sept. 8, Mrs. T. F M 40 Ovarian cyst, filling lower abdomen. In bed for past Ovariotomy. Cyst. Very long pedicle, twisted three times. Ad- hesions all over cyst. No. Recovered. Dr. Smalley, Hector, Minn. 1894. ten days. Peritonitis. St. Luke's. 153 Sept. 16, Mrs. B. 55 4 Ovarian tumor filling en- tire abdomen. Weight, 50 Ovariotomy. Tumor almost solid. Incision 14 inches long. Dense No. Recovered ; tedious Drs. Cressy and convalescence ; dis- charged, cured, 11, 15, 1894. Stratton, Granite pounds. adhesions. Falls. St. Luke's '94- Hospital. Catgut for Ligation of the Pedicle. 9 154 Sept. 17, 1894- Mrs. W. B. H. 33 Ovarian cyst as large as Both appendages removed. Irri- gation and drainage. Glass. Recovered ; small mu- ral abscess at site of drain ; cured. Dr. Hunt, North- field. St. Joseph's Hospital. Mrs. J. C., private patient, St. Luke's Hos- pital. 47 child's head. Right pyo- salpinx. Procidentia, third degree. Plastic operations at Dr. Bissell's hospital, 3, 8, '90. 155 Sept. 20, 1894. Coeliotomy. Ventro-fixation. Two buried silkworm-gut sutures. Appendages both adherent. Sepa- rated. No. Recovered ; 3, 20, '95, cured ; no pain ; good position. 156 Sept. 26, 1894. Mrs. A. C. H. 30 3 Fibroid uterus as large as child's head ; very painful. Supravaginal amputation of uter- us. Calcareous fibroid. No. Recovered. Dr. I. Wear, F argo. St. Luke's. 157 Oct. 1, 1894. M iss S. 40 Chronic ovaritis ; several Coeliotomy. Both appendages, which were practically normal, removed. No. Recovered ; Feb. 1st died of chronic gastri- tis ; autopsy, Dr. Brig- ham. Dr. C. E. Riggs. St. Luke's. attacks of pelvic peritoni- tis ; chronic gastritis. 158 Oct. 13, 1894. Mrs. E. J. H. Dr. H. Johnson, St. Paul's. St. Luke's Hospital. 51 I 2 Carcinoma of cervix and a little on post-vaginal wall; pain, tender, haemorrhage. Vaginal hysterectomy. Difficulty in enucleating disease in right side. No. Recovered ; 12, 20, '94, mass in right broad ligament. 159 Oct. 20, 1894. Mrs. N. M., 3° I Ovarian cyst. Right as large as adult head. Both appendages removed. Right cyst contained clotted blood. Left ovary as large as a goose egg. No. Recovered ; 12, 20, '94, does all her own work; cured. Pine Bend. Dr. T. DeWitt. St. Joseph's Hos- pital. l6o Mrs. J. K. Dr. Smalley, Hec- tor. St. Luke's Hospital, 45 2 Multinodular fibroid uter- Baer's amputation of the uterus. No. Recovered. Oct. 20, 1894 us, flooding for several months. 10 Arcnwa.a McLaren, M. D. Number of cceliotomy and date. Name. <15 bJC Ch. M. Disease. Operation. Drain- age. Results. 161 Oct. 27, 1894. Mrs. L. H. Dr. J. H. Dorsey Glencoe. St. Luke's Hospital. 29 I 1. 3 years sick. Left tubo-ovarian abscess closely adherent to both large intestines and blad- der. Cceliotomy. Suppurating ovary removed. Five catgut sutures in large intestine. Bladder appar- ently sound. Irrigation. Glass. 48 hrs. Gauze. Died Jan. 31, 1895 ; bladder opened; urine discharged through ; wound could not be closed; died of ex- haustion. Mrs. J., private patient, St. Luke's. 3° Ventral hernia following laparotomies three and five years ago by Dr. C. A. W. Cceliotomy. Omental hernia ad- herent. Two continuous catgut sutures, and interrupted silk- worm gut in skin. No. Recovered ; 3, 20, pain no better. Nov. 3, 1894. 163 Nov. 10, 1894. Miss O. Dr. Beebe, St. Cloud. St. Luke's Hospital. 35 Chronic appendicitis. En- larged right ovary. Cceliotomy. Appendix bound to under surface of caecum. Re- moved. Right ovarian cyst re- moved. No. Recovered ; improved. 44 164 Nov. 22, 1894. Mrs. C. C. F. Consultant, C. E. Riggs, St. Paul. St. Luke's Hospital. Uterine haemorrhage. Both ovaries removed 7, 5, '92. Supravaginal amputation of uter- us. No. Recovered ; 3, 20 '95, very much improved. 165 Nov. 24, 1894. Miss C 3° Double pyosalpinx follow- ing gangrenous cervical polypus. Cceliotomy. Both appendages removed. Both tubes contained about one drachm of pus. Irri- gation and drainage. Glass. Sinus closed twenty- Dr. Dunning, St. Paul. St. Luke's Hospital. 48 hrs. Gauze. fifth day. Recovered ; 3, 20, '95, doing almost all her work. 166 Dec. 1, 1894. Mrs. John L. McC. Dr. Aylen, Woods, N.D. St. Luke's Hospital. 40 Multinodular fibroid ; uter- us as large as child's head. Supravaginal amputation of uter- us. Both appendages enlarged, diseased, and adherent. No. Recovered. Catgut for Ligation of the Pedicle. 11 167 Dec. 2, Mr. Thos. K. Dr. R. Jackson, 69 Carcinoma of rectum, deep and diffuse. Patient not Inguinal colotomy. Cancerous mass in pelvis much larger than No. Recovered ; 12,17,'94, discharged from hos- 1894. Faribault. St. Jo- seph's Hospital. very strong. was supposed. pital ; improved. 168 Dec. 5, 1894. Mrs. John J. Dr.T.F. DeWitt, St. Paul. St. Luke's Hospital. 30 Ovarian cyst, complicating pregnancy at second month. Ovariotomy. Left unilocular cyst. Right appendage removed. Pregnancy months. No. Recovered ; 3, 20, '95, pregnancy not inter- fered with. 169 Dec. 8, 1894. Mrs. A. B. City Hospital patient. 27 3 I, 3 weeks ago. Left pyosalpinx. T wo drachms of pus. Coeliotomy. Left appendage re- moved ; pus-stained ; few active germs. Irrigation. Gauze. Recovered; sinus closed quickly. 170 Dec. 15, 1894. Miss M. K. City Hospital patient. 22 I Ovarian cyst ; right as large as Florida orange. Ovariotomy. Multilocular cyst of right ovary ; very adherent. Left tube clubbed, containing bloody, purulent fluid. No. Recovered ; severe bronchitis for one week. 171 Dec. 16, 1894. 24 Recurrent appendicitis ; several attacks; last two weeks ago. Coeliotomy. Appendage closely bound down by strong adhesion. Chronic appendicitis. Stump cov- ered. No. Recovered ; 2, 17, '94, at work and feeling very well ; cured. Dr. Daigneau, Austin. 172 Dec. 19, 1894. Mrs. L. S. M. Consultant, Dr. DeWitt, St. Paul. 26 Pyosalpinx, perhaps open- ing into bowel. Has had gonorrhoea. Coeliotomy. Double pyosalpinx ; leaking, septic peritonitis. Ad- herent appendix. Examination of pus ; numerous micrococci. Glass Sinusclosedonemonth. and gauze. Recovered ; much im- proved. 173 Dec. 22, 1894. Mrs. S. A. City Hospital patient. 32 1. 4 years ago. Double hydrosalpinx ; coe- liotomy July 1st. Opening and draining of pelvic ab- scess. Coeliotomy. Right hydrosalpinx. Cystic ovary as large as a goose egg. Left hydrosalpinx. Few adhesions. No. Recovered, 2, 9, '95 ; no pelvic pain ; does her own work, cured. 174 Ian. 1, '1895. Mrs A. W. C. 45 3 Multinodular fibroid uterus. Baer's supravaginal amputation of uterus. No. Died Jan. 10, 1895. Constant vomiting of chronic gastritis ; no peritonitis. Private patient, St. Luke's Hos. In bed for several months ; pressure symptoms. Archibald McLaren, M. D. 12 Number of coeliotomy and date. Name. <D Ch. M. Disease. Operation. Drain- age. Results. 175 Jan. 5, i895- Mrs. B. S. City Hospital patient. 44 IO I Complete procidentia. Lac. of C. and P. Small fibroid ; can not work. Vaginal hysterectomy by morcel- lation and dissection, anterior col- porrhaphy and Emmet's perineor- rhaphy. No. Died Jan. 15, 1895, pneumonia ; no peri- tonitis. 176 Jan. 8, 1895- Miss J. H. City Hospital patient. 25 2 I Tubercular salpingitis ; strong adhesions. Both appendages removed. Irri- gation and drainage. Glass. Recovered. 177 Jan. 8, 1895- Mrs. B. O. B. City Hospital patient. 40 Sev- eral. Pyosalpinx puerperal. Last child three weeks old. Cu- retted eighteen days ago. Coeliotomy. Intraperitoneal ab- scess connecting with pyosalpinx. Four ounces of thick pus. Irri- gation and drainage. Glass and gauze. Sinus closed seventh week. Recovery pro- tracted and very tedi- ous ; cured. 178 Feb. 5, 1895. Mrs. G. O. B. Dr. Dampier, Crookston. 45 Sev- eral. Ovarian cyst right ; left ovary also cystic. Coeliotomy. Right cyst as large as adult head. Very dense ad- hesions. No. Recovered ; cured. 179 Feb. 16, 1895. A. L. City Hospital patient. 24 1 Left hydrosalpinx. Right appendage closely adherent. Coeliotomy. Left tube contained 3 oz. of serum. Removed. Right appendage not removed. No. Recovered : 4, 5. very much improved. 180 Feb. 16, 1895. Mrs. J no. L., No. 92. .... Ovarian cyst, complicating pregnancy. Ovariotomy. Two months preg- nant. Conceived when the ovary was as large as foetal head. No. Recovered. Pregnancy not interfered with. 181 Feb. 22, 1895. Mrs. J. E. R. Dr. Dunning, St. Paul. 35 Double hydrosalpinx ; en- dometritis ; wishes to con- ceive. Left ovary cystic and left hydro- salpinx removed. Right tube liberated. Opened, washed out, and not removed. No. Recovered. Catgut for Ligation of the Pedicle. 13 i82 Feb. 23, 1895- Mrs. J. V. Dr. C. L. Clark, White Bear. 28 7 Suppurating dermoid tu- mor of right side. Ovariotomy. Adhesions very dense. Irrigation. Glass and gauze. Sinus closed fifth week. Recovered. 183 Feb. 23, 1895. Mrs. K. Dr. 11. Johnson, St. Paul. 4i 3 Multilocular ovarian cyst. Ovariotomy. Thirty-five pound cyst adherent to under surface of liver and to gall bladder. No. Recovered. 184 Feb. 23. 1895- Mrs. A. C. City Hospital patient. 34 1. 2 wks. ago. Pelvic cellulitis ; septic en- dometritis. Has been cu- retted (blunt) twice. Coeliotomy. Both appendages nor- mal. Curettement; sharp. Much broken-down tissue ; gauze pack- ing. No. Recovered. See No. 191. 185 Feb. 27, 1895. Mrs. S. E. B. Dr. H. M. S. Stover, LaMoure, Dak. 32 3 1 Retroflexed uterus. Uter- us and appendages fixed and painful. Coeliotomy. Dense adhesions broken. Right appendage torn and removed. Left not removed. Ventro-fixation. No. Recovered. 186 Mar. 2, 1895. Mrs. D. H. Dr. A. O. Beal, St. Paul. 36 I 1 sick ever since. Tubo-ovarian abscess. Much emaciated; acute delirium last two days. Coeliotomy. Deep tubo-ovarian abscess as large as Florida orange. Left pyosalpinx. Both append- ages removed. Gauze. Died 28 hours after operation; exhaustion; autopsy ; no haemor- rhage ; pelvic cavity dry and clean. 187 Mar. 9. 1895. Miss L. N. City Hospital patient. 26 1 1 Pyosalpinx. Right as large as my thumb ; small ova- rian cyst. Coeliotomy. Right appendage removed. No. Recovered. 188 Mar. 12, 1895. Miss L. C. Dr. Brigham, St. Cloud. 18 Tubercular salpingitis right. Right ovary as large as hen's egg- Coeliotomy. Right appendage removed. Strictured appendix removed. No. Recovered. 189 Mar. 13, 1895. Mrs. G. D. G., Miles City, Mont. 32 2 Retroflexion fixed ; endo- metritis. Coeliotomy. Left ovary resected, Ventro-fixation. Two buried silk- worm-gut stitches. No. Recovered ; cured. 14 Archibald McLaren, M. D. Number oi cceliotomy and date. Name. <D bJO <5 Ch. M. Disease. Operation. Drain- age. Results. I90 Mrs. C. W. W., 30 Ruptured, extrauterine ges- Cceliotomy. Free peritoneal cav- Rub- Recovered. Mar. 14, Little Falls, tation. Rupturelseven weeks ity not opened. Pus and broken- ber 1895. Dr. B. Walrath. ago ; in bed ever since. down blood clot; placental tissue. tube. 191 Mrs. A. C., 34 I Pelvic cellulitis. Great No Mar. 16, No. 184, prostration. both normal. Cellular abscess 1895. City Hospital opened through vagina. patient. 192 Mrs. J. V. T., 41 Chronic salpingitis. Tubes No. Recovered. Mar. 22, Austin, adherent. Endometritis. Curettement and gauze packing. 1895. Dr. Daigman. 193 Miss L. A. 18 I Chronic salpingitis ; dense Cceliotomy ; both appendages lib- No. Recovered. Mar. 23, City Hospital adhesions. erated and removed. 1895. patient. 194 Miss B. McD. 18 Tubercular salpingitis. Tu- Cceliotomy ; both appendages re- Glass. Recovered. Mar. 30, Dr. B. Walrath, bercular peritonitis and as- moved. 1895. St. Paul. cites. 195 Miss T. M. F. 35 3 Double suppurating der- Cceliotomy. Double dermoids, Glass Recovered. Fsecal fis- Apr. 6, Dr. Henderson, moids. Very much pros- size of Florida orange. and tula closed on 24th 1895. St. Paul. trated. gauze. day. 196 Miss J. B. 25 Double hydrosalpinx. Has Cceliotomy. Both tubes and ova- No. Recovered. Apr. 6, City Hospital recently had gonorrhoea. ries removed. Each tube the size I895- patient. Prostitute. of a goose egg. 197 Mrs. C. E. L. Intestinal adhesion to the Cceliotomy ; adhesions separated. .No. Recovered. Apr. 10, Dr. McLain, back of uterus. One silkworm-gut suture re- 1895. Hillsboro. moved from the uterus. Uterus No. 120. well attached by long pedicle to anterior abdominal wall. Catgut for Ligation of the Pedicle. 15 ig8 Mrs. S. 26 1 Suppurating ovarian right Coeliotomy. Both ovarian tumors Glass Recovered. Sinus Apr. ii, Dr. Tollington, side. Multilocular ovarian removed. Abscess ruptured. Ir- and closed in three weeks. 1895. Clearwater. on left. rigation. gauze. Cured. 199 Mrs. Chas. H. 30 2 Tubercular peritonitis. Tu- Coeliotomy; separation of omen- Gauze. Recovered. 5, 7, '95 Apr. 12, Dr. A. |. Gillette, bercular tubal abscesses. turn. Abscess opened, filled with sinus still discharging 1895. St. Paul. Large cheesy nodules in iodoform and drained. Very much improved omentum. 200 Mrs. F. S. I. 1 Haematosalpinx. Lac. of Coeliotomy; adhesions of right No. Recovered. Apr. 13, Dr. Chas. Green, cervix. Endometritis. appendage separated. Left ap- 1895. St. Paul. pendage removed, curetted and packed. Miss M S No. Apr. 13, Dr. B. Walrath. Suspected tubercular in- vaginal fistula made last Septem- opened a pyonephritic 1895. St. Paul. flammation. ber. abscess. 202 Mrs. C. F. W. 26 Tubo-ovarian abscess; Coeliotomy. Suppurating ovary Gauze. Recovered. Apr. 16, Dr. Whitney, right as large as Florida and tube removed ; very offensive 1895- St. Paul. orange. Chronic sepsis. pus. Nearly died on table from exhaustion. 203 Mrs. L. R. W. 34 2 Extrauterine gestation. Foetation sac rupture; necrotic Gauze Died on third day; Apr. 18, Dr. Tollington, High temperature. foetus and placenta. and septic peritonitis; liga- 1895. Clearwater. glass. ture in place ; no haem- orrhage. 204 Miss F. B. 17 Tubercular peritonitis; Coeliotomy. Omental tissue re- Glass Recovered. Sinus still May 3, City Hospital double tubercular salpin- moved ; both appendages, which and open, June 1, 1893. 1895. patient. gitis ; necrotic omentum. were cheesy, removed. gauze. General tuberculosis. 205 Miss M. H. 43 3 Double hydrosalpinx; small Coeliotomy ; both cystic tubes re- No. Recovered ; improved. May 10, City Hospital fibroid uterus. moved. 1895- patient. 206 Mrs. C. H. S., 38 2 Intraperitoneal abscess Small abscess at summit of left Yes. Recovered ; improved. May 14, No. 108. from silk ; vaginal abscess broad ligament opened. 1895. opened last week. 16 Archibald McLaren, M. D. Number of cceliotomy and date. Name. <u bO Ch. M. Disease. Operation. Drain- age. Results. 207 May 14, i895- Mrs. E. D Dr. Hanley, St. Paul. 19 Double pyosalpinx; mar- ried three months ; gonor- rhoea. Both suppurating appendages re- moved, ruptured. Glass and gauze. Recovered ; cured. 208 May 18, i895- Mrs. I. K. Dr. H. Day, Eau Claire. 40 2 Ovarian cyst. Cceliotomy ; ovariotomy. No. Recovered. 209 May 18, 1895. Miss K. W. Dr. H. Bissell, St. Paul. 17 Ovarian cyst, complicated with true perityphlitic ab- scess entirely in mesentery of the caecum ; no connec- tion with the bowel. Cceliotomy. Cyst removed ; ab- scess ruptured into peritoneal cavity; considerable haemorrhage. Gia s and gauze. Died in six hours; acute sepsis and shock from haemorrhage. 210 May 23, 1895- Miss D. Dr. Dunning, St. Paul. 23 Tubercular peritonitis ; double tubercular pyosal- pinx. Cceliotomy. Omentum loosened ; ascitic fluid sponged out; both appendages removed. Glass and gauze. Recovered. 211 May 24, 1895. Mrs. S. E. B., No. 185. 32 3 I Inflamed cystic left ovary. Cceliotomy. Cyst as large as an orange removed ; uterus firmly attached. No. Recovered. 212 May 24, i895- Miss F., prostitute. City Hospital patient. 21 I Right pyosalpinx ; two weeks ago produced an abortion on herself. Cceliotomy. Right appendage removed ; abscess ruptured dur- ing enucleation. Glass and gauze. Recovered. 213 May 25, 1895. Mrs. S. G. W. Dr. Darrow, Fargo. 3Q Multinodular fibroid uterus; profuse haemorrhage ; very anaemic. Supra-vaginal hysterectomy. No. Recovered. Catgut for Ligation of the Pedicle. 17 In addition to my own cases, Dr. Robert Wheaton, of St. Paul, who for several years acted as my assistant, reports to me that he has used catgut for pedicle ligature in fifteen cases, with one death, the death not due to catgut. Dr. John Rogers, who was also an assistant of mine, has operated upon ten cases without a death. Dr. Edward Boeckman, to whom we are indebted for this catgut, tells me that he has used catgut upon at least twenty pedicles without a death. Dr. F. Dunsmore writes me that he has used this catgut in ten abdominal cases without a death. Dr. C. A. Wheaton tells me that he used this catgut for all abdominal work for the past eighteen months, with the greatest satisfaction, having no death which he could ascribe to the influence of catgut; that his results are very much better than with the use of silk.