fairly accurate diagnosis without the aid of an exploratory laparotomy. In fact, this latter procedure should be the final and not the first step in the establishment of a diagnosis. The operator making a practice of saying he does not know what is the nature of the growth but will ascertain when he opens the abdomen in the no distant future will find his occupation gone. Surgery means more than whirlwind operating without accurate diagnosis. If it stands for anything, it is for careful, conscientious study of each individual case with the idea of arriving at a correct diagnosis. After every diagnostic expedient has been exhausted, then and only then should the knife be employed.

The physical signs of free fluid in the abdominal cavity are known to you all, but for completeness it may be well to review them in order:

1. Inspection. With the abdomen and chest of the patient fully exposed and the latter in the recumbent posture, an abdomen, the seat of free fluid, is seen to be symmetrically distended in the flanks. Unless the accumulation reaches large proportions, the abdomen is broader than it is high. Thus it differs in shape from the dome-shaped abdomen so characteristic of confined fluid as met with in an ovarian cyst. The degree of bulging will depend largely upon the conditions of the abdominal walls. In multiparæ, with flaccid walls, the bulging may be extreme. On the other hand, a large collection of ascitic fluid in a young nullipara may show but little distention in the flanks and the swelling may more nearly resemble that of an ovarian cyst. The umbilicus in ascites may or may not protrude, depending upon the conditions of the wall and the amount of fluid. The superficial abdominal veins may or may not be dis

tended, depending upon the amount of interference with the return circulation. This phenomenon is not so common in ascites of pelvic origin as it is where the collection is due to some derangement of the liver.

2. Palpation: The feel of the abdominal enlargement in ascites will depend upon the condition of the abdominal wall, and the amount of fluid present. With a small amount of fluid and flaccid wall, there will be considerable compressibility. Such an abdomen will feel not unlike that of a very fleshy person. In a nullipara, on the other hand, there will be a tenseness of the abdominal wall which may resemble the feel of an ovarian cyst. The percussion wave elicited by tapping one side of the abdomen and feeling the impulse on the other is distinct in all free ascitic serous accumulations.

3. Percussion. Since the fluid will seek the lowest point in the abdominal cavity and the intestines will float on top of the fluid, the percussion note will be flat in the flanks and tympanitic above. With the patient on the back, the flatness will extend above the pubes in the median line to a varying distance according to the amount of fluid present. A change of position of the patient will cause a re-arrangement of the flat and tympanitic percussion notes, owing to the change in the level of the fluid.

4. Vaginal examination. Fluctuation may or may not be made out by palpation through the cul-de-sacs. If the fluid can reach the pelvic side of the vaginal wall, fluctuation will be elicited. The reverse will be the case where exudates or new growths are interposed between the fluid. and the vaginal walls.

It is comparatively easy to differentiate between a non-encysted ascitic collection

and an ovarian cyst. In the latter, in contradistinctions to the signs just considered, there will be a dome-shaped abdomen. The latter is symmetrical only in the later stages of the disease, after the cyst has risen above the umbilicus. By palpation the cyst wall often can be differentiated. Owing to the semi-solid contents of certain cysts, or in very tense cysts, the percussion wave may be absent. Percussion shows tympany in the flanks and flatness in the median line; except in intraligamentous ovarian cysts, vaginal examination usually fails to detect fluctuation because the upper border of the cyst is carried beyond the reach of the examining finger. The wall of an ovarian cyst may be so thick as to mask the signs of fluctuation.

Where the ascitic fluid is encysted, as not infrequently happens in cases of tubercular peritonitis of pelvic origin, the differential diagnosis between such a collection and an ovarian cyst may be difficult, as shown by the following case:

Mrs. A. H., age 29, married; referred by Dr. J. B. Bradley, of Eaton Rapids, entered my private hospital June 28, 1902, and was operated upon the following day. The patient's family history was negative. She has always been healthy up to her present illness, which is of some months' duration. For the past few months she has noticed a gradual increase

in the size of the abdomen. This has been especially noticeable on the left side. She has had but very little pain, but has lost. some flesh. An examination showed an abdominal swelling extending from the pubes to just above the umbilicus. The abdomen was asymetrical, being larger on the left than on the right side. Percussion showed dullness in the left and tym pany in the right flank. There was no distinct percussion wave, and when the

patient was placed on the right side the dullness in the left lower abdominal quadrant did not disappear. In the median line, the dullness reached above the umbilicus. What appeared to be a distinct cyst wall could be made out just above the umbilicus. A vaginal examination showed the uterus and appendages fixed in the pelvis, and tender. This should have led to a strong suspicion of tubercular peritonitis, but the absence of positive signs of free fluid, and especially the apparently distinct cyst wall led me to think that I had to deal with an ovarian cyst. Operation the following day showed tubercular peritonitis, probably of pelvic origin; the intestines were matted together and there was encysted fluid in the left side, but quite a large amount free in the abdominal cavity. The cecum was considerably distended. The supposed cyst wall turned out to be rolled up and matted omentum running transversely across the abdomen just above the umbilicus. The breaking up of the adhesions and the evacuation of the encysted fluid resulted in a cure.

Signs of free or encysted fluid in the abdominal cavity, accompanied by enlarged or adherent and tender appendages are strongly suggestive of tubercular peritonitis. The possibility of matting together of the intestines and omentum, and the consequent simulation of intraabdominal solid growths should ever be borne in mind. I have seen an apparently solid malignant tumor in the lower portion of

the abdomen associated with free ascitic fluid turn out to be a tubercular peritonitis with an agglutination of intestines and omentum. At times, the history is likewise misleading. In both affections there may be loss of flesh and strength.

There may be only a slight rise of temperature in tubercular peritonitis, and not symptoms pointing towards the pelvis. Even in the presence of large accumulations of ascitic fluid, patients with malignant disease of some of the pelvic organs and an abdomen studded with tubercular growths may be quite free from pain. Later in the disease, pain is more characteristic of malignant affections. A persistent, even though slight rise of temperature, is more indicative of tubercular disease. The tuberculin test is often of advantage for differential diagnosis. In the later stage of malignant disease of the appendages with secondary deposits in the peritoneum and other portions of the body, there may be an elevation of temperature associated with considerable abdominal tenderness.

There are two forms of malignant tumors of the ovary, the adeno-carcinomata and sarcomata, which may be accompanied by ascites. The adeno-papillomata, or papilliferous ovarian cysts, while not histologically malignant, will fall into this category from a clinical standpoint. This is because of their tendency to rupture and the consequent implantation of the papillary masses in other portions of the abdominal cavity. Quite a proportion of ordinary multilocular ovarian cysts will be found histologically to be papilliferous. Hence the necessity of a microscopic examination of every ovarian cyst, for the apparently benign tumor may return after removal, if it is histologically a papil

loma.

Clinically, all these malignant types of ovarian growths may be considered together, the distinctions being largely histological. The accompanying ascitic accumulation may be small or may reach enormous proportions. The fluid is usually

bloody and of a high specific gravity. The peritoneum is thickened and injected and apt to be the seat of numerous metastases. The physical signs of cystic or solid tumors of the ovary, accompanied by loss of flesh and prostration, associated with ascites, would lead one to suspect malignant disease. Ascitic fluid is an unusual accompaniment of a benign ovarian cyst.

The following is an illustrative case of malignant disease of the ovary, accompanied by ascites: Miss B., Gyn. No. 924, single, age 57, entered the University Hospital, June 13, 1904, having been referred by Dr. B. A. Tracey, of Manchester. The patient has been a healthy woman until within a few months, when she noticed an enlargement in the right lower abdomen, accompanied by some pain and tenderness on pressure. Recently there has been a decided increase in the abdominal enlargement. There has been a marked loss of flesh and strength. Examination showed a symmetrically distended abdomen with a protrusion of the flanks. On deep palpation, a mass could be made out in the lower right abdominal quadrant. It was slightly movable and nodular. The presence of ascitic fluid was shown by percussion sounds and their change on change of position. Vaginal examination failed to connect the growth with the uterus or appendages. Operation showed the growth to be a partially solid tumor of the right ovary. There were about 6 litres of ascitic fluid. The glands along the aorta in the region of the stomach were enlarged. There were also metastases in the liver.

The prognosis in this case is, of course, unfavorable. Not until a few months ago. were her symptoms so severe as to lead her to seek medical advice. It probably was a slow growing malignant tumor

with sudden development of acute symp

toms.

In contradistinction to this kind of tumor, where under the best of circumstances the prognosis is unfavorable, ascites is at times associated with benign solid tumors of the ovary, such as fibromata. I have had two such cases in the last three years. I have also had a third case, but this was unassociated with ascites. I have shown in a recent monograph on ovarian flbromata that out of 82 cases collected from the literature, together with my own two cases, at least forty per cent. were accompanied by ascites. In 8 cases the ascitic fluid reached such proportions as to necessitate tapping. One of my cases was tapped 65 times, under the impression that the fluid was a dropsy, due to organic liver trouble.

It is not difficult to make a diagnosis in these cases. While ascites may be present and bimanual examination may show a solid tumor of the ovary, there are no accompanying symptoms. Such a growth is slow growing and, while it may produce ascites, there is no accompanying loss of flesh or strength. The prognosis here is entirely different from where the ascites is due to a malignant growth. The removal of the tumor and the evacuation of the ascitic accumulation will result in a cure if the growth histologically proves to be a fibroma. It is sometimes difficult to distinguish these tumors by the microscope from fibro-sarcomata.

Finally there is a class of cases where it is exceedingly difficult to make a diagnosis of fluid in the peritoneal cavity associated with an ovarian growth. I refer to the so-called pseudo-mucinous ovarian cysts. In these cysts the walls are apt to rupture and allow the escape of the col

loid-like material into, the peritoneal cavity. The contents of such cysts are not fluid, but more nearly resemble masses of jelly. It has been called apple-sauce degeneration of an ovarian cyst. When such a fluid occupies the abdominal cavity, one can see that the signs will differ materially from those where we have to deal with a serous fluid. This material clings to the abdominal wall and the surface of the intestines. It may cause changes in the epithelial layer, and such changes in connection with ruptured pseudo-mucinous cysts give rise to what is known as pseudo-myxoma-peritonei. When such a cyst ruptures and its contents are poured out into the peritoneal cavity, a low grade of peritoneal inflammation is set up. Such an abdomen will be tender and held perfectly rigid by the involuntary contractions of the recti muscles. A fluid wave will be absent. Percussion will show not only dullness in the median line, but also in the flanks. The percussion note will not change on change of position, because the contents are too thick to flow to the other side of the abdomen. Such cysts can be diagnosed by considering the history of abdominal enlargement originating in one side of the abdomen and gradually becoming symmetrical. Suddenly, there is a development of abdominal tenderness, accompanied by more or less fever. Then the signs noted above will be found present, viz.: dullness in the flanks and also in the median line, and no change of percussion note when the patient changes position. The prognosis in these cases will depend largely upon the length of time which has elapsed since the rupture of the cyst. If the colloid material has become organized, the mortality is considerable, no matter how thoroughly one may try

to wash the substance away at the time of operation. If, on the other hand, the peritoneum has not become changed, the removal of the cyst and the thorough wash

ing out of the cavity ought to result in a cure. I have had four such cysts within the last three years with three deaths and one recovery.

In the treatment of compound fractures it must be remembered that we are dealing with a lacerated wound of delicate structures, easily infected and of lowered vitality.

These fractures, regarded with extreme alarm in olden days, are still not to be treated in a careless manner. Chelius, of Heidelberg, wrote in 1821: "The inflammation is always very great and requires strict antiphlogistic treatment, blood-letting, leeches, cold applications, and opium, and that mortification and delirium tremens may occur, especially in old people, and that if sleep does not take place, death is the consequence. On dissection, frequently there is exudation on the archnoid, pus in the joints and in the sheaths of the tendons."

This picture brings to our minds constitutional disturbances from an infected wound improperly treated.

In the treatment of compound fractures, modern surgery has made advances which are not exceeded in any other branch of surgery. In modern hospital treatment, it has attained to a nearly perfect state,

*Read before the Section on Surgery, Ophthalmology and Otology at the Annual Meeting of the Michigan State Medical Society at Grand Rapids, May 25, 1904, and approved for publication by the Committee on Publication of the Council.

while in general practice outside of the hospital there yet remains much to be desired, yet by strict observance of welldefined lines of asepsis and immobilization, many useful limbs can be saved that formerly were the victims of that mutilating operation, amputation.

Compound fractures belong to the class of injuries which cannot receive too prompt and careful attention at the hands of the attending surgeon. In the treatment of this condition the first thing which the surgeon should have in mind is the wound, and the securing of its primary healing. Our effort, therefore, must always be to substitute a closed fracture for an open one, and then to treat the damaged bone on the ordinary principles.

With successful attention directed to this end, the fracture can often be quickly converted into a simple one.

The surgeon must "start right," and nowhere else in surgery is this so important, and the surgeon can never hope by scrupulous later attention to atone for his laxness of the first dressing. I desire to particularly emphasize the fatter of rigid asepsis and immobilization.

The surgeon should never attempt to manipulate the injured parts in the endeavor to make a diagnosis, until the patient has been placed in proper condition and place for good work. The fate of a