Skip to main content

Full text of "Annals of Medical Practice"

See other formats


This is a digital copy of a book that was preserved for generations on library shelves before it was carefully scanned by Google as part of a project 
to make the world's books discoverable online. 

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject 
to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books 
are our gateways to the past, representing a wealth of history, culture and knowledge that's often difficult to discover. 

Marks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the 
publisher to a library and finally to you. 

Usage guidelines 

Google is proud to partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the 
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to 
prevent abuse by commercial parties, including placing technical restrictions on automated querying. 

We also ask that you: 

+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for 
personal, non-commercial purposes. 

+ Refrain from automated querying Do not send automated queries of any sort to Google's system: If you are conducting research on machine 
translation, optical character recognition or other areas where access to a large amount of text is helpful, please contact us. We encourage the 
use of public domain materials for these purposes and may be able to help. 

+ Maintain attribution The Google "watermark" you see on each file is essential for informing people about this project and helping them find 
additional materials through Google Book Search. Please do not remove it. 

+ Keep it legal Whatever your use, remember that you are responsible for ensuring that what you are doing is legal. Do not assume that just 
because we believe a book is in the public domain for users in the United States, that the work is also in the public domain for users in other 
countries. Whether a book is still in copyright varies from country to country, and we can't offer guidance on whether any specific use of 
any specific book is allowed. Please do not assume that a book's appearance in Google Book Search means it can be used in any manner 
anywhere in the world. Copyright infringement liability can be quite severe. 

About Google Book Search 

Google's mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers 
discover the world's books while helping authors and publishers reach new audiences. You can search through the full text of this book on the web 



at |http : //books . google . com/ 



3 9015 00205 082 4 



"iip*^. 









r-1 - . •. 






^^^fii^-^ 








Digitized by 



Google 



Digitized by 



Google 



ANNALS 



—OF— 



GYNJICOLOGY AND PJIDIATRY, 

A MONTHLY REVIEW OF 

Gynaecology, Obstetrics, Abdominal Surgery, 
and the Diseases of Children. 



EDITORS : 

ERNEST W. GUSHING, M. D., 

GHARLES G. GUMSTON, M. D., HAROLD WILLIAMS, M. D., 

BOSTON, 

WITH THE COLLABORATION OF 



Dr. APOSTOLI, Paris. 

Prof CHARPENTIBR, Paris. 

Dr. ANDREW F. CURRIER, New Yoric. 

Dr. O a. DIRNER, Buda-Pesth. 

Dr. B. DOLERI8. Parts. 

Dr. GEO. F; BNGLEMANN, Boston. 

Prof. BARTON COOKE HIRST, Philadelphia. 

Prof. L. EMMETT HOLT, New York. 

Prof. M. D. MANN, Buffalo. 



Dr. LEOPOLD MEYER, Copenhagen. 

Prof. THE0PHILU8 PARVIN, Philadelphia. 

Prof. W. M. POLK, New York. 

Dr. JOSEPH PRICE, Philadelphia. 

Dr. M. SAENQBR, T^ipsio. 

Prof. EUSTACE SMITH, London. 

Prop. T. O. THOMAS, New York. 

Prof. G. WINTER, Berlin. 

Prof. W. G. WYLIE, New York. 



DBTROrr GTKJDOOLOeiOAL SOOIBTY. 

VOLUME VIII. 
October, 1894, to September, 1895. 



BOSTON, MASS.: 

Annals of Gynecology and PiCDiATRY, Publishers. 

1895. 



Digitized by 



Google 



Copyrighted by 

Ernest W. Gushing, M. D., 

1895. 



Digitized by 



Google 



CONTRIBUTORS TO VOLUME VIU. 



Baldy, J. M., Philadelphia, Pa. 
Boise, Eugene, Grand Rapids, Mich. 
Boyd, J. B., Philadelphia, Pa. 
Brown, Bedford, Alexandria, Va. 
BuRRAGE, W. L., Boston, Mass. 
Clarke, A. P., Cambridge, Mass. 
Collins, A. M., Detroit, Mich. 
Cooke, E. D., Detroit, Mich. 
CoPLiCK, Henry, N. Y. City, N. Y. 
CoRDiER, A. H., Kansas City, Mo. 
CoROMiLAS, Geo., Greece. 
Crowell, H. C, Kansas City, Mo. 
CuLLiNGWORTH, C. J., London, England. 
CuiMSTON, C. G., Boston, Mass. 
CusHiNG, Clinton, San Francisco, Cal. 
Davis, E. P., Philadelphia, Pa. 
Derby, R. H., N. Y. City, N. Y. 
Dewees, W. B., Salina, Kan. 
DoRSEY, F. B., Keokuk, Iowa. 
Dudley, A. P., N. Y. City, N. Y. 
Dunn, F. D., Philadelphia, Penn. 
Edebohls, G. M., N. Y. City, N. Y. 
Flemming, C. K., Denver, Col. 
Fox, J. F., New Philadelphia, O. 
Frederick, C. C Buffalo, N. Y. 
FuLLERTON, Anna M., Philadelphia, Pa. 
Garceau, Edgar, Boston, Mass. 
Gilliam, D. Tod, Columbus, O. 
GoGGANS, J. A., Alexandria City, Ala. 
Glasgow, Frank, St. Louis, Mo. 
GoELET, A. H., New York City, N. Y. 
GoLTHWAiTE, S. Vale, Boston, Mas^. 
GuiNARD, AiME, Paris, France. 
Hayd, H. E., Buffalo, N. Y. 
Hall, C. L., Kansas City, Mo. 
Haiviilton, H. H., Harrisburg, Pa. 
Harris, Philander, Paterson, N. J. 
Headley, W. B., Melbourne, Australia. 



Digitized by 



Google 



iT CONTRIBUTORS TO VOLUME VIII. 

Heldreth, J. L., Boston, Mass. 
Hirst, B. C, Philadelphia, Pa. 
HowiTT, H., Guelph, Ont. 
Kelly, Howard A., Baltimore, Md. 
Lapina, Kaplan, Paris. 
Lewis, Den slow, Chicago, 111. 
Mann, M. D., Buffalo, N. Y. 
Martin, F. H., Chicago, 111. 
McCall, Hugh, La Peer, Mich. 
Montgomery, E. E., Philadelphia, Pa. 
Noble, C. P., Philadelphia, Pa. 
NoRRis, R. C, Philadelphia, Pa. 
Parvin, Theophilus, Philadelphia, Pa. 
Peck, S. S., Youngstown, O. 
Peterson, Reuben, Grand Rapids, Mich. 
Prince, Morton, Boston, Mass. 
Rawson, Allen A., Corning, Iowa. 
RoBB, Hunter, Detroit, Mich. 
RocKEY, A. E., Portland, Ore. 
RosENWASSER, M., Cleveland, O. 
Shoemaker, Geo. E„ Philadelphia, Pa. 
SCHOELENBERGER, C. F., Denver, Col. 
Shirer, I. W., Wallisville, Tex. 
Smith, A. Lapthoun, Montreal, Canada. 
Stone, T. S., Washington, I). C. 
Stowell, E. C, Boston, Mass. 
Talley, Frank, Philadelphia, Pa. 
Thornton, J. B., Boston, Mass. 
Tuttle, a. H., Boston, Mass. 
Van de Warker, Ely, Syracuse, N. Y. 
Van der Veer, A., Albany, N. Y. 
Wathen, W. H., Louisville, Ky. 
Will, O. B., Peoria, 111. 
Williams, Harold, Boston, Mass. 
Wilson, W. R., Philadelphia, Pa. 
Wright, A. H., Toronto, Out. 



Digitized by 



Google 



INDEX TO VOLUME VIII. 



Abscess, Double Tubo-ovarian . . 763 
Abdomen, Laparotomy for Gun-Shot 

Wounds, 666 

Abdominal Surgery, Report on . . 1 

Abortion, 838 

Abortion, Management of ... . 636 

Accouchement forc6, 474 

Accouchement fo/c6, 632 

Albuminuria in Pregnancy, . . . 320 

Alopecia Areata in Children, . . . 222 

Appendicitis, Report of Four Cases, 81 

Appendicitis, ' 831 

Artificial Feeding of Infants, ... 421 

Aseptic Groodale Dilator, .... 269 

Auto Infection in the Puerpera, . . 186 

Bladder, Suprapubic Puncture of 

the . . . • 820 

Blood Examination in Septicemia, . 386 

Boston Society for Medical Observa- 
tion, 269 

Breast, Benign Tumors of ... . 603 

Caesarian Operation, 404 

Caesarian Section, 417 

Caucer of Cervix with invasion of 

Ureters, 693 

Cancer, Treatment of Inoperable . 734 

Chorea, Treatment of 289 

Chloroform, Therapeutic Action of 608 
Cocaine in Rigidity of the Cervix 

during Labor, the Use of . . . 279 

Coma in Hysteria, 137 

Cystitis, Treatment of 70 

Cystitis of Pregnancy, 204 

Cystitis in Children, Treatment of . 222 

Demography, Contribution to . . . 472 
Dermoid Cysts of Ovary, Diagnosis 

of 382 

Dermoid Ovarian Cyst, 137 

Diagnosis in Gynaecology, .... 811 

Diphtheria, Anti-toxine Treatment of 214 

Diphtheria, An ti-toxi ne Treat men t of 427 

Eclampsia, 486 

Ectopic Pregnancy, 509 



Ectopic Pregnancy, 687 

Episiotomy, 674 

Extra Uterine Pregnancy, Original 

Lecture on 261 

Extra Uterine Pregnancy, .... 270 

Extra Uterine Pregnancy, .... 293 
Extra Uterine Pregnancy, Operation 

for 399 

Extra Uterine Pregnancy, .... 790 
Eye, Affections of, Dependent upon 

Uterus 496 

Fallopian Tubes, Treatment of Dis- 
tention of Without Removal, . . 126 

Fallopian Tubes, 631 

Fallopian Tubes, ....... 664 

Feeble Heart in Infectious Diseases, 

Treatment of 83 

Fibroma of Broad Ligament, . . . 406 

Fibroids, Electrical Treatment of . 678 
Fibro-myomata, Parietal, . . 229, 298 

Forceps in Labor, 338 

Foreign Bodies in the Heart, . . . 286 

General Paralysis in Female, . . . 207 

Genitals, Vegetation of 771 

Gonorrhoeal Arthritis, 69 

Gonorrhoeal Endometritis, .... 137 

Gonorrhoeal Infectioti in the Female, 617 
Gyufficology, Progress During the 

Last Decade, ^23 

Haemoptysis in Children, Treatment 

of 162 

Hay Fever, 638 

Health in Massachusetts, Hartwell . 283 

Haemorrhage, Accidental, Concealed 652 

Hereditary Syphilis, 345 

Hereditary Syphilis, 15Q 

Holmes and Puerperal Fever, . . 263 

Hydrocele of the Canal of Neck, . 69 

Hydrocele of Neck, Congenital,. . 161 

Hydro-salpinx, 99 

Hydro-nephrosis, 535 

Hydatid Cyst of Uterus, 204 

Hysterectomy, Evolution in America 

of Abdominal ........ 573 



Digitized by 



Google 



VI 



INDEX TO VOLUME VIII. 



Hysterectomy for Puerperal Septi- 
cemia^ 482 

Hysterectomy for Periuterine Sup- 
puration, 386 

Hysterectomy for Cancer, .... 612 

Hysterectomy, 629 

Hysterectomy, total ...... 779 

Hysterectomy, tot^l 803 

Hysterectomy for Puerperal Infec- 
tion, S09 

Hysterectomy, Abdominal Supra- 
vaginal, 205 

Hysteria, Relation to Structural 

Changes in the Uterus, .... 65 

Incontinence of Urine in Women, 770 
Infection Simulating Lymph 

(Edema 341 

Insomnia of Children, 218 

Intestinal Occlusion after Operation, 136 
Intra-pelvic Haemorrhage, .... 94 
Intraperitoneal Adhesions, . . . 694 
Intussusception in the Infant, Sur- 
gical Treatment of 75 

Iodoform, Anti-septic Action of . . 327 



Kidney, tumor of, removal . 



471 



Lactation, Certain Phenomena Ob- 
served in the Sudden Arrest of . 751 

Laparotomy in Child, 843 

Lithsemia, * . . 599 

Malt Diastase, a Cheap Form of, 

for Poor Practice, 282 

Massage in Gynaecology, . . . .409 

Measles, Antisepsis in 83 

Measles, Contagion of 356 

Merckl's divei-ticulum, 306 

Medical Inspection of Schools, . . 845 

Milk Supply of N. Y 359 

Mixo-Sarcoma, Congenital colloid, . 136 
Myoma of Uterus, Treatment of . . 345 
Myoma, Large Oildematous, Electro- 
puncture, 757 

Neuralgia and Uterine Affections, . 797 

Obstetric Forceps, a Clamp for . . 103 

Obstructed Labor, 818 

Ocular Affections of Uterine Origin, 46 

Osteo-Malacia, 363 

Osteo-Malacia, 556 

Osteomalacia, . ■ . • 278 



Ovarian Tumors, Rate of Growth of 822 

Ovary, Cavernous Angioma of . . 770 

Perineal Retractor, Self Retaining, . 690 
Peritonitis, so called Idiopathic 

Purulent, in Children, .... 212 
Puerperal Goitre, Contribution to the 

study of 280 

Pelvic Abscess, Puerperal .... 130 
Pelvic Cellulitis, a Few Cases of 

True 747 

Pelvic Floor, Injuries of ... . 516 

Pelvic Inflammations, 194 

Pelvic Suppuration, Discussion of 

the Treatment of, at Berlin, . . 388 

Pelvic Surgery, 643 

Pelvimeters and Pelvimetry, . . . 243 

Pessaries, Injurious Affects Of . . 157 

Phantom Perineum, 670 

Placenta Pravia Centralis, .... 824 
Popular Education, Wherein it has 

Failed, 128 

Polypus of Rectum, 407 

Pneumonia in Children, '. . . . 361 

Pregnancy, Affects of Quinine on . 137 

Pregnancy, Extra-uterine .... 167 

Pregnant "Women, Care of . . . 38 
Primary Schools, Effects on Health 

of Children, 431 

Prolapse, Freund's, Operation for . 372 
Puerperal Cellulitis and Peritonitis, 189 
Puerperal Endometritis, Septic . . 648 
Puerperal Endometrium, Septic In- 
fection of 187 

Puerperal Fever, the Cause . . . 560 

Puerperal Infection, 743 

Puerperal Insanity, 278 

Puerperal Pelvic Cellulitis, ... 663 

Puerperal Saprtemia, 188 

Puerperal Septicemia, 827 

Puerperal Septic Phlebitis, .... 191 

Pus in Pelvis, 174 

Pyelo Nephritis, 659 

Quinine, Action upon Internal Geni- 
tal Organs, 

Renal Insufficiency, Relation to Op- 
erations, 33 

Salpingitis, the Treatment of Catar- 
rhal, by Electricity, 318 

Sarcoma of Breast, Recurrence, . . 70 



Digitized by 



Google 



INDEX TO VOLUME VIII. 



vii 



Sarcoma of the Uterus, 279 

Sewer Gas — What has it to do with 
had results in Obstetrics and Gy- 
naecology, 223 

Sterility in Females, 497 

Stitch Abscess, 517 

Sub-involution, 200 

Saspensio Uteri, Abstract of a Paper 

on, 725 

Symphyseotomy, 171 

Symphyseotomy without Suture, . 280 

Training School for Nurses at the 
Johns Hopkins Hospital, Address 
to the Graduating Class of the . . 726 
Transactions American Association of 

Obstetrics and Gynaecology, 57, 104, 173 
Transactions Detroit Gynaecology 

Society, 194, 338, 486, 694 

Transactions New York Academy of 

Medicine, Meeting of 273 

Transactions New York Academy of 
Medicine, Section of Paediatrics, 

286, 359, 430 
Transposition of Viscera, .... 430 
Transactions Obstetrical Seciety of 
Philadelphia, 129, 186, 270, 397, 472, 

523, 757, asi 

Tubal Pregnancy, 531 

Tubal Pregnancy, 758 

Tuberculosis and Diphtheria, . . . 286 
Tuberculosis, De Viqueratis treat- 
ment of 140 

Tuberculosis in Children, origin of . 151 
Tubercular Peritonitis, 635 

Urine, Suppression of after Abdomi- 
nal Section, 153 

Urinary Tract and Bladder, Infection 

of, after Labor, 190 

Uro-€^enital Fistula, 138 

Urticaria PigmentoBa, 221 

Ustilago Maidis, for Uterine Con- 
tractioDB, 346 



Uterine Appendages, Etiology and 
Treatment of Inflammation of . . 711 

Uterine Appendages, Removal of for 
Uterine Myoma, 467 

Uterine Appendages, Results of Re- 
moval, 661 

Uterine Fibroid, Anuria Hysterec- 
tomy, 137 

Uterine Fibroids, 523 

Uterus and Appendages, Inflamma- 
tory disease of 104 

Uterus and Adnexa, Removal of for 
Purperal Sepsis, 190 

Uterus and Ovaries, Remote Results 
of the Removal of 330 

Uterus and Ovaries, Tuberculosis of 346 

Uterus, Repair of Injury following 
Labor, 632 

Uterine Retrodeviations, .... 69 

Uterus, Suture of the Tom Cervix, 556 

Uterus, Treatment of Fibroids of . 554 

Vaccination during Skin Eruption, 677 

Vaginal Douching, 48 

Vagina, Double, 493 

Ventro Fixation of Uterus, followed 

by Pregnancy, 397 

Vagina, Tumors of 433 

Vaginal Fixation, for Retrodisplace- 

ment of Uterus, 545 

Vaginal Hysterectomy and Professor 

Richelot, 265 

Vaginal Hysterectomy, Technique, . 539 
Vaginal Hysterectomy, the French 

Method of 374 

Vaginal Hysterectomy for Uterine 
Myomata and Diseases of the 

Adnexa, 740 

Vaginal Route for Operations, . . 808 
Vulva, Less Common Diseases of . 771 
Ventral Fixation, Sudden Death Fol- 
lowing, 129 

Whooping Cough, Treatment of . . 142 



Digitized by 



Google 



Digitized by 



Google 



ANNALS 



—OF— 



GYNECOLOGY AND PiEDIATRY. 



Vol. VIII. 



OCTOBER, 1804. 



No 1. 



Report in Abdominal Surgery, Being an Analysis of One Hundred and 
Forty.five Cases not Previously Reported, Done upon the Ovaries 
and Uterine Appendages, with Special Remarks as to Preparation 
of Patient, Place of Operation, Use of Drainage, Treatment and 
Results. 



BY A. VAN DER VEER., M. D., 

ALBAKt, N. T. 



Mr. President and Fellows : — 
In presenting this report in abdominal 
surgery, with accompanying table, I 
desire to state that the 145 cases do 
not include any of my work in su- 
pravaginal hysterectomy, excepting 
Nos. 112 and 114, cases complicated 
with ovarian tumors, or solid tumors 
of the ovaries or broad ligaments, 
cases of hystero-epilepsy, cases of 
tubercular peritonitis, of gall-bladder 
surgery, of appendicitis ; or of any 
operations whatever within the peri- 
toneal cavity, previously reported by 
myself in former papers, with one ex- 
ception, case 42. The operations here 
reported were done for removal of 
ovarian tumors and pathological con- 
ditions associated with the ovaries 
and uterine appendages. It is true 



Read before the American Association of Obstetri- 
cians and Gynsceologists, Toronto, 1891. 



that some of the cases were simple 
tubercular peritonitis, in which the 
appendages were not removed, but the 
history of the case, in each instance, 
and direct physical examination, gave 
some little question as to whether there 
might not be an ovarian complication 
with the suspected tubercular trouble. 
It is my desire in making this an- 
alysis to present first the rate of 
mortality, and in doing this I realize 
that my work is far from being as 
successful as I could have wished, and 
yet, in a personal, critical retrospec- 
tion of the causes of death, I feel that 
I have gathered an experience that 
will be to the benefit of my future 
patients, and I trust somewhat to 
those of my associates and successors 
why may continue to do this line of 
work. 

In examining the table you will 



Digitized by 



Google 



A. VAN DER VEER. 



observe that there have been 17 
deaths. My criticism upon this mor- 
tality would be that these cases should 
be classified under two heads, avoid- 
able and unavoidable deaths. In the 
former I would place cases Nos. 10, 
43, 66, 86 and 102. 

Case X. — Miss M. W., a simple, 
uncomplicated ovarian cyst ; death on 
14th day, with no serious symytoms 
presenting at any time, excepting a 
rapid pulse, for a period of nearly 
three days previous to death. Au- 
topsy revealed pelvis containing a 
large number of clots, and the same 
condition of haemorrhage had ex- 
tended up into the abdominal cavity, 
particularly in the right lumbar re- 
gion, clots undergoing septic change, 
but no pus present, nor had there been 
any evidence of distension of the ab- 
domen or any condition to indicate 
true peritonitis. On careful exami- 
nation of the pedicle the ligature had 
evidently loosened, and on tracing its 
history it was found to have come 
from a stock of silk imperfectly pre- 
pared, and of which I did not use any 
afterwards. Could the haemorrhage 
have been discovered earlier, which 
would have been the result had a 
drainage tube been made use of, the 
pedicle re-ligated, and cavity washed 
out it might have saved her life. 

Case XLIII. — Miss J. S. Another 
case of uncomplicated ovarian cyst, 
the last case in which I made use of 
the Staffordshire knot. Patient did 
well for five hours after the operation, 
then internal haemorrhage presented, 
abdomen re-opened, pedicle re-ligated, 
free use of saline solution into the 
peritoneal cavity, drainage, and while 



she did well for a time, yet she died 
within twelve hours from the time of 
the operation from immediate haemor- 
rhage. 

Case XL VI.— Mrs. M. K. A case 
of immediate haemorrhage from a 
broad pedicle; controlled at once. 
Patient gave evidence of internal 
haemorrhage at end of five hours; 
pulse 140, was restless ; abdomen re- 
opened; everything found in good 
condition. Patient did weU later on, 
but died unexpectedly, February 8, 
1892, at 5 p. M., from pulmonary em- 
bolism of right lung, with clot in right 
heart. 

Case LXXXVI.— Mrs. M. B. A 
case of early tapping, when the oper- 
ation should have been done ; compli- 
cated with pregnancy, and an early 
operation was eminently the thing 
for her. 

Case CII.— Mrs. J. C. D. Plainly 
a case of delayed operation for extra 
uterine pregnancy, and illustrates the 
necessity of the surgeon not allowing 
the pleading of the patient to move 
him in the least in his line of action. 

Of the unavoidable cases, 1, 80, 
116, were cases of intestinal obstruc- 
tion, following adhesions of coils 
of small intestine to the stump of 
pedicle, producing obstruction. 

Case CXXIV.— Mrs. M. S. This 
was a desperate case of multilocular 
ovariancystinapatient aged 71. Pre- 
viously tapped, had recently suffered 
from grippe and she really died from 
shock. 

In some of my earlier exploratory 
operations I gained the impression 
that perhaps I ought to have been 
more thorough in the removal of 



Digitized by 



Google 



REPORTS IN ABDOMINAL SURGERY. 



3 



diseased tubes, although I felt at the ' 
time it would be entirely at the risk 
of the patient dying on the table, or 
from shock. With a larger experi- 
ence, and fuller confidence, I have of 
late completed operations that were 
quite formidable, and in doing these 
have possibly added to my mortality 
list somewhat, but where death has 
resulted I do not see how it could 
have been avoided. 

Case XX. — Mrs. B. A. aged 
22, grandfather died of phthisis; 
menstruated at sixteen, always had 
dysmenorrhoea ; never pregnant. Met 
with an injury May, 1888, and dates 
trouble from that time. October 
following abdomen began to enlarge. 
April 18, 1889, was tapped and 50 
pounds of fluid drawn. When in full 
health weighed 138 poimds. Men- 
struation previous to operation some- 
what irregular; lost much in flesh, 
great loss of appetite ; bowels regular, 
pulse 120, respiration 22, circumfer- 
ence at umbilicus about 44 inches. 
Though desperately iU, yet she and 
her friends were anxious to have an 
operation. Coeliotomy August 22, 
1889 ; time required, one hour and 
thirteen minutes. Very extensive 
and firm adhesions of sac to periton- 
eum, requiring much time in controll- 
ing haemorrhage, with thorough irrigar 
tion of abdominal cavity. Removal of 
multilocular cyst, left ovary. Right 
ovary somewhat enlarged with evi- 
dence of another cyst developing 
also removed. Glass drainage tube, 
Shock very severe. Every effort 
made to bring patient out of this 
condition; hot saline injections into 
peritoneal cavity, etc., but she died 



in a condition of collapse 4 p. M. 
August 30. Autopsy showed no 
hsemorrohage within the peritoneal 
cavity, everything correct in that 
direction. The case was probably a 
hopeless one from the beginning and 
illustrates the seriousness of delay and 
the evil results of tapping. 

Case LXXIIL— Mrs. L. G., aged 
42, married, family history negative. 
Menstruation at thirteen ; normal. 
One child, no miscarriages. July, 

1891, suffered pain in region of right 
ovary. Severe attacks since, with 
continued vomiting. Two years after 
first attack abdomen began to enlarge^ 
continued to increase in size, and 
measured 46 inches around umbilicus. 
May 27, 1892. Constant thirst. 
Examination of urine showed speci- 
fic gravity to be 1038, and a large 
quantity of sugar present. Notwith- 
standing this I was induced to oper- 
ate and did a coeliotomy May 29, 

1892. Multilocular cyst from left 
ovary ; glass drainage, removal second 
day. Up to this time patient gave 
no unfavorable symptoms. Secretion 
of urine had been abundant, specific 
gravity 1030, color unchanged, reac- 
tion acid, ethereal odor, no albumin, 
but large quantity of sugar present. 
Amount of urine passed on second 
day, 24 hours after operation, was 
56 oimces, when secretion suddenly 
ceased, patient suddenly sank into a 
comatose condition and died on the 
night of the third day after operation. 
Truly this was a case not suited to 
any operative interference, and should 
have been left alone or merely tapped. 

Case LXXXIX.— Mrs. D. S., aged 
34, married, family history negative. 



Digitized by 



Google 



A. VAN DER VEER. 



Menstruated at 13 ; normal. Mother 
of three children, one living; five 
miscarriages. March, 1892, was very 
ill and from the history of the case 
probably had pelvie peritonitis. Hus- 
band very dissipated, and treated 'for 
specific urethritis. After this illness 
she was able to get up and about, but 
not in full health, and in August, 
1892, was taken ill with another sim- 
ilar attack, and from that time up to 
the date of operation was confined to 
her bed most of the time, much ema- 
ciated, suffering much pain in region 
of pelvis, very tender and sensitive 
over abdomen. I saw the patient 
first November 7, 1892, and advised 
her to come to the hospital for re- 
moval of the uterine appendages, 
believing the case to be one of double 
pyosalpinx, having a specific origin, 
but she was dilatory in following out 
advice; growing constantly weaker, 
finally reached the hospital February 
8, 1893. Requiring preliminary treat- 
ment, coeliotomy was done February 
11. Tubes were found very much 
distended, filled with pus, and on the 
left side large abcess. Sac attached 
to rectum, very serious adhesions, 
and operation long and tedious, but 
finally completed, cavity thoroughly 
flushed with hot saline solution, and 
left in nice, dry condition, ^11 bleed- 
ing points having been controlled. 
No drainage. Patient reacted well 
from anaesthetic, kidneys did their 
work well, very little vpmiting, and 
symptoms seemed favorable, but she 
died in a condition of exhaustion on 
the third day. 

Case CXXIII.— Mrs. E. M., fami- 
ly history good. Patient usually in 



fairly good health, though suffering 
much from pelvic pains at different 
times, but able to get about until two 
months previous to operation, when 
she suffered from severe pelvic peri- 
tonitis, with undoubted salpingitis. 
On examination, diagnosis of double 
pyosalpinx, with adhesions. Patient 
emaciated and weakened. Coeliotomy, 
December, 15, 1893, at 11 A. M. 
Left ovary very adherent to sur- 
roimding structures and liberated with 
great difficulty. Trendelenberg po- 
sition, considerable haemorrhage. 
Right ovary very adherent and great 
difficulty in realeasing it. Appendages 
thorougly removed. Bleeding points 
controlled with one exception down 
on right side, where it seemed impos- 
sible to place a ligature. Long artery 
forceps placed and left in position. 
Cavity of abdomen thoroughly flushed 
with saline solution. Glass drainage 
and tampons of iodoform gauze in- 
serted around tube and forceps. Op- 
eration, 80 minutes. Took anaes- 
thetic very nicely, but none given for 
last half hour of operation. Patient 
did not rally and died from shock at 
10.50 p. M., day of operation. Im- 
possible to have lessened this opera- 
tion in any way. It was either to 
abandon it in the beginning or to go 
on and complete, and the result 
proved that it was too much for her 
strength. 

It will be observed the table con- 
tains a record of two cases dying from 
peritonitis, and as given below. 

Case XVI.— Miss I. R., aged 26. 
Family history only fairly good. Pa- 
tient from time of menstruation, at 
13, had always suffered from dysme- 



Digitized by 



Google 



REPORTS IN ABDOMINAL SURGERY. 



norroea and had had severe, well- 
marked attacks of pelvic peritonitis. 
When I saw her with her family 
physician she was very much emaci- 
ated and feeble, but with great effort 
continued her work, that of book- 
-keeper in a large store. Had had 
much trouble with her stomach with 
Yoniiting, and continuous indigestion. 
Operation seemed advisable, the case 
being evidently one of salpingitis, and 
probably double pyosalpinx. Coeli- 
otomy, April 5, 1889, revealing very 
many firm adhesions, difficult of sep- 
aration, but removal of appendages 
completed. Haemorrhage well con- 
trolled and pelvis left in a good, dry 
condition. Patient continued to vomit 
almost from the time of operation^ at 
last a spinach-like substance. No dis- 
tension of abdomen; bowels were 
moved safely, no symptoms of obstruc- 
tion, but patient died from inanition 
on the 11th day. Autopsy showed evi- 
dence of general peritonitis. Careful 
going over of the technique .of the 
operation and surroundings failed to 
show any evidence of error. 

Case LXXVIL— Mrs. H. C, aged 
40, widow, family history of phthisis. 
Menstruated at 12, regular but pain- 
ful, always more or less nauseated at 
this time, with vomiting. Married at 
36. Husband dissipated and married 
life not a happy one. September, 
1890, had her first attack of pelvic 
peritonitis, six months later another 
attack; three months after her first 
attack her physician noticed enlai^e- 
ment on the left side near broad liga- 
ment. Tumor gradually enlarged. 
December 11, 1891, patient suffered 
from chills and other evidences of 



suppuration, had trouble in urinating^ 
great insomnia and nervousness ; dif- 
ficulty in getting bowels to move. 
Patient continued much in this con- 
dition, at times improving sufficiently 
so that she could get about, and at 
one time came to my office, where, 
on examination, I had but to confirm 
her physician's diagnosis of double 
pyosalpinx with pelvic abscesses ; 
origin probably specific. After much 
hesitancy the patient finally consented 
to an operation. An attempt had 
been made to reach the tubes through 
the vaginal wall by aspiration, by 
another physician. Coeliotomy, Oc- 
tober 10, 1892. Double pyosalpinx, 
removal of uterine appendages very 
tedious, taking a long time. They 
were the largest and abscess cavity 
the greatest of any specimen I have 
ever removed. Glass drainage ; the 
discharge being carefully examined by 
my assistant, gave evidence of gono- 
cocci present. Patient rallied well 
from the operation and everything 
seemed to be going along safely up to 
the end of the fourth day, when she 
began to vomit; presented evidences 
of peritonitis and died at the end of 
the sixth day. 

Case CXXXIV.— Mrs. H. A. L., 
aged 43, married thirteen years, 
no children. Widow at time of 
operation. During her married life 
almost constantly under treatment, 
seeing many physicians for uterine 
trouble, had worn all manner of 
pessaries, confined to her bed fre- 
quently for one year at a time, suffer- 
ing much from severe leucorrhoeal 
trouble, at times from dysmenorrhoeal 
trouble, and in fact all the symptoms 



Digitized by 



Google 



6 



A. VAN DER VEER. 



peculiar to pelvic disturbances. I 
saw her five years previous to opera- 
tion in consultation with her family 
physician, found her suffering severely 
fron retroversion, enlarged tubes and 
every evidence of pyosalpinx. Ad- 
vised an operation, but patient would 
not consent. She was of a very ner- 
vous, fretful temperament. During 
the five years following this consulta- 
tion she had a variety of treatment, 
but most of the time made use of tam- 
pons herself; would recover, get up 
for a month or two, but confined 
most of the time to her bed, suffering 
from great irritation of the bladder ; 
frequently was constipated, and very 
careless in every respect, in the care 
of her person ; had little love for med- 
ical profession, and no kind word for 
any one. Finally in February, 1894, 
she consented to have an operation, 
it requiring nearly a week's labor on 
the part of the nurse to get the sur- 
face of the body and the vagina in 
any kind of aseptic condition. She 
was absolutely rebellious to the tak- 
ing of a bath and proper evacuation 
of her bowels. Made an effort to 
quarrel with the nurse and on the 
morning of the operation, furious be- 
cause the nurse insisted upon giving her 
an additional scrubbing. Coeliotomy 
March 30, 1894. Diagnosis con- 
firmed. Operation diflBcult, though 
adhesions gave little trouble in the 
way of hemorrhage. Patient recov- 
ered from the ether quickly, but was 
rebellious in every respect as to carry- 
ing out the line of treatment. In- 
sisted upon sitting up in bed, objected 
to the use of bed-pan. Little dis- 
turbance from vomiting, not much 



tenderness over abdomen, but it was 
very diflScult to keep the dressings 
on, she was so restless. Bowels 
moved at the end of second day thor- 
oughly Veil. At this time noticed 
an abscess developing in left labia, 
which was opened and discharged pus 
very freely. Stitch-hole abscess in 
lower end of incision. At this time 
began to vomit, and this kept up 
more or less continuously. Wore out 
the patience and strength of two 
nurses, and at last we gave her a 
hypodermic injection of morphia, 
learning then that she had been using 
it for a long time. The wound in 
every respect, aside from stitch-hole 
abscess, presented a healthy appear- 
ance, and healed quickly, but the 
patient died, evidently of septic peri- 
tonitis, April 5, 1894. No autopsy. 
I think I voice the sentiment of every 
operator when expressing the desire 
to be delivered from such a patient. 

The last case on the list of mortal- 
ity belongs to a class in which I have 
not had much personal experience, 
i, 6., puerperal pyosalpinx. 

Case XCIII.— Mrs. S., aged 27. 
About two weeks previously she had 
been confined, accouchement being 
apparently normal in every respect. 
On the fourth day she developed 
chills and a high temperature, when 
her consulting physician deemed it 
advisable to do a thorough curetting 
of the uterus, bringing away some 
detritis and patient improved, but 
relapsed again in a few days, when a 
second curretting was done. Believ- 
ing then that the case was one of 
pyosalpinx I was called in consulta- 
tion, telegram requesting me to come 



Digitized by 



Google 



REPORTS IN ABDOMINAL SURGERY. 



prepared to operate. Patient was 
having a temperature of 104 and up- 
wards, with very decided chills and 
severe perspiration. There was no 
abdominal distension, no evidence of 
general peritonits, bowels moving and 
in good condition, but local tender- 
ness over the pelvic region. Uterus 
well contracted. Coeliotomy, April 
19, 1893. Left tube and ovary foimd 
absolutely normal; right ovary en- 
larged, as well as tube, giving some 
evidence of septic condition, and 
removed. Patient recovered well 
from the operation, although there 
was a slight tendency to suppuration 
of one superficial stitch. Chills were 
not controlled. Everything had been 
done from a medical standpoint, as to 
remedies, but patient gradually grew 
worse, developed casts in urine and 
died on fourth day. Examination of 
the ovary did not reveal any marked 
septic suppuration. This case was 
probably one of true septicaemia. 

I am not unmindful that it would 
have been much more comforting to 
myself to have commenced this paper 
by reporting to you first my success- 
ful cases ; cases that have brought to 
me much encouragement in my work, 
meeting patients in improved health, 
and receiving letters filled with grati- 
tude and acknowledgementj of recov- 
ery, but to most of these the table 
gives suflBcient reference. 

Regarding the preparation of pa- 
tients, it seems to me quite difficult to 
establish a fixed line of action. I 
believe that, so far as possible, it is 
wise to carry out the preparations at 
home, before the patient enters upon 
hospital life. It is true that there 



are some cases very calm and not 
affected by the thought of entering 
the hospital, and yet there are many 
who are made somewhat nervous by 
being kept under observation too long 
away from home. I would like 
to emphasize somewhat the im- 
portance of regulating the bowels 
and proper attention to such diet as 
does not contstipate, previous to the 
time of operation. I also wish to 
say that I place much stress upon the 
importance of a careful examination 
of the urine. 

Now that we understand so well 
the evil effects of the bacillus coli com- 
munis we should see that the intes- 
tinal tract is put in a good, sanitary 
condition. The previous habit of the 
patient as to the use of morphine or 
opium should be carefully observed, 
and is not a contra-indication to oper- 
ation, but the same will necessarily be 
needed after, and without fear in 
giving as full doses as may be re- 
quired to control pain. 

As to the preparation of the room, 
I have long since done away with the 
use of the carbolic spray, having had 
a tiresome experience in that direc- 
tion, and rely upon thorough cleanli- 
ness, washing all wood work, walls 
and floors with the bichloride solu- 
tion. 

A large proportion of these cases 
reported were operated upon in the 
amphitheatre of the Albany Hospital, 
and some in the presence of one hun- 
dred and fifty or more students. As 
to the length of the incision I can 
only say that my experience endorses 
all that Dr. Joseph Price has said in 
his admirable paper upon this sub- 



Digitized by 



Google 



8 



A. VAN DER VEER. 



ject. I have endeavored to make it 
as short as possible with safety. 

As to the use of the drainage tube it 
may be said that I have used it with 
greater freedom than most of the 
operators at the present time. I 
must be excused somewhat by reason 
of the anxiety I have experienced in 
immediate hsemorrhage, in the two 
cases reported, and therefore, have 
felt that the tube wherever ther6 
was any possible fear of this occuring, 
or where the oozing was likely to be 
greater than* the pemtoneum could 
care for, was the safest procedure. I 
have employed it in 39 cases, exclu- 
sive of the cases of tubercular peri- 
tonitis proper, and have not hesitated 
to leave it in as long as the gauze 
tent introduced through the calibre of 
the tube gave no disageeable stain- 
ing, removing it sometimes within six 
hours after after the operation, and 
sometimes leaving it in from eight to 
ten days. Where left in this length 
of time have followed it with the 
rubber tube. I have invariably made 
use of the rubber dam and then em- 
ployed the gauze packing instead of 
the syringe for removal of the accum- 
mulatiug fluid, and have found this 
procedure quite as comfortable to the 
patient, and to myself it has seemed 
better than the employment of the 
syringe. I may be mistaken, but I 
believe that this table of cases exhi- 
bits quite as many and as severe 
adhesions as present in the average 
nm of coeliotomies. Of the wholenum- 
ber 12 cases gave a record of pre- 
vious tappings, and only two or thaee 
had escaped adhesive inflammation. 

Regarding the closure of the wound 



in the use of silk, however well pre- 
pared, I have had occasionally a 
stitch-hole abscess. For the past 
four years I have used silkworm-gut 
exclusively, and have very seldom 
met with this condition, as the table 
will show. I desire to emphasize 
here that I know of no kind of opera- 
tive surgery that requires such care- 
ful apposition of wound surfaces, 
bringing like tissue in connection with 
like, ^ in the abdominal incision. I 
have not made use of the different 
rows of sutures, still I am ,not un- 
mindful of the valuable arguments 
presented in favor of this procedure. 

As to the time of removing the 
stitches it is well if the superficial 
ones are removed at the end of the 
second day, or during the first dressing 
of the wound, and then the deep ones 
I believe it is wise to leave until 
about the tenth day. They do no 
haim and certainly help to keep the 
abdominal incision in more perfect 
apposition. 

In conditions of continued oozing 
from adhesions, and where the ab- 
dominal walls have been greatly 
stretched by size of the tumor, I must 
say that I have seen, in two of my 
cases, a most happy result from fold- 
ing the abdominal wall over, having 
previously jput in through and through 
sutures of silkworm-gut, taking them 
out at the end of forty-eight hours. 

As to hernias resulting, as far as I 
have been able to learn, I know of 
but three cases, and in one instance 
this was plainly due to the careless- 
ness of the patient in attempting too 
much heavy lifting within so short a 
time after the operation. 



Digitized by 



Google 



REPORTS IN ABDOMINAL SURGERY. 



9 



As to the dressing of the wound I 
have uniformly employed the pow- 
dered iodoform, then the iodoform 
gauze, with the Gamgee pads and 
flannel bandage, doing the first dress- 
ing at the end of forty-eight hours, 
removing what is usually but soiled 
iodoform gauze, reapplying the second 
dressing and letting it remain until 
the wound is healed, except in cases 
where the drainage tube may have 
produced some soiling. 

Out of this number of cases I can 
report only one where the Fallopian 
tubes were freed from adhesions, 
straighened — not removing the ova- 
ries — and a good result followed. 

It will be observed that my mortal- 
ity list contains three cases in which 
a fatal intestinal obstruction was due 
to a coil of intestine becoming fast- 
ened to the stump of the pedicle. 
For the past two years, in such cases 
where the stump seemed to flatten 
out over the ligature, I have brought 
the peritoneal surfaces together with 
one, two or three interrupted sutures 
of very fine silk, and comfort myself 
with the belief that it has perhaps 
had some effect in obviating this 
unfortunate post-operative complica- 
tion. 

The annoying cases I have found, 
and somewhat disastrous, are those 
brought to me by the family physi- 
cian desiring an immediate operation 
that day or the next morning, in 
order that he might return home, 
but anxious to see the operation. 
These cases are fortunately growing 
less and less, as the members of the 
profession realize more and more the 
importance of preparatory treatment. 



and of the operator seeing the case 
long enough in advance to feel sure 
of his diagnosis and- operative proce- 
dure. I wish to make an observation, 
and that is in reference to the serious 
cases that are likely to come from 
one particular practitioner, one who 
procrastinates and keeps the patient, 
either by medication or tapping, 
under his treatment as long as possi- 
ble, and then suggests operative in- 
terference when all the chances are 
against the surgeon. My mortality 
list contains three of these cases from 
one practitioner. I do not wish to 
criticize, but would enter a plea that 
wherever an adominal tumor presents, 
in the practice of any physician, that 
it becomes almost his duty to call in 
the aid of a surgical assistant, that 
the line of treatment may be agreed 
upon as early as possible. In the 
study of these cases I have been 
impressed in one or two or three by 
the very marked history given by 
the patient of the tumor having ap- 
peared on one side, and yet when the 
operation was reached the pedicle 
and attachment was foimd on the 
other side. 

As to the pulse and temperature I 
am satisfied that the former is of far 
more importance than the taking 
of the latter. The heart's action 
plainly tells of serious trouble going 
on in the way of intestinal obstruct 
tion, or of either form of peritonitis. 
There are many conditions really 
non-essential as to the recovery of our 
patient, that will cause an increase 
in temperature, apparently alarming. 
Any nerve strain, a visit from a 
friend, the dischai^e of blood that 



Digitized by 



Google 



10 



A. VAN DER VEER. 



occurs from the vagina after an operar 
tion, and which appears in quite a 
number of cases, will sometimes pros- 
trate the patient mentally, in itself 
producing an increase of temperature, 
but is of no serious import as regards 
recovery. 

In getting the histories of patients 
I have been much impressed with the 
number of cases having a family 
history of phthisis, or malignancy. 
Thirty-nine cases of this table gave a 
district history of phthisis, 16 of 
cancer in some form, while 57 gave 
a history of marked irregularity of 
menstruation, with dysmenorrhoea, 
many of them from the beginning 
of the menstrual act. 

Making a closer analysis of the 
table there were 89 cases of ovarian 
cyst, multilocular, with five deaths ; 
25 cases of ovarian cyst unilocular, 
with two deaths; three cases of 
double ovarian cyst, multilocular, 
with one death ; two cases of multi- 
lociJar cyst complicated with preg, 
nancy, with one death ; two cases of 
double multilocular ovarian cyst, com- 
plicated with fibroid tumors, with 
one death; there were 27 cases of 
double pyosalpinx, with three deaths ; 
20 cases of pelvic peritonitis and 
salpingitis, with two deaths; four 
cases of pyosalpinx, imilateral, with 
one death ; tubercular peritonitis, six 
cases ; tubercular peritonitis, with re- 
moval of one or both ovaries, five 
cases ; chronic ovaritis, six cases ; 
extra-uterine pregnancy, three cases, 
with one death ; exploratory incision- 
relieving adhesions and straightening 
tube, one case ; one case double pyo- 
salpinx and removal of appendix ; re- 



moval of uterine appendages for uter- 
ine fibroid, one case, making a total 
percentage of mortality in 145 cases 
of 11 per cent. 

Among the cases of recovery there 
are a few thoroughly instructive, to 
which I would like to refer for a 
moment. 

Cases XXXV and LIX constitute 
the same patient. Miss L. McC, 
aged 23, in good health up to 14, 
when she had scarlet fever. Men- 
struated at 13, regular, painful and 
troublesome, vomiting at this time. 
Met with an injury and was treated 
for a long time for spinal trouble. 
Finally was told that she had a retro- 
verted uterus. Had treatment for 
this for a period of four months, then 
slipped on ice, receiving a severe fall 
and strain, and not well after. 
Vomited for four weeks, March, 1889, 
in Seney Hospital, Brooklyn, and Dr. 
Pilcher did Alexander's operation for 
relief of the retroversion. After that 
suffered more severe pain during her 
menstrual period, confined to her bed 
most of the time, and not able to 
walk. Flow presented with many- 
clots. Entered Albany Hospital, April, 
1890, and uterus carefully curretted 
after rapid dilatation, but no improve- 
ment followed. Complained of con- 
stant pain in region of right ovary. 
Patient no better, celiotomy done 
October 7, 1890. Right ovary en- 
larged, about size of a turkey's egg, 
tube much thickened and removed 
with ovary. Left ovary and tube ap- 
parently in a healthy condition and 
not disturbed. Recovery uneventful, 
and discharged November 3, 1890. 
Operation did not afford permanent 



Digitized by 



Google 



REPORTS m ABDOMINAL SURGERY. 



11 



relief. Later patient continued to 
suffer severely with pain in back and 
left inguinal region. Various kinds 
of treatment tried, tonics, outdoor 
exercise, etc., yet continued to grow 
worse apparently, and on November 
9, 1891, second coeliotomy was done. 
Left ovary size of a small orange 
found undergoing cystic degeneration, 
tube also enlarged, and both removed. 
Patient reacted well from operation, 
much nauseated for several days, after 
which made an uninterrupted re- 
covery. Discharged on twenty-ninth 
day, began to improve and in excellent 
health September 1, 1894. 

Case XXXVIIL — Mrs. S. K., 
family history good. Menstruated at 
12, always painful, flow at times dark 
and clotted, otherwise bright red 
looking. For four years previous to 
operation had severe brownish-look- 
ing, offensive discharge from vagina. 
Married over two years, no pregnan- 
cies. Steady pain in ovarian and 
across lumbar regions. Husband ad- 
mitted having had specific urethritis. 
On examination tubes could be well 
defined. Diagnosis of pyosalpinx, 
and operation recommended. Coeli- 
otomy, October 30, 1890. Bi-lateral 
pyosalpinx with double parovarian 
cysts and a small fibroid size of an 
English walnut discovered on fundus 
of uterus. Uterine appendages re- 
moved and then the fibroid. The 
latter carefully dissected from the 
fundus, but the bleeding was very 
severe and controlled by the applica- 
tion of the therm o-cautery. Glass 
drainage tube introduced. Drainage 
kept up quite freely for forty-eight 
hours, then a rubber tube substituted 



and kept in for another five days. On 
November 2d there was a copious 
sero-sanious discharge from vagina, 
not offensive. Bowels moved on third 
day with enema. About this time 
pulse reached 102, then became nor- 
mal. Vaginal douches were made 
use of freely. Recovery uneventful. 
Discharged on eighteenth day. Eight 
weeks after the operation a small 
abscess formed in sinus left by the 
drainage tube, through which escaped 
one of the ligatures. 

Case XLL — Miss E. K., age 83, 
health during childhood not good. At 
11 had trouble with abdominal en- 
largement, which she thought due to 
dropsy, Drs. March and Swinburne 
giving a very unfavorable report. 
Under treatment of local physician 
enlargement disappeared. Had mul- 
tiple abscesses about left leg, above 
anlde, finally operated upon by Dr. 
March and njBcrosed portions of bone 
removed. No further disturbance 
imtil 1886 when old cicatrices opened 
up partially. Dr. Morrow advised 
her to go to Albany Hospital, but 
advice not followed. First menstru- 
ated at 17, regular until three months 
previous to operation, when flow 
ceased. March, 1890, felt sudden, 
sharp pain in each groin, after lifting 
a heavy washing, followed by en- 
largement on both sides correspond- 
ing to double femoral hernia, from 
which she then suffered. Abdomen 
now enlarged. In July, 1890, Dr. 
Townsend advised an operation for 
ovarian tumor. Patient did not fol- 
low advise, nor consult any one imtil 
December, 1890, when she came to 
me. Growth increased rapidly in 

Digitized by VjOOQ IC 



12 



A. VAN DER VEER. 



the meantime. Enlargement began 
on right side. Coeliotomy, January, 
30, 1891. Cyst connected with right 
ovary had ruptured. Multilocular 
cyst of left ovary, togetherwith uterine 
appendages, also removed. Both cysts 
contained a viscid, glairy mass, some 
remaining behind having become ag- 
glutin;ited to intestine. Thorough 
irrigation; glass drainage tube re- 
moved third day; bowels moved 
fourth day several times. Severe diar- 
rhoea developed, finally controlled. 
Tenth day lower angle wound opened 
and discharged four to five oimces of 
fetid pus, after which patient im- 
proved rapidly, made a good recov- 
ery, and discharged April 29, fistula 
almost healed. 

Case XLIV.— Mrs. A. E., family 
and personal history good. No preg- 
nancies. Trouble began December, 
1890, enlargement of right side near 
spine of ilium going on rapidly. 
Much emaciated. Abdomen much 
distended above umbilicus, dullness 
over part of epigastrium, whole of 
hypogastric region, both inguinal and 
lumbar regions. On percussion deep 
wave transmitted, palpitation showed 
solid growth situated on left side. 
Stomach in good condition. Coelioto- 
my March 3, 1891. Cyst from left 
ovary papillomatous in character, con- 
taining three gallons of fluid, some ad- 
hesions. Connected with right ovary, 
and closely adherent to surrounding 
tissues was another cyst. Tapped and 
emptied of a viscid fluid, of a dirty 
brownish color. In bottom of cyst 
was another papillomatous growth- 
Adhesions were such that it was im- 
possible to remove this entire; cyst 



walls were stitched to abdomina 
wound, and rubber drainage intro- 
duced. In pelvic cavity, on left side, 
a glass drainage tube was placed. 
Patient recovered quickly and was 
discharged much improved. May 18, 
1891. A slight sinus connected with 
the cyst on right side still existed. 
Re-admitted June 13, 1891, with a 
partial obstruction of bowels, which 
yeilded, however, to calomel, salines 
and enemas. Sinus closed but wound 
showed tendency to open and mass 
could be felt connected with right 
side of pelvis. Occasionally suffered 
pain and morphia required. Im- 
proved slowly and was finally dis- 
charged August 12, 1891, having 
gained in flesh and strength. Was 
seen occasionally afterwards, and Jan- 
uary^ 1892, was in very good health, 
free from pain, able to go on with her 
work, gaining greatly in flesh and 
strength. January, 1893, she had a 
return of the intestinal obstiniction, 
and was re-admitted to the hospital. 
Great distension of abdomen. Lower 
portion of old cicatrix incised and 
immediate presentation of the old 
papillomatous growth filling right 
side of pelvis. In attempting to 
enucleate the mass the small intestine 
was opened into. Gauze packing 
was introduced, supposing that the 
patient coiJd scarcely recover, but by 
continuous irrigation a great amount 
of detritus was washed out. Finally 
fecal fistula closed, patient had nor- 
mal movements, gained in health, and 
returned to her work, but during the 
latter part of the winter of 1894 
growth had increased, and in May 
she suffered from a fistulous open 



Digitized by 



Google 



REPORTS IN ABDOMINAL SURGERY. 



13 



ing connected with the sarcomatous 
growth, giving off an offensive dis- 
charge. Was losing in flesh and 
strength. Not heard from since. 

Case XLIX.— Mrs. E. C, aged 
83, family history good. Menstruated 
at 12, not painful until 18,. after that 
suffered from dysmenorrhoea. At 
20 had severe peritonitis following 
exposure and cold. Married at 21, 
first child one year after ; labor very 
difficult. Dysmenorrhoea ceased after 
that. Since then has had dull, ach- 
ing pain on both sides^ over ovarian 
regions. Three years before opera- 
ation more marked on left side ; men- 
stural flow scanty. In years previous to 
operation had much headache, con- 
siderable pyrosis, and bowels consti- 
pated. Treated fall of 1890 for 
stricture of* rectum and lacerated 
cervix; no improvement. Left side 
of pelvis filled with mass as large as 
a good-sized orange. Diagnosis of 
salpingitis, operation advised, and 
coeliotomy done May 27, 1891. Both 
ovaries enlai^ed, cystic in character, 
double pyosalpinx. Uterine append- 
ages removed. Many firm adhesions. 
Glass drainage tube, rubber substi- 
tuted on third day. Serous discharge 
still quite free. Rubber drainage re- 
moved on seventh day. Some pain 
over abdomen, dragging pain in pel- 
vis, otherwise recovery uninterrupted, 
and discharged on twenty-first day. 
This patient has gone on to a perfect 
condition of health, and September, 
1894, has gained much in flesh and had 
strength ; able to get about with ab- 
solute comfort. 

Case LVIII.— Miss I. R., aged 19. 
Diseases of childhood ; typhoid fever 



at 16. Family history good. Mens- 
truated at 13 ; menorrhagia and dys- 
menorrhoea, confined to bed part of 
time during menstrual act. Always 
suffered tenderness, particularly over 
left inguinal region, where pain is 
constant. Continual pain in back, 
confined to bed much of the time, and 
much disturbance of stomach. Dia- 
gnosis of chronic ovaritis with salp- 
ingitis, and operation advised. 

Coeliotomy, October 19, 1891. 
Left ovary very much atrophied 
and removed with Fallopian tube. 
Right in a condition of cystic degen- 
eration, also removed with tubes. 
Patient had some nausea and vomit- 
ing, with considerable pain in abdo- 
men after operation, but soon re- 
covered and had an uneventful 
convalescence, returning home on the 
twentieth day. Three months after 
began to vomit, though having gained 
much in flesh and strength, which 
continued more or less, until finally 
patient became much emaciated, and 
died with all symptoms of cancer of 
the stomach, one year after opera- 
tion. 

Case LXIIL— Mrs. M. B. M., 
aged 33, family history negative. In 
good health until birth of first child, 
November, 1888. Since then had 
severe attacks of pelvis peritonitis, 
and suffered constant pain, more or 
less severe. Under continuous treat- 
ment at her home. New York, and 
elsewhere. No permanent improve- 
ment. Patient lost in flesh and 
grew very despondent. I saw her 
first with her family physician. Dr. 
Pond, of Rutland, Vt., December, 
1891, and agreed with him fully as to 



■ Digitized by 



Google 



14 



A. VAN DER VEER. 



the diagnosis, pelvic peritonitis with 
probable pyosalpinx. 

Coeliotomy, December 14, 1891. 
Tubes found very much enlai^ed, 
distinct hydrosalpinx on right side, 
ovaries in a condition of cystic degen- 
eration, many adhesions and a tedious 
operation. Glass drainage tube. 
Good recovery, discharged thirty- 
second day. Remained well, but in 
October and November, 1898, had 
discharge from vagina very much 
like her menstrual flow. This was 
repeated once during the winter of 
1894, and just previous to the latter 
period Dr. Pond was able to make 
out a cystic enlargement connected 
with the right comu of the uterus. 
Aside from this, patient in good 
health. I saw her in May, 1894 ; no 
return of discharge ; uterus seemed to 
be atrophied somewhat, but in good 
position; otherwise pelvis presented 
normal condition. 

Case XCVI.— Mrs. E. P., aged 
65, family history of cancer. Three 
children ; no miscarriages. In 1879 
had ovarian cyst removed from left side 
by Dr. Thomas, of New York, and 
menstruation normal after that until 
menopause, which occurred just previ- 
ous to second operation. No further 
trouble until 1880, when right side 
began to gradually enlai^e, and she 
was very much distended. Diagnosis 
multilocular ovarian cyst. Coeliotomy, 
May 16, 1893. Multilocular cyst right 
ovary. Uneventful recovery. Dis- 
charged on fifteenth day. Case of in- 
terest simply, being second operation, 
second incision being made through 
the line of old cicatrix, which was 
foimd to be in a very good condition. 



Case CVIL— Miss E., aged 20, 
menstruation fairly regular, but for 
two years previous to operation suf- 
fered much pain in left inguinal 
region; mental condition not at all 
good ; irrational in talk at times, with 
a tendency to melancholia. Admitted 
to Albany Hospital, spring of 1893, 
found to be suffering from ischio- 
rectal abscesses, with fistulous tract, 
also an opening into vagina discharg- 
ing pus. Very severe case of vagin- 
itis, requiring thorough operation, 
but at last patient made a good 
recovery, with the exception of sinus 
connected with vagina. Mental con- 
dition such that later it was thought 
best to do an oephorectomy. Coeli- 
otomy, October 4, 1893. Left ovary 
diseased, double pyosalpinx ; removal 
uterine appendages. Patient made a 
good recovery and some improvement 
in her general condition. Oinus 
healed in vagina wall left side. 

Case CXII.— Mrs. H. M., aged 
36, family history of cancer and tu- 
berculosis. Menstruated at 14, regu- 
lar. Married 11 years ; four children, 
no miscarriages. Had when 16 years 
old what was called bowel complaint, 
which confined her to bed for some 
time. In 1891 began to flow more 
than usual, told by a physician that 
she was pregnant, but passed period 
of confinement, then saw Dr. Ross- 
man, of Ancram, N. Y., who told her 
that she had an ovarian tumor. Does 
not know on which side tumor was 
first observed. Tumor did not en- 
large rapidly. October, 1892, by 
advice of Dr. Rossman she consulted 
me and remained at the Albany 
Hospital for a short time. Distinct 



Digitized by 



Google 



REPORTS IN ABDOMINAL SURGERY. 



15 



fluctuation could be made out in right 
side of abdomen, from pelvic region 
up. Owing to her feeble condition 
did not operate, but drew off about 
two quarts of fluid. This was re- 
peated two or three times during the 
following year; patient gradually- 
improved, and grew stronger, though 
her flow continued irregular. (Edema 
of lower extremities gradually dis- 
appeared. October, 1898, I advised 
an operation, as her condition seemed 
very much better, diagnosis being that 
of double ovarian cyst, possibly asso- 
ciated with a fibroid. Cceliotomy 
October 21, 1893. Double multilocu- 
lar ovarian cyst removed in the usual 
manner, fibroid size of cocoanut con- 
nected with fundus of uterus, intersti- 
tial. Uterine artery secured and 
broad ligament tied in sections. No 
clamp. Few adhesions. Bleeding 
thoroughly controlled, but drainage 
tube was introduced, removed at end 
of six hours, packing not stained. 
Operation one hour and fifty minutes. 
Fourteenth day lower end of woimd 
opened and quite a portion of pedicle 
with two silk ligatures came away. 
Some discharge of pus for ten days. 
Sinus packed. Patient made recov- 
ery and discharged on twenty-seventh 
day. Doing nicely March, 1894. 

Case CXIV.— Miss M. N., aged 
31, family history good. Menstruated 
at 16, never regular, sometimes flow- 
ing every seven or ten days. Spring 
of 1893 noticed grovrth in left side of 
abdomen. Diagnosis of multilocular 
ovarian cyst. Patient increased very 
rapidly in size previous to operation. 
Suffered pain in lower part of abdo- 
men, frequent desire to micturate, 



and bowels constipated. Before 
entering hospital ankles were oedema- 
tous. Cceliotomy October 30, 1893. 
Double ovarian cyst multilocular, 
One contained about ten pints of 
fluid, the other not so much. Large 
fibroid of uterus ; removed by supra- 
viganal hysterectomy, Tait clamp. 
Patient made a good recovery and 
discharged December 23, 1893. 

Case CXL.— Miss H. V., aged 19, 
family history good ; always healthy 
with exception of scarlet fever eight 
years previous to operation. Men- 
struated at 18 ; regular. First noticed 
enlargement left side of abdomen, 
August, 1893, accompanied with a 
good deal of aching pain. Tumor 
increased rapidly. Bowels regular. 
Loss in flesh quite decided. Cceliot- 
omy January 2, 1894. Large multi- 
locular cyst left ovary containing 
eleven quarts of fluid, thick viscid, 
dark-colored. Firm adhesions from 
left side of abdomen and with some 
coils of small intestines. Right ovary 
in a condition of cystic enlargement, 
and removed with tube. Glass drain- 
age removed second day. Recovery 
very rapid. Patient homesick and 
allowed to return home on the tenth 
day. Returned May 15, 1894 with 
marked growth left side of pelvis, 
probably nature of sarcoma. Patient 
very much emaciated. No further 
operation advised. 

A word as to the time of patient's 
returning home after an operation. I 
do not believe that it is always the 
greatest wisdom to hurry a patient 
home with encouragement to go on 
with their household and other duties, 
and particularly is this true in cases 



Digitized by 



Google 



16 



A. VAN DER VEER. 



of removal of uterine appendages, for 
pyosalpinx and such like conditions. 
They must be made to understand 
that all their unpleasant symptoms 
will not disappear at once. It takes 
months for them to recover, and they 
are sometimes greatly disappointed in 
their hopes not being promptly real- 
ized. 

I have but one case to report of keen 
anxiety in the loss of a foreign sub- 
stance in the peritoneal cavity, and 
that is case 82, Mrs. J. V., where a 
small sponge became entangled in 
mesentry of the small intestine and 
gave great trouble in the search for 
it. I am now exceedingly careful 
about having any very small sponges 
handed me. 

I regret that more careful atten- 
tion was not paid to the weight of 
tumors in the table, but part of the 
work was confided too much to 
advanced students and house surgeons, 
and not done thoroughly well. 

Three cases give an interesting 
history of ligatures escaping through 
the sinus left by the drainage tube, 
the ligature in one case being of 
coarser silk than ought to have been 
used. No ill effect followed, the 



sinus being closed as soon as the 
ligature was recovered. Possibly in 
one patient, case 31, Mrs. E. H., it 
may have assisted in causing the 
hernia. 

As to the after treatment I am 
most rigid in not allowing the patient 
the use of the hypodermic injection 
of morphia any more than is abso- 
lutely necessary, but prefer to give it 
wl^pre there is restlessness due to a 
weak heart's action, and where the 
pain is so great as to be intolerable. 

For treatment of persistent vomit- 
ing I have seen excellent results from 
the combined administration of co- 
caine, calomel and oxalate of cerium, 
and then I can only endorse the use 
of calomel and salines for moving the 
bowels. A movement should be 
secured if necessary by the aid of 
injections, as early as the second or 
third day, not later than the fourth 
day after the operation. As to diet, 
my patients have been greatly bene- 
fited by the carrying out of the hot 
water treatment, and the use of 
matzoon, particularly if the stomach 
is at all nauseated; also, for relief 
of thirst, rectal injections of hot 
water, slightly saline. 



Digitized by 



Google 



TABULATED LIST OF CASES. 



Digitized by 



Google 



18 



A. VAN DER VEF.R 



08 



■iineaH 



> 

% 

H 



H 
O 



125 



■KoixvwaJO 
JO aiva 






2*0 



bDoS 



III 



•Koixiauoo 
iiAio -aov 



-<0 






s 

*« . 






§.2 



P 



c 
IB ee 








^ 










m 


c't- 


}^ 




V 


p^ 


si 


■^ s 


5 


c - 


a 


O 


fc.'M 




d. " 


fS 


- ef 




C V 


o 






Sc/J 


b 


t^ 






I 



§ I ^ 



I » 





■3 


§ 


■§ 


U 


s 


o 




5 




p. 




s 


OQ 


A 


1. 


i 




u^ 


u^ 


u^ 


a 


Q 


Q 



I 

Q 



CS 



ISS 

o 



ON 



A 


d 


Q 


^' 


CG 


W 


o 


ao 


e 


E 


£ 


e 


s 


S 


5? 


s 


" 


« 


" 1 


" 1 






Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



19 



J. O ^« 

illlr 

G 



t: 

a 



u 

Mm S 



I 

I 

& 












> fe s 

III 



i 

|i 
Is 






• c ^ 3 a 



3 5 



4^3 



3 



I I'' 



:p ' 5 



Is 

As 
O 



EC 



i!s 



=■ l« l« 



& 

^ 



S 

D 












c m iJ 



c o 










tt 


<M 


— o 


ri 




c^ 


^ 


"< 



1 


IS 






^ 


CD 


E 


5. 


« 


> 


t 


1 


1 


s 




♦J 

o 


> 


1 


s 


? 


s 

8S 


s 

o 

1. 




o 


CD 


«4 
i 


1 


I 


2 

o 

3 


3 


el 


g 


1! 


1 


1 


3£ 

C 

"S. 


s 


V 




1 




a 

8 


3 
1 


s 


;3 


1 


CO 


s 


H 






3 O 


c 


5 


OQ 


a 


s 


^ 


?3 


?5 


:« 


^ 


S' 


s 


?. 


8 


35 


s 


8 


^ 


^ 


S 


i? 


^ 


§ 


?^ 


g 


;z5 


1 


> 




a 

4 




1 




^ 


1 


s 


o 


.5 




£ 


X 


< 


Ja 






^ 


^1 


1 


a 

I'' 




> 




CO 








§ 


^ ^ 


i,j 


»:» 


l:> 


i^ -^ 


x:> 


*;?5 


^,5^5 




uH 


u^z; 


s^ 


S 


Q 


C 




Q 


fi 


fi 




Q 


Q 






*3 


oi 








S 








^ 


^ 


H 


s 


QQ 


IS, 


?: 


H 


d 


^ 


< 


s 


o 


S 


a 


» 


"^ 


•^ 


S 


u 


fa 


CO 


s 


S 


2 


s 


2 


2 


« 


2 


2 


£ 


JS 


s 


s 


S 


s 


S 


s 


S 


S 


S 


s 


?! 






•N 


CO 


<* 


! *^ 


1 vo 


1 ►* 


1 « 


o> 


8 


2 


«-• 


^ 


-^ 




^ 


1 -" 


1 ^ 


1 '^ 


'^ 



Digitized by 



Google 



18 



A. VAN DER VEER. 



•xansHH 



III 



■S S 4^_; 



mi 






Ij «: V- M, 



o 

H 
P5 






•KOixvHa.10 
JO axva 



•Koixiaxoo 
aiAij -aov 



ea Q 



^S 



*9 «? 

Sir 



2 



52. 



0^ 



CO ^ 
CO V 



I ^ 









o M 2 

>>co7 




2 






I' 



t 






bitti 

2^ 



ri 



CO 8 

"a 



m 



« o « 

S0| 



ft) -e • 

IsES. 

o 



a s <e 



O 



Ei: 



EaJ 






I s 






o f^ 

I- 

o o 
Sen 



I 



©13 






o u 

hi ». 

« e« 

B 9 



SR 



r 

n 



s . 



^ 



a 

eS 

a 

Q 



s 


^ 


q6 


P^i 


J:; 


§ 


S 


5 


i: 


03 


tT 


jT 


Jj 


^ 




<s 


3 


o 


"6 


a 


!>; 


1 


CO 


3 




h 


1. 


^ 

^>; 


u£ 


u'A 


u^z; 


uJz; 


Q 


Q 


Q 


Q 



i '^ 



II 



m 


6 


Q 


^' 


c» 


X 


o 

OD 


cc 


c 


£ 


W 


e 


R 


S 


i? 


R 


1 " 


„ 


' 


" 1 















•ox 



Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



19 



c ^ * 5 



O^ o 3 J; 

ilili j i 



is 



£ m 



® ® Ik 






ii 









11 












5i 












3 « 



' »3j* 



5 






1 ^ . • 

« '5 5 

1 Z C«-3 
I ^-^^ 



I ^" t 



2 



•a 
a 



o 



o 
O 



5g^ 



P 






o 

i 






1= 






55 



• CO 



00 


S 


S 


?5 


•i 


>*' 


e 






;^ 


o 


d" 


fa 


^ 


.>i 


c^ 


J4 . 




225 


« 


•s; ' 


^ 


^1 


o 



I s 






o 
2 



s 

Q 






5- 

O 



^* 

d s 
o* 

fen's 

;5 * 

• c . 

® b£& 

CO "jJ 









r- 


<a 


S. 


I? 


o 


S 




u. 


I 


t 

O 




»« 




e9 






Xi. « 




fct'S 


o 


c-« 















s 






£• 

5 


i 


<; 


5 


CD 


o 








« 


QQ 


% 


s^* 


JS- 


Q>^ 


^^ 


t;>5 


u,'A 


fi 


Q 





s 


X 


» 


rj 


s 


09 


£ 


5 


^ 



o 



5. 

i? 

3 






2 • 



o 



Is 







Ift 


?J . 


& ^ 


ti§ 




p^ 


^ 


<5 






- I 






Digitized by 



Google 



20 



A. VAN DER VEER. 



< 
SB 
H 



'xinesH 



»4 

> 
O 

H 

% 

o 



o 

O 






'KOIXYVa^O 



s 

i 



'KOIUOKOD 
1IAI0 •■OT 



£ 



H 

< 

S5 



II 

es 

.a o* 

*|& 

ft 
l§l 

e|8 



I 



I 

B 

a 



I 






9 



22 

111 



I 






i 






"S 






^ 


















* 








1 


i 


II 


1 


a 




i 


1 


a" 


JS 


5 


S m 


s 


o 


ll 


1 


1 


Q 


p 


Q 



!l 



I 

•a o 



a 

ill 

H 



(>j 



11 



« b 

§1 

o 



t 






s . 



1^ 



I 



1^ 





^ 




ii 


S" 


1- 



I- 



I 
2 ^ 



P 



1 1 


as 


o 


£ 


•^ 



H 
&a 

is 

11 



I- 



I 



I 

8 



1^ 



£5« 






3 






1. 
II 



a 
a 
P 






3 
r . 

It 



S 



1^ 






4 

I. 






§ 



5'- 

o 



e 



OGg 



ft'' 









c 



•OK 



Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



21 



lilli 


3. 




lliil 


3 


8 






1 




^Jk 






s 
1 



5 

A. 



IS 



1^^ 







a o 






N 



1^" 






II 



^ 

^ 



§1 



|8 









^1 

11 



1 



I 



V d 



H 






r 

3 

p 



r 



I 
f 



3 

8?^ 



s- 



I 






ii 



M 

r 



-2 



I 



II 









1^^ 

d On 






Am 

-Si 

II 

IS. 



o 



» 
a 






I 






i 



% 



I 

Qi 
ft 

I 





p 



I 

A 






E_ 



3i 



Digitized by 



Google 



22 



A. VAN DER VEER. 



'XiflsaH 



0< 



H 

O 

h 

O 



2S 



'KOiXYsa^O 



o 

g 

US 



'noixiatcoo 



if 



B 

■a 

s 

r 



84 



12 



1i 5.13 









00 "O 



2 4 o ^ o 



a 



=55 



l| 

a? 



a 



^ i ■ ^"^ 



el 

9 

9a 
a 



a 



^1 

ill 



'a 



eg 
II 

O 



d 



S 

tf 

i 



It 






3^a 



a3 



13 

■5 






„-ss. 



If 



i 



mi 

•oS'd'2 
8893 



I 



s 






SI 

1- 

it 

.a" 

Q 












g 



3 



I" 

Q 



i 



OD • 

Q 












03 . 
^1 






•ox 



! $ 



Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



23 



SSS 

3ia 



-ads: 

I? * 



— ads: 



I'- 



ll 



s 

t 

i. 

Si 

If 



a . 
-I 
II 

^1 

11 
II 



li 






ar. — 
.1j — 

L- II >■ 

^ * s 

I- ^ 

SSe 
o 



S2 



rl 



TS « 

hi* "^ 

? 1 1: eS 

P- a = dn 






ll 



Si 



I 



fii 



»i 



(A 



i 



s 






n 



3 



I.. 

« 



H 

e 



e 

I 

9 






i ^^ 



a 

r 

I 

3 

3 

3 



I 

5 



Q 






i i 



I 






lli 

a 



d 

^ 



T3 
>» 

A 



I 



4»'0 



I 



I 



s 



ll 





ts 



^ 



(S- 






(D . 



00^ 



s-^ 



o 


It 
ll 

•DO 

o 



§ 

1. 

11 



OQ 



i 

^ 



►J 

I 



s 



I 

I 

I. 

«>^ 

Q 



I 

►J" 



I 



s« 



s 



bo 



,t 



OP 



5| 

it. 
IS 

1^ 



a 
I 



©ci 

ll 



I 

if 

.§ 

Q 



5 












> 

is 

3tf 



I 



i 



t 



^1 

.-I 






3 






1 

8 



Digitized by 



Google 



24 



A. VAN DER VEER. 



•xinsa'S 



I 



04 

o 



r 



llil. 






I: 



It 



8 
S 



^'^P'o^ 







l« 



s . 
s 



o 

I 



a o2 

-ssa 
sill 

5 8'. 

Ilia" 



o O O -H 

JB 



'JioixYva^O 
dO ajTva 



I- 



2 

I 



if 
ll 



J? 3 

O 



t 

? 



t 



s* 



IS 

OD 



'KOIXIOKOO 

oiAio *aoT 



s 






I 

ft 



^ 



OR 



o 

5 



6 

I 

1' 



1^. 



»:^ 



Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



26 



s 



Pi 



II 

§1 
1= 

s * ■ 

IP 
III 



r 



I 



p 



0O 






9 



I 



.s 



"5 



6 

6< 



^1 



if 

S f m ^ 

« I? 

00 



9 



^1 



I 



'•2 



II 



^1 



I- 

III 

b 



«1 

II 

82® 
gas* 

lit 



I 



I 



a 1 1 



s 



a" 



IPS 
s 



s- 



g= 



I 



1 
I 

o 



I 

I 

s 

g 

J 



I 



1^ 



U 

•al 

h 






4 







«2 


o 


^ 


n 


{! 


J 


s 


a 


8 


n 



1^: 









I 






i 



i^ 



I e 



Digitized by 



Google 



fl6 



A. VAN DER VEER. 



'irmix's 






I 

a 
o 

& 
% 



3 

i 

.a 
•d 

I 



oaCm 

S 0« 

s o 

lis"* 



u 



It 

Is 

Hi 

Sil 

g«5 



oS 



I 

OS . 

II 



bfiS 



o 



s 






ft 



! 
i 
I 

I 



I 

el 



S8 



I 

s 

r 
2 

9 

s 



•1 

il 
11 



li 



oo 

It 



'JlOUYHX^O 

do axva 



il 









I 

o 



i 




g 




1 


H 

O 


1 




s 


a 


1 


1 


1 





1 



It 



I' 



S 
P 

P 

hi 



§ 



9i 

■Ss 

!l 



i 

t 



li 

II 

p 



it 



a I 

tit 

1.1 



'NoixiaKoo 
oiAio •aov 



5 



Q 



o 
Q 



S 

i 



s 

s. 



5 

O 



i^ 



< 



»4 



•ox 



I 8 



Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



27 



o o 
o s 

SgS§ 

O^ 0. 



s 


Ce- H* 


i 




A 


4^i 


3 


r, U ^ 


"M i 


g 




^ ■ s 


5 


^s-^ 

rp5 




> ^'3 






e? 








§s 


-^! 



I 









lis 



is 



g2 



w4 C (i 



ogg-c 

O S fc2 

:si| 

o 



9 



P. 

s 

a 

t3 



e 



0? 



■gsS 
III 

111 



bfig 
t . 



55 s 



-5 

i 



I 

a 



t 



A 



SI'S 
all 






1^ 






p 



p 



*S 






© 1- 

OQ 



I 

"a, 

3 

I 



8 
go 

O o 



p 
If 



1 
I 



1 



2 

I 



t 



e8 

5 



t 



ejAi'd 



9 O e« 






I 

I 



ft 






s 

& 

e 

o. 

^% 

♦'•Si 



S 
S 



^ 






hid 

Q 



s| 



I 



s 






«>< 



^S 



2»5 

i 

Q 









c 

is 



s 



Digitized by 



Google 



28 



A. VAN DEIJ VEER. 






'xiasxH 









tS 



33 



I 



s 

I 



rf I rf 



£ 



8 

a . 






Mi 

- d 
111 

^^§ 

I. -I 

s: - 



2 






0a 



o 

SB 
H 






5i5 



5 
s 

•d 
So 



1^ 



ll 
PI 

III 

b 



^1 

g| 

CIA 

111 



'KOIXTHS^O 



F 



il 






♦»♦■ 

II 
If 



a 

s. 

s 
I 

D 



it «* 
« 

Is* 



t3 



# 






I 



5J7 



1 

i 



t 



P.o 



t. 

II 

b 



5^ 



"3 



11 



^ 



1^ 



i 



I 
1 



s 

o 

I 



*1IOIXICQIOO 






s 

« . 

Q 



J 






s 

9 





t 


16 


»< 


9 


.52; 


:i 


g 


a . 






o5 


• 


•^ 


^9 


1 




■*8 


§>; 


1 

3 


csi 


fcisz; 


u>* 





Q 


Q 



i 

1 



l> 



ft 

o 






I 

I 
I.; 



e 



ox 



Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



29 



ii 

Hi 

Hi 

fc»'2'S 



t 

5 



e 






sis 

ill 



i 

s 

•d 

8 

o 



. . ^ * * 



mil 

o 



S 
S 

a 



si 



I 
S 

I 
1 

>3 



|« 



(^ 



M 









4a 

I" 









Ii 



1^ 






IF 



leg 

as 

§P5 



Ss 
^-° 

"I 

s 






5 . 



11 

r 



g 

■s 
I 



a c -I 



tl 

U 
n 





So 

II 
III 



1=^ 



1^ 



|S 






I » 



I- 



ri 

I" 

Ih 

ft 



si 

1^ 





i 


I 











a 


^ 




1 


a«i 


1 


i 


k S 


t 


ll 


§ 


•3 


p 


« 


OQ 


a 


% 


« 


s 



a 

S 



I 



I 






1 

& 

04 



a 



a 

9 










s 






09 

e 

is 



s 

I i 






2 



a . 

*^ 

p 









5* • 







.1 
I- 

I 

Q 



s 



Digitized by 



Google 



80 



A. VAN DER VEER. 





1 

1 




suffered from grippe, 
liuonary infarction. 




atient made good recovery. Re- 
turned in August with marked 
giowth, left side pelvis, probably 
nature, true sarcoma No further 
operation done. 




Dt recovery. 


t 




Patient on returning 
tl pain, relapsing into 
ne habit. 


^ 


II 

= 1 
§1 


a 

2 


c a 


1 

2 

1 


1 


® 
1 

H 
o 


> 

s 


1 


1 




» 


Q 


O. 


o 


0. 


o 


CO 


u 


o 


c 


•xansau 


tf ' 


Q 


a 


AS 


« 1 


tf 


« 1 


(ki 


pii 


^ 


< 

> 

H 

O 

s 

i 

H 


s 

•c 

is 

§ 

-1 


i 

> 

1 

a 

II 


£? 

OS 

S 

9«3 


1 

If 

•cs 

It 

a 


III 
ti 


a 
9 . 

^& 

is 
F 

II 


|i. 

pa 
III 
g % 

III 


f 
{I 


g 
1 

P 

•il 

28 


> 

III 
fell 
r- 


?5 


_Q 


I* 


S 




wi 


fc 


CO 




P 


JS 


•MOiivasdO 
du axvQ 


ii 


i 


ti 


Ii 


- 

03 '^ 






C 


Q 


1 


(s. 


fc 


b. 


F^ 


= 




li, 


4. 


^J 




^ 


« 


<ba 


00 


■o 





CO 
<< 
H 
CO 

Q 

E« 

o 

to 

1 

O 

s 


0) 

1 


o 

2 
IS 

« 5 
>^ 


a 

> 
O 

9 


CO 

>. 

s 

p 


1 

> fl 

11 
H 


CO 

"S . 

OH 


0^ 

III 


H 

ji 
1^ 


II 

II 

I- 


s 
s, 
% 

If, 

Q 


•N'OIAiaKOD 


cc 


s 


:^ 


?=' 


^' 


:? 


or} 


e£ 


« 


i^d 


aiAia -aov 


s 


^ 


^ 


ST 


2 


^ 


^ 


^ 


s 


§5 


Is 

li 

53 


1 


s 

1 

i 


^1 


2><' 

^55 


i 

a 
O 
e 

L 


1 


1 


< 
p 
1.2 


^4 

^a 


11 

as 


0L4 


Q 


c 


c 


P 


Q 


Q 


Q 


Q 


Q 


Q 






d 








cxi 








d 


H 




S 


CO 


cd 


> 


^ 


Q 


H 


Q 


•^ 


•< 


ao 


u 


S 


Cu 


X 


» 


•^ 


^ 


S 


5?; 


1 




2 

5? 


1 




1 


1 


J 

S 


oo 


1 


•ox 


s 


§5 


S 


§ 


§ 


g 


s 


s 


§ 


s 



Digitized by 



Google 



REPORT IN ABDOMINAL SURGERY. 



81 



§ 



t 

s 
s 



II 

a* 



•05 



§0 
Ill 

00 



s 



a 

I 

II 






S 

t3 



S 

^ 






ee o 



§ 


S" 


9i 


•B 




9 


CD 

%f6 


s 


J?^ 


SP 


S,2 


IS 

Is 


g-^ 


ol^ 




•« 


» ./ 


V e« 


3a 


•c> 


u 


u ^ 


s^ 


iii, 


D 


D 



.eo 
if ►» 

8§ 



l^& 



i! 

o § 

e 



r 



3 

•c 



o a 

C 



I 

'I 

Is 

*» el 
»- o 

it 

o 



I 



S3 



at"* 






c- 
-< 






«2 






2'- 



3 

O 



o 



« 



H 

a 



i 1^ 
I &. 

I flu 



O-M 
^ — 

X 



as 



a 



c 



"^1 






"32 



OS'S 

El 



^ a 
.c o 



H 



^ 



S5 



S 



00 



» > 



a 



® 


•s 




ee 


> 


(» 






2 







i2^ 


ObH 


»• 


S 


•a 


^» 


uh) 


ft 


Q 






s 



^ 



^ 


^ 


?3 


-< 


»-» 


» 


J 


2 


s 


3 


s 


s 









S I 



s 

eg 

. o 



^^ 






izi 


6 


?r» 







d 


H 


^ 


u. 


«>^ 


g 


3^ 


>« 




£ 


^-S* 


ulH 


^•5 





Q 



i 



a 



I' 

PS « 

G 



Digitized by 



Google 



82 



A. VAN DER VEER. 



H 



'xiasxH 



a 

o 
k* 
o 

H 

M 

h 



•KOixYHaao 
JO axTQ 



6 



6 

5 



'HOIXIOKOO 

1IAI0 -aov 



S 



3 



•OK 



^11 



Isl 



IS 



tx3>H 



« a ^ d 9 A 

II ill! 

-jy E« S*;: 

<— ^ ^ ^4^5 



1^ 



^1 

IS 






p 



a 


a 





D 


00 


as 


s; 


9 



Digitized by 



Google 



RENAL INSUFFICIENCY. 



m 



The Relations of Renal Insufficency to Operations.^ 

C. C. FREDERICK, B. S., M. D. 

BCFFALO, V, T. 

AdJtUant Professor Obstetrics^ Medical Department^ Niagara University, 

Swrgeonrivr-Uhief Buffalo Woman's Hospital, Obstetrician^ 

St, Mary's Widows and Infants Asylum, Gyn/B- 
cologist Erie County^ Hospital. 



During my entire experience in the 
practice of medicine, I have been 
mnch interested in the relations of 
excretion to health and disease. 
During my experience as an operator 
this interest has been enhanced by 
observing the results of operations as 
dependent on the patient's general 
bodily condition. So-called vitality 
is really the resistance which the sys- 
tem offers to disease, and depends en- 
tirely upon the healthy condition of 
each organ which has to do with 
building up the tissues and getting 
rid of tissue waste. Of all of the 
bodily functions in this relation none 
holds quite so important a place as 
the condition and working power of 
the kidneys. 

Gynaecologists have done more in 
the past two years to develop this 
subject than have the general 
surgeons. Very few have written on 
this subject. There is nothing in the 
standard text-books about it. 

Dr. Co^,^ in his first paper on this 
subject states that "inquiries ad- 
dressed to a number of prominent 
operators showed that some regarded 

1. Bead before the American Association of 
Obstetrielans and Gynscologlsts. Toronto, Sept. 

mil, ISM. 

2. Concra-indication to laparotomy, etc. 



albuminaria as a positive contrain- 
dication to operation, others as of no 
significance and others never ex- 
amined the patient's urine at all." 

To deny a patient operation be- 
cause she has albuminaria, simply, is 
wrong; to say that the albuminaria 
she has may not be of significance 
without further investigation is 
wrong ; to disregard the character of 
her excretions if she is to undergo an 
operation is wrong. Each of these 
attitudes is a gross injustice to the 
patient. In this connection there are 
many factors to consider, and a chance 
for the exercise of much discretion, 
before a conclusion can be reached 
which will be doing justice to the 
patient as well as to the operator. 

Observations have been going on 
for several years and now there are 
enough data upon which to formulate 
a concise opinion as to the relations 
which exist between renal insuffici- 
ency and operations and the role that 
anaesthetics play in the results. 

I wish to occupy your attention for 
a brief statement of some conclusions 
which I have drawn from observations 
of nearly three hundred operations at 
the Buffalo Woman's Hospital and at 
the same time supplement them with 



Digitized by 



Google 



34 



C. C. FREDERICK. 



those of gentlemen who have either 
written upon this subject or with 
whom I have had correspondence con- 
cerning their experiences and opinions. 

By the term renal insufficiency I 
desire to be understood as meaning 
any state or condition of the urine 
showing deficient elimination of waste 
products whether from functional in- 
activity or from lesions of the kid- 
neys. 

If the question be asked whether 
renal insufficiency is a contra-indica^ 
tion to operation, the answer must be 
determined by the consideration of 
three factors : 1. The amount and 
nature of the renal insufficiency ; 2. 
The character of the lesions for which 
operation is proposed ; 3. The causal 
relation which the patient's disease 
holds to the renal insufficiency. 

On admission to the hospital, my 
custom is to have the patient's urine 
collected for 24 hours. If she be 
menstruating or has an abundant 
muco-purulent discharge, albumen will 
•surely be found. To avoid this 
source of error she is catheterized. 
The 24 hour sample is measured, 
reaction and specific gravity taken, 
then examined for albumen and 
sugar. If there be albumen, a low 
specific gravity in proportion to the 
amount voided, or if there be sedi- 
ments, it is examined microscopic- 
ally. If there be a suspicion of renal 
lesions the urea is determined quanti- 
tatively. The presence of albumen 
pus and blood in the urine may be 
accounted for by cystitis, ureteritis or 
pyelitis, but the quantity and specific 
gravity will not be affected, and casts 
will be absent. 



The principal facts to ascertain are, 
whether the quantity of urea and 
solids excreted in 24 hours is below 
normal, and if so whether there are 
tube casts or other evidences that the 
deficiency is dependent on true renal 
lesions. Therefore the 24 hour 
sample is absolutely necessary for 
every examination of urine, which is 
to carry with it solid facts upon which 
to base an estimate of the working 
power of the kidneys. 

The question is not the presence of 
albumen, hyaline, or a few granular 
casts, but are the kidneys crippled. 
The mere presence of albumen and 
hyaline casts in the urine, tmless 
there be deficient excretion, therefore 
portends no evil. They are often 
transient. 

Some gynaecological patients on 
entrance are found to be voiding as 
low as eight or ten oimces daily, and 
that not of high specific gravity. 
Women with chronic endometritis 
especially are liable to this. Such 
women do not take much fluid. I 
do not operate till I have given them 
some preparation, which consists in 
taking water freely and keeping the 
bowels and skin free. In a few days 
they pass much larger quantities of 
urine of better specific gravity. These 
are not good subjects for prolonged 
anaesthesia without this preliminary 
preparation. 

If the quantity of urine is above 
twenty ounces per day, of specific 
gravity 1,015 to 1,018, the quantity 
of urea not more than 25 per cent, 
below normal, even if there be albu- 
men, hyaline, or a few granular casts, 
my experience is ably seconded by 



Digitized by 



Google 



RENAL INSUFFICIENCY. 



35 



my correspondents that there exists 
no real contra-indieation to a neces- 
sary operation. 

The knowledge of this condition 
renders it possible for the operator 
to take extra precautions to avoid too 
prolonged anaesthesia by doing a 
rapid operation and thus saving a life 
when it might be -sacrificed if ignorant 
of the true conditions. 

Another point of importance is, 
that an operator may be lead to do an 
operation at an earlier date because 
the condition of the kidneys shows 
beginning disease, which may have 
for its cause some obstruction to the 
ureters in the pelvis, thus forecasting 
what might be in the future much 
more serious renal trouble. Hence 
discovery of b^inning renal disease 
may lead the operator to advise im- 
mediate operation for growths which 
otherwise might show no urgent rea- 
sons for removal. 

If the quantity of urine be persist- 
enly small, twelve to fifteen ounces, 
of low specific gravity, a much de- 
creased elimination of urea, whether 
there be much albumen and tube casts 
or not, it is more than questionable 
whether operation should be done for 
a condition which is less serious than 
the kidney disease itself. 

A plastic operation, a section for 
inflammatory disease of the pelvis 
without pus would hardly be justifi- 
able in such conditions of the kidneys. 
However if there were pus in the 
pelvis or a large tumor producing 
these pressure symptoms an operation 
would be justifiable. 

Often the renal condition is the 
result of the chronic invalidism and 



systemic infection incident to pus col- 
lections in the pelvis. Remove the 
cause and if the patient survives the 
operation she may entirely recover. 
The operator is justified in taking 
larger chances in puriform disease of 
the pelvis than in any other condition 
except large tumors. Sometimes the 
renal symptoms are serious, due to 
increased intra-abdominal pressure by 
a large tumor in which event the 
prompt removal of the growth is the 
most rational and certain way to re- 
lieve the renal symptoms. Such cases 
are an exact parallel to those we see 
in pregnancy, when by delivering we 
relieve the pressure, the kidney activ- 
ity is resumed and the patient recovers. 

There are cases of extreme gravity, 
such as ruptured ectopic pregnancy, 
where the patient is in great immedi- 
ate danger. In such renal condition 
can not be considered. Operation 
is imperative. 

Contracted kidney (chronic inter- 
stitial nephritis) is the most com- 
monly fatal lesion after or at operation. 
It is also the most liable to be over- 
looked. It is difficult to diagnose. 
The quantity of urine found is so 
frequently deceiving by its abimdance. 
There may be no albumen or per- 
chance a trace. Microscopical exami- 
nation may fail to discover a cast. 
At times they may be found. One 
condition is usually common, the 
extremely low specific gravity. 

If, after repeated examination the 
urine continues to present these char- 
acters it is not safe to operate. I 
have twice refused operation under 
such circumstances, and the patit^Klt 
died soon from the kidney disease. 



Digitized by 



Google 



86 



C. C. FREDERICK. 



Nearly every operator whom I have 
met or have corresponded with has 
had deaths from contracted kidney, 
after operation. 

It is the general observation of 
operators that their patients pass less 
urine than normal for several days 
after operation not only after abdom- 
inal section but after plastic opera- 
tions. To a certain extent this may 
be accounted fpr after sections by the 
smaller quantity of fluids ingested for 
the first twenty-four or forty-eight 
hours. I do not believe however that 
this entirely explains the almost total 
suppression which at times occurs 
and sometimes endures to an alarm- 
ing degree before secretion again 
begins. I believe that the anaesthetic 
is one factor in this production and 
that shock especially in abdominal 
sections, is the other and larger one. 
The functional power of the stomach 
is abolished, intestinal peristalsis is 
inhibited and there is present that 
intense peritoneal thirst, all showing 
shock to the solar plexus and other 
sympathetic nerve centres. 

In suppression or partial suppres- 
sion following operation drugs are of 
no avail. Water by stomach or if 
vomiting, by the bowel, together with 
cups over the kidney, steam baths 
or the hot pack accomplish the resto- 
ration of renal activity if it can be 
reestablished. Real suppression I do 
not believe can be overcome. 

Does renal insufficiency render the 
patient more liable to shock or slower 
convalescence ? 

There can be no question that 
shock occm-8 most frequently in wo- 
men having -renal lesions, because of 



their lower vitality and power of 
resistance. That the convalescence is 
retarded seems reasonable from the 
fact that the recovery especially after 
a major operation depends so much 
upon the rapidity with which effete 
products are excreted. 

The danger of operating on all 
patients with chronic lesions of* the 
kidney is the occurrence after opera- 
tion of acute congestion. This may 
even occur and often does occur to 
a marked degree in patients who 
have no well marked disease of the 
kidney previous to operation. There 
may develop de novo after operation 
congestion, acute pyelitis, or inter- 
stitial nephritis. Dr. Coe has ob- 
served acute congestion so intense as 
to result in punctate haemorrhages. 

Dr. Geo. B. Wood, of PhUadelphia, 
has recently made a valuable series of 
experiments on dogs, some having 
healthy and others having diseased 
kidneys. He found that ether exists 
in a free state in the blood during 
and for some time after inhalation. 
Ether is not excreted by the kidneys 
to an appreciable amount; the kid- 
neys of healthy dogs become con- 
gested, and on microscopical examina- 
tion the cells show cloudy swelling. 
The cells of the convoluted tubules 
are primarily affected, the tufts 
and collecting tubules only evincing 
change when the anaesthesia had been 
prolonged. Repeated administrations 
of ether, if kept up long enough, 
would probably cause desquamation 
of the epithelial cells. In cases where 
ura3mic poisoning was beginning to 
make itself apparent, it was shown 
that there existed a liability to sudden 



Digitized by 



Google 



RENAL INSUFFICIENCY. 



37 



death during ether narcosis, due to 
the action of ether on the abeady 
depressed centres of respiration. 

Dr. Russell has shown in observa- 
tions of 200 gynaecological operations, 
at the John Hopkins Hospital, that 
albumen appears in a lai^e number 
of cases for the first three days after 
operation, in whom no albumen was 
found previous to operation. There 
were 10 per cent, more who had 
albumen after than before operation, 
and thirteen cases had hyaline casts 
and five had granular casts who did 
not have them before operation. This 
shows the marked effect that anaes- 
thesia and operation has upon the 
kidneys. 

Wunderlich (centralblatt for chir- 
urgie) reports on the examination of 
100 cases of ether and chloroform 
narcosis. The urine was examined 
chemically and microscopically before 
and after operation. 

He reports that all cases taking 
ether, in whom albumen is present 
before operation, the amotmt of albu- 
men is greatly increased. 

He seldom found albumen or casts 
appeared after ether when none had 
existed before. In conclusion he says 
the so-called "ether nephritis," may 
be excluded from medical litera- 
ture. 

His observations on the effect of 
chloroform are that albumen and 
casts are frequently seen in the urine 
after its inhalation, usually disappear- 
ing in from twenty-four to forty-eight 
hours. 

He believes that both ether and 
chloroform produce an ischsemia of 
the kidney or an increase in blood 



pressure, thus accounting for the casts 
and albumen. 

Rindskopf (centralblatt for chir- 
urgie) reports 93 observations on 
chloroform narcosis. In 31 cases, 
exactly 33 1-3 per cent, albumen, 
casts, leucocytes and epithelial cells 
were found in the urine. In the 
majority of the cases the urine cleared 
up after seventy-two hours. The 
quantity of chloroform given influ- 
ences the character of the urine. No 
case should be chloroformed every 
three or four days, as the kidneys will 
not have had time to recover. 

There is prevalent among a large 
majority of our best operators a belief, 
which has been freely expressed to 
me in correspondence that chloroform 
is the safer anaesthetic in renal in- 
sufficiencies. Yet many of them have 
reported deaths from suppression* of 
urine or uraemia after its administra- 
tion. The deaths from chloroform 
seem to be quite as frequent as after 
ether narcosis. 

It is interesting to note that 
Wunderlifeh ascribes to chloroform 
more irritating properties as far as the 
kidneys are concerned than he does to 
ether. 

A few gentlemen with whom I have 
corresponded still give their allegi- 
ance to ether because they say its 
after effects are no worse than chloro- 
form and that it is safer during the 
period of administration. 

It does not seem that clinical experi- 
ence, as deduced from the observers 
whom I have quoted, carries out the 
widely extant impression that ether 
is contra-indicated in renal lesions or 
insufficiencies. 



Digitized by 



Google 



38 



WILLIAM DEWEES. 



From the foregoing I would deduce 
the following conclusions : 

1. Every patient's urine should be 
examined quantitatively and qualita- 
tively before operation if possible. 

2. Minor degrees of renal insuffi- 
ciency and minor degree of renal 
lesions are not conti'a-indications to 
operations. 

3. The graver forms of renal dis- 
ease are contra-indications to operation 
except it be for disease or growths 
which have a causal relation to the 
kidney disease. 



4. Patients are more liable to 
shock and slow convalescence after 
operation when suffering from kidney 
disease. 

5. Patients may develop acute 
renal congestion de novo after opera- 
tion and are especially liable to do so 
if there have been old lesions. 

6. That there seems to be little 
choice between chloroform and ether 
as the anaesthetic in renal insufficiency, 
both alike, producing congestion. 

64 Richmond Avenue. 



The Care of Pregnant Women.' 



BY WILLIAM B. DEWEES, A. M., M. D. 

SALINA, KANSAS. 



It is a stirring conviction with 
many reputable, earnest, and pro- 
gressive obstetricians, that the time 
has come when we must disclose our 
power to the world by increasing the 
usefulness of our labors ; and begin to 
use it for the prevention, as well as 
for the alleviation, of the sufferings of 
pregnant women, as has not yet been 
done, or else get out of the way. In 
such an event, deliverance will come 
to this class of suffering women from 
another source ; but woe to those of 
us who are found at ease with the 
assumptions of this responsibility. 
The responsibility is tremendous, but 
the obstetrician cannot evade it. He 

1. Read before tbe American Association of Ob- 
ietricians and GsmsDCOlogists, Toronto, 1894. 



may selfishly shirk it; but it is 
absolutely out of his province to shift 
it. We have need, therefore, to be 
taught again our first duty; to pre- 
serve the human body sound, which 
be the first principles of the oracles of 
God. 

After carefully studying the ground 
we may very naturally and wisely 
conclude that it is unnatural for civi- 
lized woman to suffer so universally 
as she does to-day ; and, that civiliza- 
tion and disobedience to the law of 
nature, is the true source of her pres- 
ent suffering during gestation and 
childbearing. Through imwholesome 
civilization — in ignorance as well as 
carelessness — have come fixed habits 
of excesses ; and if excesses must be 



Digitized by 



Google 



CASE OF PREGNANT WOMEN. 



3» 



indulged, evil consequences will fol- 
low and must be endured; for 
Nature's law would have to be 
changed before they could be either 
prevented or banished by any method 
of treatment. It follows then as a 
natural consequence that to prevent 
these sufferings vnll depend, not so 
much on treatment by application or 
administration of therapeutic agents, 
as on the successful education and 
training of these women, so that they 
"wUl learn to know how to — and will 
actually — cultivate the self-discipline 
requisite to enable them to prevent 
the continuous irritation from ex- 
cesses in their modes and habits of 

me. 

If the writer's observations have 
been correct and unprejudiced, it 
seems that a revival of learning in 
obstetric science must needs be insti- 
tuted among us, destined to find the 
true cause, or causes, of the unnatural 
and needless suffering of civilized 
women. The progress of obstetrics 
in the immediate future must be made 
through the knowledge that will be 
wrought out by the devotees of biol- 
ogy- Thus we shall find our way, 
on positive ground, back through the 
morphology of organs, tissues, cells, 
and blood, to a clear comprehension 
of the origin of vital activity in pro- 
toplasm and the pabulum which sus- 
tains it. This is the only way open 
for us into the primitive arcana of 
nature, if we would have the wisdom 
essential to intelligently inculcate that 
r^imen which will successfully pre- 
vent the needless sufferings of preg- 
nant and parturient women. The 
future distinction of obstetric science 



can obtain only by an advanced study 
of human biology. When this truth 
is propounded, there opens before the 
thinking mind a vista so transcend* 
ing all ordinary limitations of obstet- 
rical knowledge, as requires such 
genius and expansion of the mental 
eye in order to embrace it in its sim- 
plicity, as scarce yet obtains. It 
remains, then, for our guide, to en- 
deavor by rigid scientific investigation 
through advanced biologic studies, 
to make patent the causes of the suf- 
ferings of pregnant and parturient 
women, and to determioe exact meas- 
ures for eliminating these causes, 
or for neutralizing their effects when- 
ever they have eluded detection or 
escaped elimination. 

I verily believe, that the next com- 
ing great advance in this, our special 
branch of medical science, will be in 
bringing home to the general practi- 
tioner the fact, that the diseases pecul- 
iar to women during pregnancy and 
parturition are very largely prevent- 
able. To make him feel his responsi- 
bility, both as to their production after 
the present generally prevailing meth- 
ods of practice, and also as to the 
possibilities of their prevention after 
improved methods. The family physi- 
cian must be fully aroused to the con- 
scious realization of the fact, that it 
lies within his power very largely to 
prevent many of the diseases among 
the women of the families entrusted to 
his care. When this obtains, his 
moral obligation will impel him to 
promptly do his full duty, by giving 
adequate instruction concerning the ill 
effects of improper posture, dress, food, 
drink, and erroneous habits of living, 

Digitized by VjOOQ IC 



40 



WILLIAM DEWEES. 



including indiscriminate, excessive, 
and impure sensual indulgences. 
When that day comes — as I verily 
believe it to be within the province 
of our intelligence to successfully in- 
culcate — then, and not until then, 
may we hope to find that the preva- 
lence of diseases among civilized 
women will cease to be a reproach to 
preventive medicine. 

But as yet we are compelled to 
meet the situation as we find it. 
The condition of the sufferings of 
civilized women of the present genera- 
tion, however grossly unnaturally it 
has been cultivated, must needs have 
our most careful attention and re- 
quire our wisest judgment, lest we 
fail to institute proper treatment for 
their relief. For the convenience of 
our consideration, the paramount 
duties of the obstetrician in the study 
and care of pregnant women may be 
classified as follows : — 

1. To discover if the patient be 
actually pregnant. 

2. To determine positively if the 
impregnation be uterine or normal as 
contra-distinguished from tubal, ab- 
dominal, or abnormal pregnancy. 

3. To carefully note the pregnant 
woman's history, including her age, 
primiparity or multiparity, environ- 
ments, station in life, general condi- 
tion of health, period of gestation ; as 
well as her dress, food, drink, and 
habits of life. To make repeated 
examinations of the urine and ascer- 
tain the temperature, from the time 
pregnancy is established to the term- 
ination of gestation. 

4. To make a physical examina- 
tion for th<' purpose of accurately 



determining the diameters of the pel- 
vic straits ; the symmetry and size of 
the bony outlet ; the integrity, condi- 
tion and position of the vagina, uterus, 
and other intrarpelvic viscera, and 
adjacent structures.; the state* of the 
abdominal muscles; the presence or 
absence of hernia, varicose veins, 
tumors, etc. ; the shape, size and con- 
dition of the breasts and nipples ; the 
condition of the heart, lungs, mind, 
stomach, bowels, etc. 

5. To observe the state of the 
foetus, its strength and viability, as 
well as the implantation of the pla- 
centa. 

With regard to the first, all experi- 
enced observers have found that, psy- 
chological phenomena often called for 
an intimate study and wise differ- 
entiation of every form of hallucinsr 
tion, delusion, illusion, as well as the 
delirium of cerebral hyperaemia, or 
the frenzy of the maniac, from toxae- 
mia and eccentric irritabilities. And 
that such abnormal conditions fre- 
quently exist unrecognized, and so 
continue until they eventually estab- 
lish their peculiar fixed impress upon 
the mind and nervous system. Thus 
when the paranoiac woman simulated 
pregnancy, and even parturition, she 
deceived the better judgment of some 
of the most skilled obstetricians. 
Pseudocyesis and pseudotocia are rec- 
ognized abnormal conditions, which 
so closely resemble the normal condi- 
tion of pregnancy, and the beginning 
of parturition, as to demand our 
highest discriminative faculties in 
arriving at an intelligently correct 
diagnosis. 

As to the second, it remains a 



Digitized by 



Google 



CARE OF PREGNANT WOMEN. 



41 



simple self evident fact, that it 
should always be positively deter- 
mined whether the impregnation be 
uterine or extra-uterine. Whenever 
extra-uterine foetation is discovered, 
either before or after rupture of the 
cyst, the question of treatment is a 
very grave one. But, experience 
teaches that this truly marvelous and 
murderous condition, admits of only 
one line of action to be followed with 
any degree of ultimate safety to the 
life of the pregnant woman. Section 
must be done. No other line of 
treatment that has been advanced is 
so rational and certain in the ulti- 
mate saving of life. The perfected 
technique, as we have it to-day, 
makes it a safe procedure. We must 
however bear well in mind what ex- 
perience also teaches us, namely : 
that when the placenta is found still 
in the tubal sac, it is best to enucle- 
ate and remove all the tubal sac and 
ovary; but, that whenever the pla- 
centa is found partially or wholly 
out of the tubal sac and adherent. to 
the peritoneum, bowel, etc., and still 
alive, the very best that can be done 
is to let it alone — to leave hands off. 
In these cases the ultimate safety of 
the patient lies in the removal of the 
foetus, cleaning out of the peritoneum 
of blood clots and all other debris, 
ligating the bleeding vessels, packing 
with iodoform gauze, and treating as 
an open wound; thus allowing the 
placenta to come away in due course 
of time by suppuration. My most 
revered friend and classmate at the 
University pi Pennsylvania, Dr. 
Joseph Price, than whose experience 
in these cases there is none more ex- 



tended and successful, and who, con- 
sequently deserves to be accepted as 
reliable authority, says : all other lines 
of treatment that have been advo- 
cated, fall into insignificance in com- 
parison with this manner of manag- 
ing these cases. He also claims that 
this is a summer disease or accident, 
being in his experience almost always 
found only during the summer 
months ; when May -comes he looks 
for extra-uterine pregnancy cases. 

The third brings us to thoughtfully 
consider the influences of those con- 
ditions which have been hitherto so 
grossly neglected, but which de- 
manded decided and determined pro- 
phylaxis. The unprecedented rapid 
progress of civilization in disobedience 
to the law of nature, as evidenced by 
the accumulation of wealth on one 
hand and extreme poverty on the 
other; the forcing or cramming sys- 
tem of intellectual education with 
lack of requisite physical training; 
custom of imwholesome food and 
drink ; deteriorating fashions of dress 
and habits of society ; unbridled sens- 
ual indulgences; and the woeful en- 
deavor to equalize the duties of 
women with those of men, have with- 
in the last generation very much 
deteriorated the child-bearing capacity 
of civilized women. True, the stand- 
ard of female beauty is increasing, 
and decided intellectual growth mani- 
fested by woman in all .departments 
of science and art ; but, in the same 
ratio, do we find the remote dangers 
as well as the immediate accidents of 
gestation and child birth have in- 
creased. Hence, we find that flaccid- 
ity of the abdominal, spinal, and 

Digitized by VjOOQIC 



42 



WILLIAM DEWEES. 



pelvic supports; chronicity of the 
shattered exotic nervous systems ; 
abnormal state of the ovaries; sub- 
involution of the uterus, etc., have 
marvelously increased in late years, 
notwithstanding the much vaimted so- 
called hygenic advances in improved 
habits of living and reform in dress. 

The thoughtful obstetrician will, 
with inexorable discipline, advise his 
patient as to the requisite regime. 
The consciousness of his full duty 
will impulse him to insist upon : 

1. Absolute, regular hours and 
wholesome environments. 

2. Plain but nutritious and whole- 
some food and drink, being principally 
composed of fresh, lean meats, fresh 
fruits, pure milk, arid distilled water. 

3. A proper amount of exercise, 
by walking or light labor on foot, and 
maintaining the correct erect posture. 
Whenever infirmity forbids such exer- 
cise, recourse should be had to ma^ 
sage, and as much time passed in the 
open air as is advisable under such 
unfortunate circumstances. Rest in 
the recumbent posture after meak and 
fatiguing efforts, with not less than 
ten hours sleep out of every twenty- 
four. 

4. An open condition of the 
bowels and skin, which is to be 
chiefly maintained by proper diet, 
exercise and bathing, the wearing of 
flannels, warm low-heeled shoes, and 
loose garments, and in rare cases, the 
proper use of laxatives and hot water 
enemas. 

Urinalysis and thermometry are es- 
pecially commended at frequent inter- 
vals from the time that pregnancy is 
established until the beginning of 



parturition. They are simple in 
detail, yet how prolific of averting 
the culmination of conditions very 
hazardous to both mother and child. 
Conditions which otherwise are fre- 
quently discovered only by the 
appearance of anasarca of the inferior 
extremities, oedema of the face and 
limgs, or a seizure of eclampsia, after 
which attention is given to these 
searching steps, but often too late to 
be of any value in devising a pro- 
phylaxis. This very naturally raises 
the question, is there a prophylaxis 
for the aforesaid (Conditions? The 
experience of an earnest, rational 
endeavor in a limited number of cases 
warrants the opinion that very much 
may be done in this direction. In 
proof of this it is needless to confine 
reference to personal experience in 
private practices, for in addition we 
find that the maternities likewise fur- 
nish abundant evidence in support of 
this declaration. Here we may cite 
as the most striking example, the 
indefatigable labors of our eminent 
fellow Dr. Joseph Price, in his con- 
nection with the Prestion Retreat at 
Philadelphia, whereby both that 
Institution and himself have become 
renowned in establishing the fact 
beyond all doubt or cavil, that these 
complications can be prevented. 

A word with regard to the term 
puerperal fever, which is misleading 
and fails to express the condition it is 
intended to imply. It should there- 
fore be expimged from our literature 
and be replaced by the proper term 
parturial sepsis. Partuxial sepsis is 
a surgical sepsis, arising from the con 
ditions in which women are found 



Digitized by 



Google 



CARE OF PREGNANT WOMEN. 



43 



during the extrusion of the uterine 
contents, similar to those during sur- 
gical procedures. The same classes 
of septic infection and septic poison- 
ing occur in the non-pregnant state 
during operations upon the pelvic vis- 
cera done without due regard to abso- 
lute cleanliness, and in hospitals where 
patients are crowded together with 
want of proper sanitation. 

Under the fourth head of the sub- 
divison of this subject, it may be re- 
marked that pelvimetry is an equally 
essential requisite with urinalysis and 
thermometry. Deviations from the 
normal, symmetrical pelvis, the diame- 
ters of the pelvic straits, and the 
inclination of the bony excavation, 
exercise marked influences in propor- 
tion to the degrees that they exist. 

In eoi abnormally broad, capacious 
pelvis, with obliquity lessened and 
supports relaxed, we find that in the 
earlier period of gestation, the tend- 
ency is to misplacement of the gravid 
uterus. These abnormal uterine posi- 
tions are usually manifested earlier 
by bladder or rectal difficulties with 
bearing down or pressure in the pel- 
vis, and a dragging sensation from 
the lumbo-sacral region, etc. It is a 
noteworthy fact that in these cases 
there is almost invariably foimd to be 
a want of the correct posture, erect 
posture. The woman herself uncon- 
sciously increases the aforesaid diffi- 
culties by assuming a more or less 
stooping posture, in her endeavor to 
make herself comfortable from the 
dragging sensation below. Thus we 
find the abdominal and spinal muscles 
relaxed, the lumbo-sacral spine re- 
ceding behind its normal axis — per- 



pendicular with ear, shoulder, hip and 
ankle — the rate of weight of the 
superior trunk gravitating back of 
this normal axis and falling perpen- 
dicularly behind the Heads of the 
femurs ; whereby the pelvis is swung 
upon the femur heads from an oblique 
to a more or less transverse position, 
while the superincumbent weight of 
the abdominal and thoracic viscera, 
instead of being directed forward by 
the normally advancing lumbo-sacral 
spine and supported upon the pubes 
and lower portion of the abdominal 
muscles, now falls directly within the 
basin of the pelvis exerting its injuri- 
ous effect upon the contents thereof. 
The real causes of these conditions 
being thus clearly revealed, the treat- 
ment becomes very simple. This con- 
sists in first re-establishing and main- 
taining the correct erect posture, there- 
by securing the normal obliquity of the 
pelvis by advancing the lumbo-sacral 
spine in its normal axis of the body. 
Experience has established the fact 
that the correct erect posture in these 
cases is secured and maintained the 
better and easier by virtue of proper 
external support. The external sup- 
port which fulfills this purpose the 
better and easier is one designed by 
the writer and fully detailed in a 
paper read before the Intetaational 
Periodical Congress of Gynaecology 
and Obstetrics, at Brussels, Belgium, 
September, 1892, — and published in 
the International Medical Magazine, 
October, 1892, — and manufactured 
by The Natural Body Brace Com- 
pany, of Salina, Kansas. The normal 
equipoising of the superior trunk upon 
the lumbo-sacral spinal axis having 



Digitized by 



Google 



44 



WILLIAM DEWEES. 



been restored, whereby the evil influ- 
encea from the weight above as a 
prime causative factor in intra-pelvic 
disturbances being happily overcome, 
there remains but attention to be 
given to the insignificant weight of 
the misplaced pregnant womb itself. 
This is usually easily corrected, when 
free from adhesions, by proper postur- 
ing and afterwards maintained by 
proper internal support with some 
pessary suitably fitted to the case. 

When, on the other hand, the pel- 
vis is abnormally distorted or con- 
tracted, the question of how best to 
conduct the gravidity has been even* 
a more unending source of discussion 
than the preceding condition. Here 
pelvimetry furnishes us the chief 
guidance. But before we progress 
further, let us first break loose from 
the. traditional shackles of our pred- 
ecessors and their authority, which 
have too long retarded freedom of 
thought to such a degree, that he 
who dared to doubt met but derision. 
I refer chiefly to the murderous prac- 
tice of inducing premature delivery 
and embryulcia in this condition. In 
the present light of science these pro- 
cedures have no place in the obstetric 
art in connection with a viable foetus. 
They simply deserve to be mentioned 
that they may be the more effectually 
relegated to the past. This leaves us 
to choose principally between but two 
procedures whenever we find the pel- 
vis so distorted or contracted, that it 
precludes all probability of delivering 
the living child, namely, symphysot- 
omy and Csesarean section. Without 
specifically considering all the points of 
this very serious condition — which 



fortunately for us is, comparatively 
speaking, very rarely encountered in 
the native bom American woman — 
I would unhesitatingly advise against 
the termination of gestation, looking 
more hopefully to ultimately saving 
the life of both mother and child by 
resorting to one of the aforesaid oper- 
ations. It is to be remembe^red, how- 
ever, that it is the duty of every 
intelligent obstetrician to become 
thoroughly familiarized with the in- 
dications as well as the technique of 
both these operations, neither of which 
are to be lightly undertaken by any- 
one who does not possess the requisite 
skill, both in the obstetric art and 
abdominal surgery. 

With regard to the proper selection 
of these two operations, I can do no 
better than refer to my friend, Dr. 
Barton Cooke Hirst, of Philadelphia, 
who is an acknowledged authority on 
the obstetric advances, in his address 
before the Washington Obstetrical 
and Gynaecological Society, Nov. 17, 
1893, and published in the Medical 
News of Philadelphia, Dec. 2, 1898. 
We may therefore be guided by the 
rule that at term, symphysotomy is 
available only in cases where the 
conjugate measures over 67mm, while 
if the conjugate is found to be 67mm, 
or under, the only recourse to be had 
is Caesarean section. 

The destruction of the embryo is, 
however, not only warranted, but 
becomes a requisite under such cer- 
tain circumstances or conditions ; such 
as the presence of large fibroids in 
the body of the . uterus, or large 
tumors involving both the ovary and 
uterus, also cancers of the uterus. 



Digitized by 



Google 



CARE OF PREGNANT WOMEN. 



46 



and in certain cases of placenta 
praevia. Placenta praevia is another 
abnormal condition deserving atten- 
tion. It properly belongs to that 
class of appalling accidents in the 
lying-in-room, such as eclampsia, post- 
partum hemorrhage, rupture of the 
womb in uterine pregnancy or of the 
cyst in tubal pr^nancy, etc., which 
allow but little time for action. Ex- 
perience teaches that the proper use of 
the forceps in these cases is to be 
preferred to the hand. The chief 
reason being that a narrow bladed 
forceps can be introduced much earlier 
than the hand — requiring a dilation 
of only about one inch as compared 
with two and three-quarters inches 
for the hand — and, by grasping the 
head and bringing it down tampons 
the placenta at once; whence time 
may be given suflBcient to obtain full 
dilation and delivery with the greatest 
possible safety to both mother and 
child. In these cases we may very 
properly follow the one line of action. 
As soon as the diagnosis of placenta 
prsevia is established our action must 
be prompt in evacuating the uterine 
contents. Haemorrhage is the danger 
signal. When this signal is given 
early, say prior to the sixth month, 
and the diagnosis established, we 
should proceed without any regard 
for the life of the child. When, 
however, this signal is given later, we 
should proceed as promptly, but with 
all possible endeavor to save the life 
of both mother and child. Whenever 
haemorrhage takes place in these cases 
it is nature^s signal to us that there 
is great danger ahead ; that the con- 
dition is so serious as to endanger, if 



not to take the life of the mother at 
any moment. We can accept the 
situation only as serious, and must 
act promptly and efficiently. The 
proper antiseptic precautions being 
observed with special reference to the 
vagina aiid the accoucheur's hand, the 
patient being placed imder anaesthesia, 
introducing first the index finger into 
the cervix, dilating gradually until 
two fingers are successfully introduced, 
and, when sufficiently dilated to ad- 
mit of the forceps, pass the fingers 
through the body of the placenta 
rupturing the membranes and place 
the forceps on the head, bring it 
down and tampon the placenta at 
once. When, as sometimes happens, 
the dilation is greater and the presen- 
tation abnormal or less favorable the 
accoucheur had better resort to the 
passing of his hand and turning by 
Braxton-Hicks method and drawing 
the child into the cervix, and thus 
arrest the haemorrhage. The haem- 
orrhage once checked, the subsequent 
delivery will be fully under control. 

I have in this paper but sketched 
some of the salient and moot points 
of the prophylaxis of the complica- 
tions and needless suffering of preg- 
nancy with no attempt at thoroughly 
elucidating or elaborating any one of 
them. Having no pet theory to 
promulgate and sustain at all hazards, 
no long list of cases and statistics 
with quotations and abstract from an 
exhaustive roll of writers has been 
made out. And, \^hile universal con- 
viction may not be with me on prem- 
ises somewhat narrowly drawn, still I 
hope the attention of this Association 
may be drawn to their thorough con- 



Digitized by 



Google 



46 



ElilTORIAL. 



sideration, that free discussion may 
evolve all the facts of this interesting 
subject, and, finally, to find with 
many of you these facts received with 



favor and not only to maintain an 
excellent reputation, but also to in- 
crease in favor on closer acquaintance. 



EDITORIAL. 



Ocular Affections of Uterine Origin. 



Cases relative to this question have 
often been reported by diflferent 
writers, and two important memoirs 
on the subject have lately been pub- 
lished, namely, a review by Dr. Janot, 
which appeared in the Montpelier 
MedicaU and a thesis by Dr. Pargoire, 
having for title, "ie« Trovhles ocur 
laires dans la menstruation^ Men- 
struation, even normal, can be accom- 
panied by different troubles of the 
eye. Finkelstein, who examined the 
functions of the eye during menstrua- 
tion, came to the conclusion that 
very often at that time there was 
a diminution of the visual field, 
which attained its greatest inten- 
fiity when the loss of blood is the 
most abundant, and the sense of 
color is also at times abnormal. 
Styes d rSpStition^ herpes of the cor- 
nea and hemianopsia have also been 
observed at each regular menstrual 
epoch. Still more, iritis and irido- 
choro'iditis have been known to ap- 
pear a few days before the menses 
and disappear with the end of them. 

Menses have an influence over the 
healthy eye, but this influence is still 
more manifest when this, abeady 



the seat of disease, the exacerba- 
tions then appear with the greatest 
ease. After a surgical traumatism 
an inflammatory attack has been 
observed to come on at the apparition 
of the menses. To these facts may 
be added cases of catarrhal conjimc- 
tiritis coming on with the menses, 
and Dr. Pargoire relates three most 
interesting examples. At the time of 
puberty, when menstruation has not 
attained its regularity, ocular affec- 
tions are not uncommon. Keratitis 
and hemorrhages have been mostly 
observed, but iritis, irido-choroi'ditis 
and even detachment of the retina 
have been met with. The greater 
part of these affections cease after the 
menses become regular. However, 
Dr. Pargoire relates a case of em- 
bolus of the central artery of the 
retina taking place during these con- 
ditions and terminating in an atrophy 
of the papilla. 

Troubles which may be produced 
at the change of life are still 
more frequent, although not many 
cases have been published. Irido- 
choroiditis is the most often met 
with, then comes optic neuritis but 



Digitized by 



Google 



OCULAR AFFECTIONS OF UTERINE ORIGIN. 



47 



Tarely, which, however, may end in 
4X)mplete cecity. The oculax lesions 
produced by pregnancy have been 
much written about. Often it is true 
albuminuria is the intermediary of 
the ocular lesion and the pregnancy, 
but in this paper the cases considered 
had no connection with nephritis. 
Amauroses, partial or complete, have 
been met with. Santession mentions 
a case of a woman who had complete 
amaurosis of both eyes during the last 
five months of her eight successive 
pr^nancies. Sight came back after 
each confinement, but in the first con- 
finements the amaurosis disappeared 
-one week after labor while in the 
last, a month elapsed before vision 
was perfect. 

Ulcers of the cornea have been 
recorded in this condition. Bloding 
mentions a remarkable *case of stra- 
bismus occurring with such regu- 
larity that the patient knew when 
she was pregnant. Detachment 
<ji the retina and especially hemer- 
alopia have been recorded. Gale- 
zowski especially mentions diseases of 
the membranes of the eye, as well 
ii8 amblyopia and amaurosis without 
perceptible lesions, but he considers 
them as symptoms of hysteria or 
due to troubles of innervation. These 
diseases may take on a great intensity 
if the eye was already diseased, which 
is consequently aggravated and more 
complicated by the existing preg- 
nancy. 

Labor and the puerperal state can 
hardly be separated. The debut us- 
ually takes place either during the 
deliverance, when for example there 
is hemorrhage due to retained pla- 



centa, or immediately after. Labor 
the more often is simply the cause of 
the aggravation of the ocular symp- 
toms which have made their ap- 
pearance during pregnancy and often 
it is at this time that their regression 
commences to finally end in recovery 
by suppression of the cause. But 
there are cases in which the ocular 
came on during labor itself; in a 
woman mentiond by Ringland, sight 
became weaker and weaker during 
labor and ended by being totally 
abolished. A few days later it again 
was normal. These are nothing more 
or less than cases of amaurosis* or 
amblyopia that have been observed in 
these circumstances, but embolus and 
irido-choroiditis have been met with. 

When the uterus is in a pathologi- 
cal condition, ocular troubles are 
still more frequent. In amenorrhoea, 
ocular congestions can occur, similar 
to real supplementary hemorrhages. 
Keratitis, hemon:hage, iritis and 
irido-choro'iditis are the ordinary 
effects ; but the optic n^rve itself may 
be interested. The consequences of 
dysmenorrhoea are nearly the same ; 
serous iritis is the most frequent 
manifestation. Its presence is indi- 
cated in most cases by photophobia, 
lacrymation, and painful tension of 
the globe. 

Ocular troubles in relation to 
abortion have not been much studied. 
A professor of Lyons reports a 
case of irido-choro'iditis following an 
attempt at abortion, and this fact 
confirms the theory that all these 
ocular affections are produced by an 
infection having its. origin in the 
uterus. Affections of the uterus, 



Digitized by 



Google 



48 



ADAM H. WRIGHT. 



other than menstrual troubles, may 
occasion ocular lesion, whether it be 
an inflammatory lesion or a- mal-posi- 
tion of the organ. In fact, the diffi- 
culty in the flow of the menses can 
favor the introduction of infectious 
germs into the organism, but that 
which is still more favorable is a con- 
tinual port cCSntrS always in con- 
tact with liquids eminently proper for 
the culture of pathogenic microbes. 
Ulcerations of the cervix, metritis, 
cancer of the uterus, can produce 
lesions of the eye. It is consequently 
most important to recognize the fact 
th&t certain affections of the organ of 
vision are under the dependence of 
uterine disease. The physician will 
arrive at the diagnosis by the peri- 
odical appearance of the lesion, which 
will oblige him to question the patient 



as to the state of her menses. But it 
is not always so, and when one has to 
do with metritis, or ulcers of the 
cervix which the patient herself 
ignores, many difficulties will be en- 
cotmtered. Consequently, it must be 
remembered that there are ocular 
affections which will persist as long 
as the uterine lesion exists. On ac- 
count of the probability of the infec- 
tious origin of these ocular troubles, 
it appears indicated, even when the 
infection is in relation with a simple 
menstrual disorder, without urethritis, 
etc. to try to bring about menstrua- 
tion at regular epochs, and during the 
interval, practice antisepsis of the 
vagina and neighborhood of the 
uterus. Perhaps, by this method, 
relapses will be avoided. 



Should Antiseptic Vaginal Douching be Made a Routine Practice During 

the Puerperium ?' 



BY ADAM H. WKIGHT, B. A., M. D. 
TOBomro. 



It is not exactly correct to say that 
Semmelweiss was the first who in- 
formed the obstetric world as to the 
true source of puerperal septicaemia; 
but his name stands out so promin- 
ently in connection with the various 
discussions on the subject that he is, 
by almost general consent, considered 
the father of modem antiseptic mid- 
wifery. In 1847 he clearly and 

1. Read before the American Association of Ob- 
stetricians and Gynaecologists, at Toronto, Sept., 
1804. 



positively enimciated the view that 
puerperal fever was caused by the 
introduction of putrescent substances 
deposited in or about the genital tract 
of the parturient woman. The con- 
freres of Semmelweiss were somewhat 
slow in accepting his views ; but 
many earnest workers in various parts 
of the world in the course of years 
proved conclusively that they were 
substantially correct. The investiga- 
tions and experiments of Pasteur and 



Digitized by 



Google 



VAGINAL DOUCHING. 



49 



Lister gave a wondrous impetus to- 
wards advancement, and did much to 
place our knowledge of antisepticism 
and asepticism on a definite scientific 
basis. 

Lister's practical application of 
such knowledge to his work in sur- 
surgery stimulated surgeons and obste- 
tricians in all parts of the word, and 
caused them to make special efforts 
to avoid septicaemia. The obstetri- 
cians of Germany were especially 
enthusiastic, and Americans were not 
slow in following their example. The 
new ideas and the new methods 
spread rapidly from hospital to hos- 
pital in Germany, France, Great 
Britain, America and other countries. 
In 1872 rigid antiseptic methods were 
carried out in a systematic way in 
numerous maternities. Mortality 
rates had a marvellous fall. Those 
horrible epidemics of that fearful 
scourge, puerperal fever, which had 
slain its thousands, were rapidly being 
repressed, especially in lai^e materni- 
ties. The bright reports and minute 
descriptions of the various methods 
were spread broadcast over the whole 
civilized world, and incalculable good 
was derived therefrom. 

But, gentlemen, puerperal septi- 
caemia or puerperal infection (caU it 
what you vnll) still exists. The 
annual reports of the Registrar Gen- 
eral of . Great Britan shows that the 
death rate from childbirth has not 
appreciably diminished 'in England 
and Wales. In fact, in certain parts 
of England the death rate from puer- 
peral septicaemia has actually in- 
<nreafied in recent years. In the 
Unit^ States and Canada the mor- 



tality from this cause is probably less 
now than it was fifteen years ago, but 
it is still very high. Why is it that 
such a deplorable condition of things 
in connection with the practice of 
obstetrics continues to exist, notwith- 
standing the flood of light which has 
been thrown on the subject during 
the last fifty years ? I will not now 
attempt to answer the question. 

Under the circumstances it be- 
hooves us as a society, which includes 
obstetrics as one of the subjects with- 
in its province, to assist others in 
carrying on a vigorous fight against 
this deadly but repressible foe — 
puerperal septicaemia. With this 
object in view it was decided by our 
council, on the advice of Dr. Mc- 
Murtry, to have a discussion on one of 
the proposed preventive measures, 
viz., antiseptic vaginal douching, and 
I have been honored with the request 
to open the discussion. 

Since the year 1848 antiseptic 
vaginal douches have been more or 
less in vogue. In the earlier years 
chloride of lime, chloride of soda, 
permanganate of potassium, sulphate 
of copper, etc,, were used by various 
obstetricians. So far as I know, such 
injections were first used in America 
by Fordyce Barker in the Bellevue 
Hospital in New York about forty 
years ago, and were continued by him 
as a matter of routine practice about 
twenty-six or twenty-seven years. In 
later years carbolic acid became the 
favorite. In 1876 Tamier recom- 
mended bichloride of mercury, which, 
to-day, is probably the favorite anti- 
septic agent in obstetrical work. I 
will not mention any of the other 



Digitized by 



Google 



60 



ADAM H. WRIGHT. 



numerous antiseptic remedies, which 
have been used, nor will I attempt to 
discuss their comparative merits. 

Vaginal antiseptic douching during 
the puerperium was most popular be- 
tween 1875 and 1885. It appeared 
at one time that it would be univer- 
sally adopted as a routine prophy- 
lactic measure. The method seems 
so charming in its simplicity, and ap- 
peared so perfectly innocuous, that it 
was considered by many somewhat of 
a crime to neglect it. In December 
of 1883, about two years after For- 
dyce Barker had given up the prac- 
tice, Gaillard Thomas became its 
most enthusiastic champion. His 
address on the subject of the pre- 
vention and treatment of puerperal 
fever, delivered before the New York 
Academy of Medicine and the discus- 
sion which followed, including a paper 
by Barker, read at an adjourned meet- 
ing, were exceeding able, and created a 
great deal of interest during the year 
1884. The douching wave reached 
its greatest height about that time, 
but since then a reaction has set in, 
and at the present day opinions are 
divided as to the utility of the mea- 
sure in normal cases. 

I consider it quite unnecessary to 
enter minutely into pathological de- 
tails. Probably all here will admit 
that puerperal septicaemia is due to 
the work of living organisms, which 
are largely, if not altogether, intro- 
duced from without. Bacteriologists 
have taught us much on the subject, 
but have not yet proved definitely 
what form, or forms, of bacteria 
cause the poisoning. Certain kinds 
of cocci, especially the streptoccus, 



have a certain connection with the 
sepsis as causation agents, but exactly 
what it is we know not now. The 
bacteria are so much under the influ- 
ence of surrounding structures, and 
are subjects to so many modifications, 
that the study of their life history 
has been found very intricate and 
difficult. It seems in some cases that 
a certain number of bacteria already 
lodged in the parturient woman are 
comparatively innocuous until other 
members of their species are imported 
from foreign sources, when sud- 
denly all commence to work together 
with deadly effect ; or sometimes they 
are kept harmless by the surroimding 
secretions, as, for instance, in the 
vagina^ until they are pushed into 
other fields, such as the cervical tears 
or the uterine cavity, when they im- 
mediately wage war. From a clini- 
cal standpoint the important thing to 
recognize is that septic matter — 
something that cripples or kills our 
patients — when introduced from 
without by dirty finger tips, dirty in- 
struments, and from dirty surround- 
ings of all sorts, creates all the mis- 
chief. 

In order to assist in avpidiilg the 
evils our Council directs me to ask 
the question. Should antiseptic vag- 
inal douching be made a routine 
practice in the puerperium ? In nay 
opinion, no. While I hold a decided 
opinion, and am quite willing to ex- 
press it, I -have a great respect for 
many eminent obstetricians who say 
yes, and am always glad to hear 
their arguments, and, I hope, weigh 
them carefully. I happen to be one 
of those who were not captured by 



Digitized by 



Google 



VAGINAL DOUCHING. 



r>l 



the fascinations of vaginal douching 
as pictured by so many in years past. 
If I were at all inclined to feel proud 
of this my pride ought to be lowered 
by a consideration of the fact that a 
large proportion of those who at that 
time held views similiar to mine were 
too lazy, or too careless, or too indif- 
ferent to give the matter much 
thought or study. I have no feeling 
but that of contempt for this class of 
obstetricians, who are" mainly respon- 
sible, in my opinion, for the high 
mortality rates which still prevail in 
midwifery. I have sometimes been 
misimderstood, and misquoted; and, 
although I am not likely to be mis- 
understood by the members of this 
Association, I desire to add that no 
man has a greater desire than I to 
see a rigid adherence to the modern 
rules of asepsis and antisepsis on the 
part of all who practice our obstetric 
art. 

I have studied the subject pretty 
carefully for the last eighteen years. 
I was much impressed with many of 
the favorable reports showing the 
good effects of vaginal douching. 
About sixteen years ago, and for a 
number of years thereafter, I watched 
the work of a friend in Toronto who 
practised the methods. We carefully 
compared notes, and had many dis- 
cussions on the subject. His methods 
of antisepticism both in surgery and 
obstetrics were very carefully and 
thoroughly carried out. He had high 
temperatures more frequently than I ; 
but for years, he thought they were due 
to accident and not to his methods. 
He thought, as did many others, that 
the douching with weak solutions of 



carbolic acid could certainly not do 
any harm if carefully done. Although 
he has since relinquished obstetrics 
for the more narrow field of surgery, 
he quite came to the conclusion before 
his departure that the douching was 
at least useless in normal cases. I 
don't know whether it was Breisky 
or Tamier who first used the expres- 
sion, "Everything that is useful is 
dangerous," but it has always struck 
me as being both true and sensible. 
If it can be shown that douching is 
useless it is surely better not to carry 
out a method which is vei*y distaste- 
ful to women, whether it be dangerous 
or not. I think, however, it is both 
useless and dangerous, and will en- 
deavor briefly to give my reasons, 
which are founded partly on the 
results of my own observations, but 
chiefly on the reports of those who 
have had experience in the larger 
maternity hospitals in various parts of 
the world. 

1. Douching disturbs that perfect 
rest and quiet which are so desirable 
for a patient after labor. I do not 
now refer to surgical rest of wounded 
tissues, but to rest in a general way 
which is so delicious to a weary and 
more or less exhausted woman. I 
have often thought, and sometimes 
stated, that meddlesome midwifery 
reached the acme of absurdity, when^ 
in 1883, a distinguished New York 
gynaecologist recommended about the 
most persistent and aggresive obstet- 
ric meddling that had ever been con- 
ceived by the brain of man. He 
advised, among other things, the 
administration of a douche every 
eight hours, and the introduction of 



Digitized by 



Google 



52 



ADAM H. WRIGHT. 



an iodoform suppository every two 
or three hours for at least ten days 
after delivery : that is to say — the 
bruised and lacerated vagina was to 
be invaded from eleven to j&fteen 
times every twenty-four hours for at 
least ten days, if the unfortunate 
victim should live so long. Little 
wonder was it that Fordyce Barker 
entered a strong and vigorous pro- 
test! 

2. Douching is unscientific on 
surgical grounds. After labor the 
utero-vaginal canal is bruised and 
wounded. On surgical principles the 
most important points in the treat- 
ment are rest, pressure, position and 
drainage. By rest T refer to that 
physiological rest to which so much 
importance has been attached by 
Hilton, and many others. The 
wounds of the cervix and vagina are 
as a rule kept closed by the elastic 
and even pressure of the surrounding 
tissues. The introduction of suppos- 
itories and douching seriously in- 
terfere with rest and pressure 
as described, and in my opinion, 
materially delay the healing of those 
woimds. The recumbent posture 
with the slight changes in position 
required in voiding urine and faeces 
is well adapted for drainage. 

3. Douching does not lessen the 
dangers accruing from the presence 
of bacteria in the vagina. This is 
probably the most diflScult contention 
to prove definitely. Do destructive 
organisms ever exist in the vagina 
after labor? Undoubtedly, yes. In 
some cases cocci of various kinds are 
present in varying numbers. The 
recent investigations of Doederlein, 



Winter, Steffek, Koenig, and others 
confirm the opinions of former 
observers as to the occasional, if 
not frequent, presence of pathogenic 
micrococci in the vaginal secretions 
after labor. It is generally agreed, 
however, that in normal cases the 
vaginal mucus is strongly acid. The 
acidity is produced by innoxious 
organisms which have their habitat 
in the healthy vagina. It happens 
that these organisms have some 
restraining, if not destructive, effect 
on the pathogenic cocci. Vaginal 
antiseptic injections may interfere 
with this normal acidity, and thus 
chemically lessen the resistance of 
the tissues to bacteria. Taking these 
views as correct we learn that nature 
has provided a secretion in the va- 
gina which prevents the wicked 
organisms from doing any harm ; and, 
such being the case, douching is at 
least useless. 

4. Douching is actually danger- 
ous. I have already alluded to cer- 
tain of these dangers, especially from 
a surgical standpoint. It is apt to 
disturb clots, and thus open ave- 
nues for infection; to open lacera- 
tions of the cervix and vagina, and 
thus prevent them from healing; to 
wash bacteria into the uterine cavity, 
and thus cause septic endometritis. 
Among other dangers which are gen- 
erally due to accident or carelessness 
are the introduction of septic matter 
by fingers and instruments. Some 
mention other rare or minor dangers 
which I will not refer to in this 
paper. 

Many of the arguments thus far 
advanced are to a certain extent 



Digitized by 



Google 



VAGINAL DOUCHING. 



58 



theoretical ; and, in connection there- 
with, the results of clinical experience 
ought to assist us materially in arriv- 
ing at correct conclusions. Fortu- 
nately statistics prove beyond the 
possibility of doubt that the results 
of our modem methods, whether with 
or without douching, are vastly better 
than those of the pre-antiseptic era. 
The fearful mortality rates of five to 
ten per cent., or even more, have 
been reduced to about one-half of one 
per cent., or less, in all our well ordered 
maternity hospitals both in the old 
and the new world. As far as I can 
learn the weight of evidence goes to 
show that the hospitals in which the 
routine douching is not practised have 
better results. Baruch of New York 
published a table, from which it 
appeared that in the following hospi- 
tals where the douche was in use — 
Charitd, Parma Maternity, and Glas- 
gow Maternity — ^the mortality ranged 
from 1.5 to 8.42 per cent., while 
in the Tamier Maternity, Paris, 
Prague Maternity, Copenhagen Ma- 
ternity, and New York Maternity, 
where the douche was not in use as 
routine practice, the mortality ranged 
from to .56 per cent. (iV^. F. Med. 
Jour,, March 22, 1894.) 

It will be seen by this that one 
maternity (the Parma) had the high 
mortality of 3.42 per cent. Now, 
although I am not partial to douch- 
ing, I do not for one moment suppose 
that the bad results at Parma were 
due to this practice alone or chiefly. 
There must have been other elements 
at work. 

More recent reports prove conclu- 
sively that the mortality rate may be 



brought down to 5 per cent, or 
less whether douches be used or not* 
From one of Boxall's papers we learn 
that the mortality in the London 
Lying-in-Hospital, for five years pre- 
vious to 1890, was only -.418 per 
cent., the number of patients treated 
being 2,150. Vaginal douching was 
done as a routine measure twice a day 
during the puerperium. I was, for a 
time, much impressed with statistics 
such as those quoted by Baruch, but 
the statistics from London, such as 
those just mentioned and other 
results under certain obstetricians in 
Edinburgh and Glasgow, have perhaps 
taught me a little humility. After 
all, douching or otherwise as a routine 
practice is simply one detail among a 
thousand or more which go to make 
up the long and perhaps tortuous 
chain of antiseptic and aseptic mid- 
wifery. 

T am very strongly impressed, how- 
ever, with the opinion that the use of 
the douche does sometimes, if not 
frequently, cause a rise of tempera- 
ture which must of course be con- 
sidered an evil. During the period 
referred to by Boxall, when the death 
rate was .418 per cent., the labors 
followed by fever from all causes 
amoimted to 40.65 per cent. In a 
a number of maternities on the Con- 
tinent where no douching is done the 
percentage of febrile, complications 
ranges from 6 to 10 per cent. Leopold 
has compared the two methods in 
Dresden with the following results: 
Of 2,388 deliveries with injections, 
17.2 per cent, had fever; of 1,136 
deliveries with vaginal washings, 20 
per cent, had fever ; of 1,123 deliveries 

Digitized by VjOOQ IC 



54 



ADAM H. WRIGHT. 



with no injection at all, only 9.7 per 
cent, had fever (^Medical News, Feb. 
14th, 1891). In all these cases simi- 
lar antiseptic precautions were ap- 
plied to everything which approached 
the patient, but in the latter series 
there was no interference with the 
parturient tract. In comparing the 
second with the third set of cases it 
will be seen that in 1,000 cases, 200 
had fever after deliveries with in- 
jections and vaginal washings ; while, 
in the same number, only 97 had 
fever when no injections had been 
employed. 

In considering the statistics from 
modernized maternity hospitals, I 
think it important to keep in mind 
the fact that the injections are ad- 
ministered with care and skill. In 
private practice they are frequently 
given in a careless and slovenly way, 
notwithstanding' conscientious efforts 
on the part of the accoucheur to guard 
against such faulty work. A large 
proportion (more than half I think) 
of our nurses do not know how to 
administer a vaginal douche properly. 
If you will admit, for the sake of 
argument, if not absolutely, that 
Leopold's results show that skillful 
antiseptic vaginal douching is not 
only useless but actually dangerous, 
then I think it follows as a logical 



conclusion that indiscriminate douch- 
ing, by good, bad and indifferent 
nurses, such as are placed at our dis^ 
posal in private midwifery, is danger- 
ous in a still greater degree. 

Such is my opinion at the present 
time, and such it has been for many 
years, but I would hesitate to say 
that it is final or unalterable. I have 
not yet reached that happy state 
when I feel that I know all that is 
worth knowing about antiseptic midr 
wifery. It is a subject which does 
not grow old with me — in fact it is 
ever new. I am as anxious now as I 
ever was to learn something new 
about antiseptic and asceptic methods, 
to adhere religiously to what I con- 
sider the best rules in both private 
and hospital practice, and to do what 
I can to teach others, especially my 
students, how to avoid preventable 
maiming, and preventable death. I 
am not sorry this question is still un- 
settled, I think it exceedingly fortu- 
nate that we are able to get from 
time to time such valuable and ac- 
curate reports from the various large 
maternities, and hope we may in the 
near future get still more light on a 
subject of such vast importance from 
a humane as well as a professional 
point of view. 



Digitized by 



Google 



STRUCTURAL CHANGES IN THE UTERUS. 



56 



The Relation of Hysteria to Structural Changes in the Uterus and its 

Adnexa/ 



BY AUGUSTUS P. CLARKE, A. M., M. D., 

OAMBBIDQB, MAB8., U. 8. ▲. 



The author says that having early 
in his practice become interested in 
the subject of hysteria he began to 
make special observations. He had 
noticed in a number of cases of girls 
who suffered more or less during the 
menstrual periods that they exhibited 
at times marked symptoms of hys- 
teria. Out of a series of twenty cases 
presenting indications of such a pe- 
culiar type of nervous disturbance he 
was able to diagnosticate in sixteen, 
well pronounced features of antever- 
sion.of the uterus. In three of the 
cases anteflexion was unusually severe. 
Another interesting phase observed 
in those cases was the position of the 
ovaries. In a larger series of such 
•cases prolapse of an ovary into Doug- 
las's cul de sac was not an infrequent 
occurrence. When prolapse occurred, 
it was not always on the left side; 
ovaritis and prolapse on the right side 
gave rise to symptoms usually more 
severe than when the morbid condi- 
tion appeared on the left side. Cases 
illustrative of the various phases of 
anteversion productive of hysterical 
symptoms are mentioned by the au- 
thor. Hysteria may occasionly be 
dependent on certain odd forms of 
procidentia uteri, on laceration of the 
cervix, and of the perineum. Gonor- 

lAn abstract of a paper read before the American 
AssociatioD of Obstetricians and Oynecolog^ts at 
its Seventh Annual Meeting held at Toronto. Sep- 
tember 19-21, 1894. 



rhoeal inflammation involving the 
Fallopian tubes and the ovaries may 
be prolific of hysteria. Such inflam- 
mation may assume a latent condition 
and so become chronic before the 
gravity of the especial morbid proc- 
esses has become fully recognized- 
It is in this class of cases that hyster- 
ical paroxysms are liable to occur. 
Morbid processes continuing for some 
considerable time in the delicate 
stroma of the ovary are liable to give 
rise to such mechanical or physical 
constriction in the parts involved, as 
to set up at intervals an irregular 
reflex irritation that may extend 
through the medium of the spinal 
nerves and the sympathetic ganglia 
to almost every part of the entire 
organism. The fact that hysteria 
often breaks out at or during the 
menstrual period favors the conclusion 
that its manifestation is due to lesions 
connectod with the uterine system. 
A severe strain at that time put upon 
these sensitive organs may, when they 
are but even in a slightly abnormal 
condition, set in motion reflexes that 
may culminate in explosive attacks. 

Temperature, occupation and cli- 
mate may to some extent act as excit- 
ing causes, but these agencies can 
hardly be considered as being capable 
of superinducing hysteria. An hered- 
itary predisposition to nervous com- 
plaints would at first thought seem to 

Digitized by VjOOQ IC 



56 



AUGUSTUS P. CLARKE. 



be sufficiently adequate for a deter- 
mining cause; the author's own 
clinical experience as carefully re- 
corded fails to give recognition to 
influences of such a taint. 

In diagnosticating chorea and 
epilepsy the existence of certain 
factors have usually been deemed to 
be essential ; in the absence of some 
such supposed factors the disease has 
sometimes been pronounced an attack 
of hysteria. 

Later observations and daily clinical 
experiences in the practice of gynae- 
cology justify the restricting of the 
terms hysteria and hysterical phe- 
nomena to much narrower limits in the 
sphere of invasion of nervous affec- 
tions than formerly. The older 
writers were inclined to indulge in too 
much metaphysical speculation ; their 
descriptions were often overdrawn. 
The causes of hysteria prevailed more 
in their theory than in their actual 
practice. 

The achievements of the gynaecolo- 
gist and abdominal surgeon, are, how- 
ever, well recognized. His attain- 
ment to the greatest proficiency in the 
diagnosis of obscure lesions in the 
genitaha has proved to be all import- 
ant in the solution of the question 
before us. 

From the author's observation and 
experience gained in conducting the 
treatment of cases of hysteria, the 
following propositions have been for- 
mulated. 

That in a large proportion of cases 
of genuine hysteria, there exists some 
distinct and tangible lesion of the 
uterus, appendages or of parts im- 
mediately connected, and that the 



hysterical phenomena resulting from 
such organic disturbances will not 
yield imtil definite measures have 
been instituted for overcoming the 
original malady. 

That in some cases impoverish- 
ment of the blood, and other constitu- 
tional influences may give rise to 
paroxysms of hysteria, that these 
attacks are often transient, much 
more mild, and when properly treated 
by constitutional measures may dis- 
appear altogether. That in those 
more obstinate cases of nervous per- 
version in which there may exist to a 
greater or less extent hypersesthesia, 
dysaesthesia, anaesthesia, analgesia and 
the like, the disease may not neces- 
sarily be dependent on factors giving 
rise to the disease in question, but 
may be of the nature of epilepsy or 
of insanity, or be dependent in whole 
or in part on morbid processes con- 
nected with some portion of the sen- 
sorium. That the diagnosis of such 
cerebral lesions will be strengthened 
when in the absence of a manif^t 
organic disturbance of the genital 
tract there is a history of a severe 
blow or injury to the head, or of 
influences or factors which have pro- 
duced a profound or prolonged im-' 
pression on the encephalic centres. 
That in hysteria, on the other hand, 
nouQ of these conditions exist ; the 
phenomena are merely the result of 
reflex movements which occur for the 
most part during the period of the 
greatest activity of the organs of 
reproduction. That at such a time a 
seemingly limited amount of tumefac- 
tion, or an adhesion of a tube or an 
ovary, or an adventitious change in 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



67 



the shape or relation of the uterus, is 
capable of effecting constitutional as 
^^ell as local disturbances of the nerv- 
ous centres. That though an heredi- 
tary predisposition may to some ex- 
tent be an exciting cause of hysteria, 
such an influence, as an original 
factor, should nevertheless be re- 
garded as unimportant. 

That when hysteria occurs later in 
life, it is prima facie evidence that 
the genital tract has become diseased or 
has taken on a preternatural condition. 



That if after careful examination 
such a diagnosis of local physical 
obUquity cannot be established, the 
practitioner should, though the patient 
suffers from perverted sensations re- 
ferable to the nervous tracts, be 
suspicious that disease has taken 
lodgement in some portion of the 
encephalon or of the organism under 
a more immediate control of the cere- 
bral nervous system. 



SOCIETY PROCEEDINGS. 



Transactions of the American Association of Obstetricians and 

Gynecologists. 



SEVENTH ANNUAL MEETING HELD IN TORONTO, ONTARIO, SETEMBER, 

19, 20 and 21, 1894. 



PRESIDENT S ADDRESS BY GEO. H. 
ROHE, M. D., ON INTESTINAL OB- 
STRUCTION FOLLOWING OPERA- 
TIONS IN WHICH THE PERITONEAL 
CAVITY IS OPENED. [ABSTRACT]. 

After collecting cases reported in 
literature and personal communica- 
tions, lie had found 75 deaths caused 
by intestinal obstruction following 
abdominal operations and belieyes 
that this represents only half the 
mortality from this cause, for no 
doubt not a few fatal cases of peri- 
tonitis and intractable vomiting after 
laparotomy are really cases of obstruc- 



tion of the bowels. Post-operative 
intestinal obstruction can be divided 
into two classes: the first from me- 
chanical causes, adhesions, volvulus, 
accidental fixation, by sutures, etc. ; 
the second due to paralysis of peris- 
taltic movement of the intestine fol- 
lowing sepsis or injury to the nerve 
supply of the muscular coat. Acute 
obstruction may occur immediately 
after or with in a few weeks subse- 
quent to the operation, or may de- 
velop gradually, not being complete 
imtil months or years later. Obstruc- 
tion is usually due to abnormal 



Digitized by 



Google 



58 



SOCIETY PROCEEDINGS. 



fixation of the intestines by adhe- 
sions, or to compression by peritoneal 
cords or bands of in flammatory origin. 
Olshausen states that obstruction 
after ovariatomy is always due to 
adhesions between bowel and pedicle. 
The speaker had seen a case in which 
the small intestine was doubled upon 
itself and so adherent that the gut 
was entirely impervious. Similar 
cases have been reported. Adhesions 
of a knuckle of intestine to the ab- 
dominal incision are frequently found 
to be the cause of obstruction by pro- 
ducing acute flexure of the bowel. 
Any hindrance to the passage of the 
contents of the bowel at the point of 
flexure causes dilatation above and 
consequent increase of flexion ; peris- 
talsis is at first increased, but if the 
obstruction is not soon overcome, 
circulation is interfered with and 
dilation of the bowel with paralysis 
follows. Spencer Wells mentions 
another form of obstruction caused by 
a coil of intestine sinking into 
Douglas' cul-de-sac and becoming 
fixed there by adhesions. King re- 
ported a case in which the descending 
colon was glued fast at an angle to 
the posterior surface of the uterus; 
and Ross, a case in which, after com- 
plete abdominal hysterecotomy, au- 
topsy showed that a small portion of 
intestine was adherent to the ab- 
domifial incision behind the edge of 
the omentum and another loop had 
slipped through this adhesion between 
the bowel behind and the abdominal 
wall in front, causing obstruction. 
Fritsch mentions a case where a fold 
of intestine was caught under a 
suture, and in another the bowel was 



found between two sutures in the 
incision. Other cases were men- 
tioned of similar cases of obstruction 
due to adhesions and peritoneal bands, 
as well as to internal hernia through 
an opening in the omentum. Volvu- 
lus sometimes occurs after abdom- 
inal section, but probably only after 
some previous adhesion or constric- 
tion of the gut. By far the larger 
proportion of cases of post-operative 
intestinal obstruction are due to adhe- 
sions of the intestines to each other, 
to the abdominal walls or to other 
organs, and it is necessary to inquire 
what is the cause of the adhesions, 
and if they can be prevented. Sepsis, 
destruction or separation of the peri- 
toneum, strong chemical antiseptics, 
rough handling of the peritoneum by 
sponges, hands, etc., prolonged expos- 
ure to air and certain suture materials 
have all been accused. Clinical and 
experimental observation have shown 
that neither is sufficient to account 
for all cases. Intestinal or omental 
adhesions are found in nearly every 
case of laparatomy to exist at the 
margins of the incision, and occur in 
cases in which all the above men- 
tioned conrlitions can be excluded. 
The symptoms of intestinal obstruc- 
tion po9t laparatomiam are essentially 
the same as in primary obstruction. 
Unless obstruction is due to some 
untoward occuri'ence in the technique, 
marked symptoms are not likely to 
show themselves for several days after 
operation. If a patient does well for 
three or four days or more after ab- 
dominal section, and is then suddenly 
attacked by pain, followed by vomit- 
ing, tympanites, flatus and arrest of 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



69 



feces, intestinal obstruction is prob- 
able ; if vomiting becomes fecal, pulse 
rapid, urine scanty, and symptoms of 
collapse set in, the diagnosis is reason- 
ably certain. When the obstruction 
is high up in the small intestine, fecal 
vomiting is usually absent and dis- 
tention less pronounced; the bow- 
els may move several times after 
pain begins, so that the diagnosis is 
more or less uncertain. Among other 
signs to be noted is the occurrence 
of local distention of bowel above the 
point of occlusion in mechanical 
obstruction. Coincident with this 
local meteorism is an increased peri- 
staltic movement above the obstruc- 
tion. In the later stages, particularly 
if septic peritonitis with intestinal 
paresis occur, these distinguishing 
signs are no longer available. Ob- 
struction due to paralysis of the intes- 
tine (probably always due to septic 
peritonitis) does not present these 
symptoms. The abdomen presents a 
uniform globular distention without 
movement of the intestines. Another 
sign is furnished by urinary reaction. 
It is claimed that in complete ob- 
fftruetion of the ileum there is always 
indican in the urine. In obstruction 
of the colon or high up in the small 
intestine this reaction is usually not 
present. Rosenbach attributed great 
prognostic significance to this reac- 
tion. • So long as it remains the case 
is a grave one. Prognosis of primary 
intestinal obstruction is grave, and, 
following closely upon an operation, 
as serious as abdominal section or 
vaginal extirpation of the uterus, this 
gravity is enormously increased. As 
to the medical treatment little need 



be said, but there are certain pro- 
cedures not strictly surgical which 
are frequently indicated, and may 
give relief, although not often cure; 
these measures are stomach-washing, 
rectal inflation of gas or air and 
injection of fluids. Klotz washes out 
the stomach with from four to six 
quarts of warm salt solution, as soon 
as symptoms of obstruction appear, 
and repeats this if symptoms do not 
subside, adding the second time 
nearly two ounces of castor oil, which 
is introduced through the stomach 
tubes after the second lavage. Rec- 
tal injections of water or air may be 
curative in intussusception, volvulus 
or in obstruction due to soft adhesions 
of the lower portion of the intestine, 
but where it is due to cords or bands 
they are of no avail. The speaker 
had seen perforation of the sigmoid 
flexure produced by passing a rectal 
tube high up into the colon. The 
rational treatment is to reopen the 
abdomen, seek the obstruction, separ- 
ating the adhesions, breaking up 
bands or untwisting the volvulus. If 
the gut is distended by gas it should 
be incised to let out gas and fluid 
feces and afterwards carefully su- 
tured. Gangrenous intestine is to be 
resected and Murphy's button em- 
ployed. Distention and congestion 
of the . intestine above and its pale, 
empty flaccid condition below the 
constriction will often enable the 
ready finding of the obstruction. To 
prevent obstruction, Morris proposes 
covering denuded peritoneal surfaces 
with aristol. Martin wipes out the 
pelvic cavity with sterilized olive oil 
just before closing it. Cases of 



Digitized by 



Google 



60 



SOCIETY PROCEEDINGS. 



so-caUed paralytic obstruction are 
usually due to septic peritonitis and 
operation is rarely of service, although 
Keen reports a case in which he 
incised, emptied the intestinal con- 
tents, flushed and drained the peri- 
toneal cavity with recovery of the 
patient. 

THE INCISION IN ABDOMINAL SUR- 
GERY. BY J. H. C^VRSTENS. 

The substance of this paper is as 
follows : With a small narrow-bladed 
knife make a clean incision through 
the skin of necessary length, and 
with another sweep or two cut 
through the linea alba muscle, etc 
Lift the peritoneum with the fingers, 
open it and enlarge the incision. 
The use of forceps to lift the tissues 
or the grooved director, is unnecess- 
sary. In closing the abdominal in- 
cision iise animal ligature, kangaroo 
tendon or catgut. Bring the peri- 
toneum carefully together with a 
running stitch, then the fascia and 
the rectus, if this muscle is incised. 
Carefully bring together — edge to 
edge — the tendinous insertion of the 
oblique muscles. The loose cellular 
tissue above and fat can be brought 
together in one or two tiers accord- 
ing to thickness. Bring skin to- 
gether with buried stitch, thus bury- 
ing all sutures. Seal with collo- 
dion, and, if everything connected 
with the operation is perfectly asep- 
tic, primary union will take place- 
the different layers of the abdominal 
wall will have been brought together 
as nearly as possible, and no hernia 
will result. In cases of extensive um- 
bilical, ventral or other hernia, bring 



peritoneum together with an over- 
and-over stitch of kangaroo tendon or 
catgut. Make a flap-splitting opera- 
tion of the ring, which is brought 
together with silkworm gut or silver 
wire, which are buried, and then the 
fat and skin are united with the 
buried animal suture. 

Dr. Willis G. Macdonald, of 
Albany, said he hardly expected to 
open the discussion on Dr. Carstens' 
paper, yet there were so many things 
in it that interested him, and still 
others that he could not agree with, 
that he felt compelled to speak. In 
his introductory remarks the essayist 
spoke of the fact of ventral hernia 
following operations for appendicitis. 
Dr. ilacdonald said he could con- 
ceive very readily, in cases of relaps- 
ing appendicitis, where we have not 
an active suppurative process, where 
the demand for drainage is not great, 
that we may close the wound in the 
way the essayist had described ; but 
there were other conditions in which 
we have localized abscess, in which 
we open the peritoneum, where we 
have to drain not only with gauze 
but with rubber. Sometimes, we 
have to introduce into the wound a 
large iodoform tampon in cases of 
this sort. The doctor would not say 
that we could employ this method of 
procedure by stages. It is in those 
cases that ventral hernia occur and 
in which trusses must be fitted. His 
experience in abdominal surgery is 
that by far the greater number of 
hernise have occurred in such cases as 
these, and he expects them to occur ; 
he does not know of any way to 
avoid them. We have to tampon, to 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



61 



pack carefully, if we have a cavity to 
drain, to prevent pocketing. In Al- 
bany it was not the custom to close 
wounds by stages ; surgeons there 
had been satisfied with one through- 
and-through suture. In coming to 
the meeting with Dr. Van der Veer, 
and in going over his (Van der 
Veer's) table of qases for some years 
back, he finds Dr. Van der Veer has 
about five per cent, of )iemia follow- 
ing his operative work. This, he 
took it, was a relatively small per 
cent. The introduction of animal 
sutures in general surgery was not 
always so. successful as it would seem. 
He had employed kangaroo tendon 
and the catgut suture in operations 
for the radical cure of hernia, and 
had seen a return of the hernia. It 
was not at all certain. So far as the 
buried silkworm-gut suture was con- 
cerned, his experience had been 
equally unsuccessful. 

Dr. C. A. L. Reed, of Cincinnati, 
had listened with a great deal of in- 
terest to the paper, but the method 
of closing the wound as outlined by 
the essayist was far from being a per- 
fect one in his opinion. There were 
some features of the paper which im- 
pressed him as rather confirmatory of 
the view which he would advance. 
For instance, the doctor had stated 
that he used the buried animal su- 
ture by layers in his general run of 
abdominal cases, and yet in his cases 
of hernia in young subjects, in which 
the wound is subjected to intra-ab- 
dominal pressure, he deems it inex- 
pedient to use it and fortifies his 
work with the interrupted en masse 
suture. He wished Dr. Carstens 



would state by what warrant he as- 
sumes, by virtue of the retching 
which follows anesthesia, that his 
cases are not going to be subjected 
to precisely the same pressure, and, 
further, why he subjects his patients 
to the risk of a suture in which he 
finds it necessary to fortify it* It 
occurred to the speaker that there 
were strange inconsistencies in the 
method. The paper itself did not 
enumerate, except by the slightest 
inference, what occurs to him to be 
the greatest danger — ^the most unsat- 
isfactory result of the buried animal 
suture. The implication was not in- 
volved in the statement that the 
wound seems to be firmer; it is 
thicker, it is denser. Dr. Reed be- 
lieves that the thickened cicatrix 
means not only a deposit of inflama- 
tory exudate, but the presence of an 
unabsorbed suture; and if he had 
contemplated participating in the de- 
bate he should have presented cica- 
trices, painful in character, which he 
had been called upon to dissect out to 
afford relief. 

Dr. E. W. CusHENG, of Boston, 
had long observed that there was a 
tendency for certain processes to come 
up and be used, fall into " innocuous 
desuetude," and then reappear. In 
regard to the matter of suturing by 
layers, he believed it was resorted to 
by Thomas as long ago as 1887, 
and he had so stated in a paper des- 
cribing this method read before the 
American Medical Association in that 
year. There were two stitches put 
through everything, in order to bring 
the wound together and prevent pock- 
eting. The rest was done with the 



Digitized by 



Google 



62 



SOCIETY PROCEEDINGS. 



animal suture and cat^t. He thought 
the use of running suture constricted 
and strangulated the tissue in a way 
that the interrupted suture did not. 
He believed that it is diflScult to apply 
a running suture in such a way that 
it is not liable to cut off the circula- 
tion from certain parts of tissue and 
cause them to necrose. In two or 
three weeks the surgeon may have to 
reopen the wound. Wounds sub- 
jected to this suture, according to his 
experience, did not do so weU as un- 
der the old-fashioned method of in- 
terrupted sutures. 

- Dr. C. C. Frederick, of Buffalo, 
took positive grounds against the use 
of buried animal sutures or the buried 
silkworm-gut suture. He had just 
operated on a patient a week since 
for ventral hernia upon whom he had 
operated last November, it being one 
of a series of twenty-five cases in 
which he had used the buried suture 
in uniting the peritoneum, fascia, 
and muscle. His experience had 
been that at least fifty per cent, of 
the cases have sizable collections of 
pus along the incision, with abscesses 
that he had to drain and wash out 
for a period of one, two, three, or 
four weeks. As extra support he 
had used silkworm gut, in order not 
to bring too much pressure on the 
buried sutures. The less the tissues 
are bruised the less necrosis there 
will be, and the better the union the 
better the results of the surgeon wiU 
be. All his herniae so far had oc- 
curred in those cases where he had 
used the buried animal suture. 

Dr. H. W. LoNGYEAR, of Detroit, 
said he read a paper before the 'As- 



sociation on a similar subject last 
year at Detroit. He thought the last 
speaker made an admission which ac- 
' counted for his bad results in the use 
of the buried suture. In the use of 
this suture one of the prime objects 
was to prevent infection after it had 
been inserted. In the first place, the 
wound and suture must be asceptic, 
and then the wound must be kept so, 
and this could not be done by rein- 
forcing the buried suture with an en 
masse suture. Dr. Carstens and the 
speaker had been working together 
in the Harper Hospital with the 
buried animal suture for years, and 
their results were not at first perfect ; 
but their experimental work with it 
since then had shown that when it is 
properly buried and sealed, without 
the application of any extra sutures 
whatever, the results were better, and 
this was the only way to get good 
results. 

Dr. Reed: What are the rela- 
tive results in cases of hernia in 
which Dr. Carstens fortifies the buried 
animal suture with the interrupted 
suture ? 

Dr. Longyear : Dr. Carstens did 
not say anything about fortifying the 
buried animal suture with the inter- 
rupted suture. You must have mis- 
understood him. He does not do it, 
to my knowledge. He said he used 
the silkworm-gut suture buried. He 
fortifies the buried suture by the in- 
sertion of a buried silkworm-gut su- 
ture, and seals the wound with col- 
lodion just the same afterward. 

Dr. DoNAU) Maclean, of Detroit 
(by invitation), had listened with 
great interest to the divergent opin- 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



63 



ions expressed with reference to the 
treatment of the abdominal incision, 
he having had considerable personal 
experience. He believed that, after 
all, what is most essential are careful- 
ness and cleanliness of the method. 
He did not believe that there is such 
a fundamental difference between the 
two sides in the debate as there 
seems to be. It does not matter very 
much which way or how the incision 
is closed, so long as the operation is 
done carefully, thoroughly, and skil- 
fully, and the wound closed in a care- 
ful and skilful manner and kept clean. 
For a long time in his operative work 
he never thought of closing the wound 
in layers, as is commonly done now, 
using the en masse suture. He 
had seen it used very extensively on 
both sides of the Atlantic, and, so 
far as he was able to judge, just as 
good results were obtained in ttat 
way as by the other method, although 
the other method seemed to possess 
the characteristic of precision, and 
perhaps there was some anatomical 
argument in its favor — viz., of bring- 
ing and fitting accurately together all 
simultaneous tissues, tendon to ten- 
don, fascia to fascia, etc. 

Dr. Tappey, of Detroit, preferred 
the tier method of suturing. It im- 
pressed him as being a very much 
more exact and thorough method of 
closing the abdominal incision, and 
he had practiced it for a number of 
years. He was not prepared to say 
that he had never had an abcess 
following its use. He had sometimes 
been dissapointed in the use of kan- 
garoo tendon, for he had found the 
wound had become infected by the 



material, or at least he supposed so. 
We cannot be too careful in the use 
of it. It must be kept absolutely 
clean. Of late he had been immers- 
ing his suture material in ether or 
alcohol and afterward in a bichloride 
solution. However, it (kangaroo ten- 
don) was perhaps the most useful 
material we have, if we are only sure 
of its being aseptic and in a proper 
condition to use, for in the manipula- 
tion of the material it was certainly 
very much easier than cat^t. You 
tie it, the knot does not slip, and it 
is not the stiff and irritating material 
that the silkworm-gut is. 

J)r. Carstens, in closing the dis- 
cussion, began by making diagram- 
matic sketches of his method of 
suturing. He said if there was any 
liability of a woman becoming preg- 
nant he did not use the buried silk- 
worm-gut suture, and that he only 
used it in exceptional cases. It 
was exceedingly difficult to keep all 
wounds aseptic; still the surgeon 
should strive to do so, and success in 
abdominal and pelvic surgery resolved 
itself largely into the question of 
asepsis. 

Dr. Joseph Price, of Philadelphia, 
Pa., read a paper on 

plastic surgery in gynaecology, 
(abstract). 

To do efficient plastic work in 
gynaecology a careful study of the 
anatomy and physiology of the parts 
injured and to be dealt with is neces- 
sary. Just as the scientific imder- 
standing of the mechanism of normal 
delivery has developed the scientific 
obstetrical forceps under the name of 



Digitized by 



Google 



64 



SOCIETY PROCEEDINGS. 



" axis traction," with the consequent 
diminution of the accident of labor 
hitherto observed, so the study of the 
function of the parts often unavoid- 
ably damaged renders their repair a 
matter of exact science, modified only 
by the skill of the 'operator. The 
mechanism of perineal resistance and 
fracture is not a matter of chance, and 
the parts to be restored to function 
must be replaced in as nearly their 
physiological condition as possible* 
A heaving up of tissue here or a 
splitting there, although simulating a 
relay of opposing structure, does not 
necessarily mean strength, and it often 
happens that the advantage gained* is 
apparent, not real. 

Let me, then, insist that in order 
to mend a perineum intelligently the 
mechanism of labor must be under- 
stood and the lines of fracture appre- 
ciated. The perineum does not break 
haphazard, but always in well-defined 
lines, save under instrumental vio- 
lence ; and when tears are due to this 
cause they must be delt with as 
lacerated wounds anywhere else. The 
anatomical fractures due simply to 
obstetric force and resistance must be 
mended in the lines in which they 
occur. 

In cases of serious pelvic invasion 
with accompanying lacerated cervix 
it is often better or imperative first to 
do the pelvic operation and to follow 
this at another time with the cervi- 
cal repair. I unhesitatingly condemn 
the plan abvised by some to perform 
internal and external operations at one 
sitting. Surgery has not for its object 
the experimental determination of 
how much endurance the surgeon may 



possess, nor of how long the sufferer 
can stand anaesthesia without collapse. 
That " enough is as good as a feast " 
is nowhere truer than in the surgery 
of gynsecolog}\ There is enough dis- 
comfort incident to the surgery of any 
one or two of the simpler procedures 
without heaping upon this the pain 
and danger of an abdominal opera- 
tion. 

Apart from the growing discomforts 
of neglected perineal and cervical 
lacerations, it must be remembered 
that the existence of a damaged and 
defective perineal structure conduces 
to future difficult and sometimes dan- 
gerous labor by prediposing to failure 
of rotation of the head. 

In reference to injuries of the cer- 
vix, it is always to be remembered 
that serious laceration of this struc- 
ture is frequently a cause of after- 
coming malignant disease, or subin- 
volution, sterility, congestion, and the 
like, often putting the patient in a 
condition of chronic invalidism from 
pain, menorrhagia, dysmenorrhea, dis- 
placement and mechanical derange- 
ments exhibited in relation with the 
bladder and rectum. 

We have reminded you that peri- 
neal tears always occur at certain 
parts of the perineal structure. With- 
out going into the anatomy of the 
parts or into a discussion for the rea- 
son of this fact, it is sufficient to re- 
member, as each one of us with a 
practical experience must, that these 
tears are either lateral, imder the 
ramus of the pubes, or central, ex- 
tending from vagina toward the 
rectum. The tears toward the rectum 
tend to nm around it rather than 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



65 



through it, owing to the differentia- 
tion of structure in these two 
tubes. Now it is to be remembered 
that the tears of the vagina are al- 
ways from within outward, from 
above downward, and that therefore 
the external or skin operations for 
perineal lacerations are essentially 
non-scientific procedures. All opera- 
tions for the restoring of the integrity 
of these pai-ts should be done in 
the lines of their destruction, and 
therefore J^rom within outward and 
from above downward. When the 
skin of the perineum is involved, 
mending of this is merely a cosmetic 
procedure. The •osmetic element too 
often predominates in many of the 
so-called perineal devices. 

In examining a perineum to deter- 
mine whether it has been ruptured 
or not, a mere ocular inspection will 
not answer. A central tear is ahnost 
always visible. Not so a lateral sub- 
ramie lacerating. To detect this the 
finger should be introduced into the 
vagina, when the laceration will be 
detected by the fissure caused by the 
separation of tissue on one or both 
sides. The early, prompt, and, if 
possible the immediate repair of these 
tears is to be performed under 
sui^cal rules applicable elsewhere in 
the body. If the patient happens to 
be too ill or too weak to endure surgi- 
cal interference, operation is not to 
be insisted upon. Discretion is to be 
used here as elsewhere in deciding 
cases. 

The silkworm-gut with shot is by 
far the preferable material to be 
used for sutures. As little tissue as 
possible is to be included within the 



ligature, and strangulation is to be 
avoided. Early operation precludes 
the necessity for clipping away even 
the minutest bit of tissue, and the 
parts are usually very prompt to heal. 
When the sphincter ani has been in- 
volved, care must be taken to bring 
the ends of the muscle into apposi- 
tion. To accomplish this a special 
stitch is necessary. So far as the 
method is concerned, it is evident 
that the one suggested is that of 
Emmet. His prodecure stands pre- 
eminent among the scientific sugges- 
tions and methods of modern gynae- 
cology. Its logic is unassailable and 
its results cannot be fairly challenged. 
His work is as delicately true and ac- 
curate as an Italian mosaic, while his 
technique is so simple that to follow 
it needs only commonplace attention. 
His demonstration of the scientific 
value of his method is as accurate as 
that of any mathematical proposition, 
and criticism of the ends obtained or 
of the method pursued arises either 
from ignorance or misunderstanding. 
In old tears the method and lines 
of denudation, as indicated in Em- 
met's own book, are unfortunately 
obscure. This fact Dr. Price be- 
lieved in a measure explains the 
reason of the operations having so 
long been questioned, criticised, and 
misunderstood. 

Dr. William B. Dewees. 

the care of pregnant women, 
(see annals of gynaecology 
and p^dla^try, page 38.) 

discussion. 
Dr. J. Henry Carstens, of De- 
troit: I desire to make a few re- 



Digitized by 



Google 



66 



SOCIETY PROCEEDINGS. 



marks on the paper just read. It 
seems to me the women who have 
the easiest confinements, who have 
the least trouble, do not follow out 
the hygienic rules laid down and em- 
phasized by the essayist. The poor 
German or Polish woman in Detroit 
does not drink any distilled water, 
but she eats and drinks what she 
gets, works around the house, and 
when confinement comes she has no 
trouble. It is the higher class of 
women that have trouble. I think 
we can do a few things. We should 
impress upon these women the im- 
portance of stopping coition during 
pregnancy ; for if we do not we will 
trouble and a gooil deal probably have 
more work for the abdominal surgeon 
in cleaning out gonorrheal pus tubes 
than we have now. If we do anything, 
let us educate these women what to 
do. Have them understand that as 
soon as they are pregnant or suspect 
pregnancy they should call in a doctor, 
30 that he can watch them during the 
course of pregnancy, examine their 
urine, pelvis, and take the necessaiy 
precautions to prepare them for labor. 
Another point : we shall try to edu- 
cate the general practitioners in re- 
gard to aseptic midwiferj- . 

Dr. Joseph Hoffman, of Phila- 
delphia : It is all well enough for 
those who are connected with medi- 
cal colleges to measure a woman's 
pelvis, but if the ordinary^ general 
practitioner were to go about with 
a pelvimeter in his pocket and meas- 
ure the pelvis of every woman who 
engages him, he would have to do it 
in a life-preserver. The question of 
delivery does not depend so much 



upon the size of the pelvis itself as 
upon the size of the child's head. 
This is an important point. 

With regard to douching, etc., it 
is my opinion that infection often 
takes place through the introduction 
of the dirty fingers of the doctor 
rather than by auto-infection. Take 
the history of many cases of confine- 
ment that have not the advantage of 
a clean basin, and not even a piece 
of soap, in which women deliver 
themselves ; no matter how squalid 
the circumstances, they come out all 
right. It is the dirty midwife or 
dirty doctor that causes the trouble. 

Dr. H. W. LoxcjYEAR, of Detroit : 
One point I wish to touch upon in 
the doctor's paper is the subject of 
albuminuria of pregnancy. It is a 
subject I have been greatly interested 
in, as I believe that the ordinary 
treatment of the condition is inade- 
quate. The essayist spoke of prophy- 
laxis, but did not say very nmch 
about the prevention of albuminuria 
of pregnancy. Prophylaxis does not 
seem to amount to much in albumi- 
nuria of pregnancy when "it is present, 
and I know of nothing that will 
do much goo(^l except emptying the 
uterus. Pui-ging may be resorted to, 
but a woman cannot be purged for 
two or three months, and so the treat- 
ment is narrowed do^vn to the one 
thing : Shall we resort to premature 
delivery' in these cases? The recom- 
mendation the doctor gave for exam- 
ining the urine systematically in all 
cases of pregnancy is exceedingly 
valuable. P^verj^ pregnant woman 
should have her urine examined two 
or three times a month initil the end 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



67 



of gestation. The more I have seen 
of the fatal results of albuminuria 
of pregnancy, the more I am con- 
vinced that the only safety to the 
mother is to give her the benefit of 
the doubt. That I do in its widest 
sense, and deliver her just as soon as 
I find albuminuria present. I believe 
this to be justifiable practice. My 
plan is to watch the woman, examine 
her urine from time to time, and 
when the system seems to be sur- 
charged with urea, as evidenced by 
certain symptoms, then deliver. I 
follow the rule. I think I have 
SJived some lives by it. I have foimd 
in a good many instances I have been 
too late when I have done this. We 
know that the consideration of the 
life of the child is the main thing 
that prevents us from doing it early. 
When we consider that many chil- 
dren are bom dead when there has 
been albuminuria present, or at least 
die soon after birth, I think the life 
of the mother should be the first con- 
sideration, and in these cases we 
should induce premature labor as 
soon as we find albumin, while the 
mother is in good condition. She 
will imdoubtedly recover promptly 
from the operation. I do not care 
whether the child is viable or not. 
Of coui'se there are some religious 
reasons why it should not be done, 
but, as the child is in danger of dying 
from the storms of eclampsia and 
uremia during two or three months, 
I do not believe the religious factor 
should preclude the induction of 
labor. 

Dr. C. A. L. Reed, of Cincinnati : 
I entirely agree with the view ad- 



vanced that these eases should be 
placed under observation and fre- 
quent urinalyses made, with the ob- 
ject of early detecting albuminuria; 
and if it be true that this condition 
is not a remediable one, then the 
position which Dr. Longj-ear assumes 
would be tenable. But these cases 
are curable, and I can see no reason 
for entering upon a murderous line 
of tactics simply because a baby is 
little. The albuminuria can be elim- 
inated from these cases, and the 
woman can be safely delivered by 
the resources of our art — perhaps 
not always. When the fact is de- 
nionstrated that the case is not cu- 
rable, then the proposition relative to 
the inducti6n of premature labor can 
be taken under consideration ; but 
the idea that we should at once bring 
on delivery the moment a diagnosis 
of albummuria has been made, as has 
been suggested, is one I cannot per- 
mit to go from this presence without 
a challenge. A much more conserva- 
tive plan is in accordance ^vith the 
spirit of our profession and of our 
science. 

Dr. J. M. DrFF, of Pittsburg: 
The paper to which we have listened 
covers a large field, and there are 
many points I would like to touch 
upon if time permitted. I congratu- 
late the doctor on the erudition he 
has shoAvn with regard to the subject 
of pelvimetry and pelvimeters. I do 
not think any rational obstetrician 
carries a pelvimeter around in his 
pocket daily. It is not necessary in 
the vast majority of cases that a 
pelvimeter should be used. The man 
who attends his cases and carefully 



Digitized by 



Google 



68 



SOCIETY PROCEEDINGS. 



and properly examines them during 
pregnancy will be able to detect any 
deformity of the pelvis which may 
exist, and determine by that exami 
nation whether a pelvimeter will be 
necessary afterward. 

With regard to the question of albu- 
minuria, if I understood Dr. Long- 
year correctly, I regret very much to 
hear him say that in every case in 
which we detect albuminuria we 
should bring on labor. About 20 
per cent, of pregnant women have 
more or less albuminuria, and there 
is not more than 2 per cent, of preg- 
nant women mth albuminuria who 
have eclampsia. It is very seldom 
indeed that we have death from albu- 
minuria where there is not eclampsia. 
I wish to be quoted, further, as 
saying that it has not been dis- 
covered how the different poisons 
are eliminated from the kidneys, 
and it has not been positively dem- 
onstrated that it is the albimiinuria 
per Be or uremic poisoning that kills 
women. 

Dr. Joseph Price, of Philadel- 
phia ; If Dr. Longj^ear were to 
write to twenty of the most promi- 
nent active practitioners in the rural 
districts or in the mountains, and 
ask them the number of cases of 
eclampsia occurring in their practice 
out of from one thousand to five 
thousand labors, he would find that 
it would be less than 2 per cent. 
But the country practitioner has not 



the time to make such researches. 
Some of the old physicians in the 
Virginia mountains have had as many 
as three thousand woman to deliver, 
and it would be impossible for them, 
without several clerks, to make cor- 
rect analyses. 

I was pleased with the interesting 
and scholarly paper, but am sorry the 
doctor omitted the idiosjTicrasies of 
old women. One of the most seri- 
ous complications of gestation is the 
gossip of the old women about mater- 
nal impressions. I find perhaps noth- 
ing that annoys and distresses the 
young prospective mother so much as 
this. They offer suggestions which 
create all sorts of vicious impressions. 

In regard to practical obstetrics, 
the practice of cleanliness was alluded 
to, as well as early investigations with 
the pelvimeter and sounding of the 
uterus. A distinguished physician, 
Albert H. Smith, insisted upon early 
examinations with the pelvimeter and 
advocated palpation and auscultation, 
and it was not long before his stu- 
dents were sounding every uterus in 
town. It seems to me old-fashioned 
obstetrics has gone out of date. 

In regard to cleanliness, I agree 
with Dr. Hoffman that the same class 
of old country practitioners I have al- 
luded to are exceptionally clean. In 
the treatment of their cases they 
rarely have childbed fever or post- 
puerperal fever. The other class are 
filthy. 

(To be continued.) 



Digitized by 



Google 



REVIEW OF GYNECOLOGY. 



6» 



REVIEW OF GYNAECOLOGY. 



Gonorrheal Arthritis. By Dr. O. 
Resxihow. (Centralblatt, F. Gyn- 
aekol ; Review in La Presse Medi- 
cale, Sept. 8, 1894. 

The case reported is interesting in 
the fact that the articulations were 
attacked before local symptoms were 
present. A girl aged 19, and who 
was without a dotibt a virgin, was 
married on Jan. 9th and had her first 
intercourse on the tenth. On the 
morning of the thirteenth she was 
taken with pains in the right shoulder 
and elbow which lasted for two days. 
On the third day she had chills and 
fever and the knee was painful. The 
writer saw the patient on the evening 
of the sixteenth and found the right 
knee tumefied, red, containing liquid 
and very painful on pressure. The 
other joints were perfectly normal. 
Examination of the genital organs 
was negative. On questioning the 
husband, it was found that he had 
contracted a clap about five weeks 
before his marriage and had not 
treated it, and it was even at this 
time in the acute stage. The patient 
remained in bed for two months, the 
knee remaining the only joint at- 
tacked. For the author, this case was 
one of gonorrheal arthritis, appearing 
four days after contagion and before 
gonorrhoea properly speaking. Perhaps 
the gonococcus more easily infected 
the organism through the wound of 
the hymen. 

(The cases of gonorrheal arthritis 
in the female are rare and reviewing 



this most interesting one I would like 
to mention a case that came under 
my observation when assistant in 
Geneva. A girl of about 22 con- 
sulted us for what was supposed to be 
rheumatism in the left elbow. There 
being very little redness or swelling 
we had no reason to suspect the good 
reputation of the patient. The arm 
was put up in a silicated plaster 
bandage and the patient told to re- 
turn in two weeks. At the end of 
that time she returned^ stating that 
aU pain had left. The bandage was 
removed and to our surprise the limb 
was found completely anchylosed. Re- 
section of the elbow was performed 
by Drs. Kummer and Cumston, re- 
sulting in a useful limb. During 
convalesence the patient developed a 
severe cystitis which was cured by a 
systematic treatment. Bacteriological 
examination of the bone exsected 
from the elbow gave pure cultures of 
the gonococcus; the organism was 
also found in the bladder. C. G. C.) 



Hydrocele of the Canal op 
NucK ; Operation ; Recovery. 
By Dr. A. J. Patek. (University 
Medical Magazine, March, 1894.) 
Patient, aged 29, said that two 
weeks before, a tumor suddenly ap- 
peared in right inginual region and 
seemed to vary in size at different 
times, but occasioned only slight dis- 
comfort. Physical examination 
showed a slightly fluctuating oval 
mass, the size of a small egg, not ad- 
Digitized by LjOOQ IC 



70 



REVIEW OF GYNAECOLOGY 



herent to skin, passing downward and 
inward, apparently below Poupart's 
ligament and outside of the pelvic 
spine ; mass was somewhat tender, 
freely movable in the line of its long 
axis but could not be lifted from 
underlying tissue. No distinct in- 
pulse in coughing. Percussion 
at times elicited tympany, at others 
dullness. Symptoms indicated incar- 
cerated femoral hernia. Incision was 
made over tumor which, when care- 
fully dissected down upon, was 
covered with a thin membrane re- 
sembling the peritoneum. The 
tumor looked like a cyst and when 
dissected from its attachments and 
followed up along its long axis, its 
bulk was found to narrow down to a 
stalk issuing from the inguinal canal. 
The wall being nicked, a serous fluid 
escaped. The sac was treated and 
operation tenninated as in hernia. 
Patient left cured in four weeks. 



A New Means for Facilitating 

M^VNUAL Reduction of Uterine 

Retrodeviations. By Dr. 

Bataud. (Congr<js de TAssocia- 

tion Francaise pour I'Avancement 

des Sciences ; review in Le Progr^s 

Medical, Sept. 1, 1894). 

Manual reduction is most difficult 

in certain cases of retrodeviations, 

either with or without adhesions, but 

in which the uterus is elongated, 

more or less limp in the middle part 

and so flexible at the isthmus that 

pressure exercised on the accessible 

part of the cervix is not transmitted 

to the corpus which remains wedged 

down and stationary. In these cases, 

the writer inserts a little rod covered 



with cotton into the uterine cavity, 
by means of a special forceps. This 
simple means, renders the entire 
organ rigid and manual reduction is 
made most easy. The use of this 
instrument is simple and without 
danger if the technique of the writer 
is followed. 



Recurrence of Sarcoma of the 

Breast. By Dr. Hoffmann. 

(Arch. J. Klinisch, Chiruizie, 1894, 

vol. XLVIII). 

A woman, aged 42, was operated 
on in Dec, 1886, for a fibro-sarcoma 
of the breast, which reappeared 
twelve times in three years, the 
twelve tumors were removed as soou 
as they appeared. From Oct., 1889, 
to Jnly, 1893, nothing was noted, 
when in August, 1893, metastasis in 
the brain, abdomen and limbs oc- 
curred with death of patient in a few 
months. This case is interesting in 
the recurrence of the growth so many 
times in three years and the interval 
of three years during which nothing 
appeared. 



The Treatment of Cystitis in 
Women. By Dr. Lutaud. 
The etiology of cystitis in the 
female is different from the affection 
in the male. The uterus in the fe- 
male acts the role of the urethra and 
prostrate in the male. Traumatism 
from labor or an operation produce 
cystitis in women and even a very 
slight cause, such as a tampon placed 
against the cervix, has been known to 
produce a very pahiful tenesmus. 
Acute ei/stitis. The first indication is 
to relieve pain, especially by local 



Digitized by 



Google 



REVIEW OF GYNJ5C0L0GY. 



71 



applications. The following suppos- 
itories are much praised by the 
writer. 



R Ung. camphor, 
Ext. belladon.» 



30 grammes. 
2 grammes. 



aa 1 centigramme. 
5 milligrammes. 
3 grammes. 



R Morphin. hydrochlor. 

Cocain. hydrochlor., 

Ext. belladoa., 

01. theobrom., 
M. F. supposit., No. 1. 

Sio. — One suppository every four hours 
until pain has ceased. Belladonna may be 
replaced by hyocyamus, when morphine or the 
opiates are badly supported by the patient. 
This formula is good: 

R Cocain. hydrochlor., 1 centigramme. 

Ext. hyocyain., 2 centigrammes. 

01. theobrom., 3 grammes. 

M. F. supposit., No. 1. 
SiG.— Three or four suppositories In twenty- 
.four hours. 

An opiate enema, laudanum perfer- 
ably, is also most useful. When 
there is insomnia the writer prescribes 
chloral, always in enema at the mini- 
mum dose of 4 grammes for an adult 
woman as follows : 



R 



Chloral, hydrat., 
Vitel. ovi.. 
Ag. dest., 



4 grammes. 

No. 1. 

150 grammes. 



But an injection, hypodermically of 
1 centigranmie of morphine is the 
surest manner of calming the par- 
oxysm of vesical pain on the condition 
that the patient is never allowed to 
inject the remedy herself. Poultices, 
sitz baths, fomentations over the 
hypogastuiimi are useful adjuncts to 
local treatment, which according to 
the writer are to be prefered to gen- 
eral treatment during the acute stage. 
Topical and calming applications may 
also be applied in the vagina and the 
author prefers this method to all 
others when there is cystitis of the 
neck. Belladonna or cocam or the 
following is employed : 



M. D. S. A tampon is smeared 
with this ointment and changed night 
and morning. When pain is severe, 
a small tampon wet with the follow- 
ing solution is introduced in the 
vagina. 



R Cocain. hydrochlor., 
Ag. dest., 



1 gramme. 
20 grammes. 



Treatment by internal remedies 
should not be resorted to during this 
stage and apart from the hypnotics 
there is nothing else to suggest. The 
writer has never had any results from 
the use of the balsamics. Oxalic 
acid so much praised for cystitis in 
man has never given the author any 
marked results in women,, especially 
during the acute stage, he says how 
ever, that he has seen the pain 
ameliorate by a prolonged use of the 
following mixture : 

R. Acid oxalic, 50 centigrammes. 
Aq. dest. 100 grammes. 
Syr. cort. aurant, 30 grammes. 
M. D. S. A soupspoonful every four hours. 

Chronic cystitis. In the chronic 
state the author employs both local 
and general medication. When the 
inflammatory and painful symptoms 
are better, intra-vesical irrigations may 
be resorted to. A perfectly aseytic 
gum or glass catheter is introduced 
into the bladder while a syringe is in- 
serted into the free end. The follow- 
ing is the author's formula for solu- 
tion for irrigation : 

R. Acid, borac, 40 grammes. 
Sodae biborat, 5 grammes. 
Ay. dest. 1 litre. 



Digitized by 



Google 



i'z 



REVIEW OF GYNECOLOGY. 



The liquid is pushed quickly into 
the organs so as to produce a rapid 
jet and the syringe is withdrawn to 
allow the liquid to escape. He advises 
not to inject more than 50 grammes 
at a time and when the bladder is 
irritable 30 gi^ammes is enough to 
commence with. The writer thinks 
that nitrate of silver is too irritating 
for the female bladder and uses iodo- 
forme, whose action is more efficacious, 
especially in gonorrheal cystitis ; he 
proceeds in the following manner. 
The organ is washed out with the 
above boracic acid solution and then 
an injection of a 150 grammes of 
tepid water to which a teaspoonful of 
the following formula has been added, 
is made : 



R 



Pulv. iodoform. 
Glycerine, 
Aq. dist. 
Gum. adragant. 



30 grammes. 
40 grammes. 
20 grammes. 
25 centigrammes. 



Pyoctanin blue has been proposed 
by Mencki, of Varsovie, in genorrheal 
cystitis, but alike all other injections, 
it should only be employed in women 
in the chronic form of the affection. 
The writer has had success with the 
following : 

R Pyoctanin. 1 gramme. 

Aq. dist. 1 litre. 

M. D. S.— For injections night and morning. 

These injections should be continued 
for 10 or 15 days if they are well 
borne by the patient. General medica- 



tion is useful in chronic systitic. Pichi 
which was used by Wyman about ten 
years ago, has been employed by the 
writer in gonorrheal cystitis in women 
with good results as follows : 

R Ext. pichi, 10 grammes. 

Tinct. cannab. indie, 2 grammes. 

Aq. dist, 90 grammes. 

M. D. S. A soupepoonful every four hours. 

Here is another formula in which 
buchu is combined with hyocyamus 
and bromide of ammonium : 



Ammon. bromid, 
Tinct. hyocyam, 
£xt. buchu fid, 
Aq. dist, 



10 grammes. 
5 grammes. 
10 grammes. 
60 grammes. 



M- D. S. A teaspoonful every four hours. 

If there is pus in the urine, Lutaud 
prescribes : 



R. 



Acid loenzoic, 
Aq. fld. aurant, 
Aq. dist 
Sacch. alb, 



M. D. S. 
meals. 



1 gramme. 
50 grammes. 
900 grammes. 
100 grammes. 



To be taken by glassf uls between 



Lastly, it must not be forgotten 
that cystitis may be of tuberculous 
origin, that it may be due to a calculus 
or kept up by tumors in the neighbor- 
hood of the bladder, the treatment 
consequently should be directed to 
these different lesions. (^Revvs Ob- 
stetrieale et Gynecologiqtce Aug 
1894.) 

C. G. C. 



Digitized by 



Google 



BOOK REVIEWS. 



7a 



BOOK REVIEWS. 



A System of Legal Medicine. 
By Allan McLane Hamilton, 
M. D., and Lawrence Godkin, 
Esq., and others. To be complete 
in two octavo volumes. New York, 
1894: E. B. Treat, 5 Cooper 
Union. 

For many years there has been no 
new work on legal medicine, either in 
the French, German, or English 
languages. The standard treaties of 
Briand et Chaudi^, Hoffmann, Taylor, 
Casper, Tardieu, Tidy, etc., have held 
their place, but a decided want is felt 
for a complete and recent work on 
this important branch of medicine. 
All progressive physicians and sm- 
geons should be well read in medical 
jurisprudence and if this were the 
case the profession would be much 
better prepared to appear in court, and 
more weight would be given to thier 
evidence were they versed in the legal 
aspects of their profession. The first 
volimie of a System of Legal Medicine 
that we have before us, is a proof that 
there is to be a work on the subject, 
that every practitioner should have in 
his hbrary. 

In the United States little has been 
written on this branch and the trans- 
Atlantic works have been consulted, 
but on account of the vast difference 
existing in the practice of medicine, 
legally considered, they are in many 
respects inapplicable to our methods 
and not in conformity with the legal 
usages of this country. The list of 
the distinguished contributors to this 



splendid work is too long to give, but 
en passant^ let it be said that they 
are all celebrites of the medical and 
legal professions and are adequately 
fitted for their work. In the first 
volume we find the following subjects 
treated : Medico-legal Inspections 
and post-mortem examinations, death 
in its medico-legal aspects, blood and 
other stains, identity of the living, 
identity and survivorship, homicide 
and wounds, poisoning by inorganic 
and organic matters and alkaloids, 
toxicology of ptomaines and other 
putrefactive products medical juris- 
prudence of life insurance, accident 
insurance, the obligations of the in- 
sured and the insurer, and the legal 
relations of physicians and surgeons 
to their patients, etc., and lastly a 
chapter on indecent assault upon 
children. The volume is illustrated 
by eight plates and a number of 
figures. Among the many features 
worthy of note, we would mention 
Bertillon's measurements and his des- 
criptions of physical appearances 
which are fully described and it is to 
be hoped that, by instructing the 
medical profession in the theories and 
the technique of this great French 
scientist, scientific work may be done 
in our jaUs and prisons for the benefit 
of humanity, as is now done in 
France. Too much praise cannot 
be said of the first volumne of the 
" System," and we await with pleas- 
ure the second which is to appear 
shortly. 



Digitized by 



Google 



74 



BOOK REVIEWS. 



Orthopedic Sukgeuy; A Manual 

FOR StITDENTS and PRACTITION- 
ERS. By James K. Young, M. D., 
Instructor in Orthopedic Surgery, 
University of Pennsylvania. Phila- 
delphia, 1 894 : Lea Brothers & 
Co. 

This volume of 446 pages is in- 
tended as guide to Orthopedic Surgery 
for both students and practitioners. 
The work is basad largely upon per- 
sonal experience, but old as well as 
new literature of its subject has been 
consulted by the author in order that 
the volume might be complete and up 
to date. The subjects are treated in 
order as follows : Pott's disease, 
sacro-iliac disease, hip jomt disease, 
ankle joint disease, diseases of other 
major articulations, diastasis, anky- 
losis, synovitis, lateral curvature of 
the spine, infantile spinal and cere- 
bral paralysis and others, torticollis 
neuromimesis, spinal and cerebral 
arthropathies, rickets, knock-knee, 
curvatures of the diaphyses, tardy 
hereditary syphilis of the bones, 
arthritis deformans, Dupuytren's con- 
traction, talipes, congenital disloca- 
tions of the hip and perverted develop- 
ment. We remark that the author 
has given at the head of each chapter 
the sjTionyms in the English, French 
and (lerman languages, a feature 
which we think most excellent and we 
find that with a gi'eat many exceptions 
in the French, they are correct. The 
work is on the whole very good, al- 
though cei-tain points in pathologj- 



might, we think, have been more 
completely treated. The treatment is 
especially well written upon and the 
chapters on the different paralyses are 
most excellently dealt with. The 
author has fully illustrated his work 
with figures from Hoffa, Davis, Brad- 
ford & Lovett, Gray and others, and a 
number of original ones. Messrs. 
Lea Bros. & Co. have done their share 
in making the work most readable on 
account of the excellent type and 
paper. The work will no doubt be 
a success, as it deserves to be. 



Transactions of the Medical 
Society of the State of New 
York, 1894. Published by the 
Society. 

This volume contains, as usual, a 
most interesting series of papers, num- 
bering in aU 45, but to give the titles of 
them all would take too much space. 
A short mention of the contents will 
suffice, as they should be read in order 
to be appreciated. Three pidncipal 
subjects were brought up. First, 
abdominal surgery, this being treated 
of in many points concerning diagno- 
sis, pathology, technique, ete. Second, 
menstration, normally and pathologi- 
cally considered, was discussed in ex- 
tenm. Third, diphtheria, which 
elicited many interesting memoirs 
concerning its diagnosis and treatment, 
both medical and by intubation. 
Many other interesting papers on 
various subjects complete this most 
excellent volume. 



Digitized by 



Google 





2 

O 

N4 

H 
Oi 

Q 

oo 

D 

Z X 

c 

Oi 4) 

en • 
2 .t: 
o > 

o n 
o 

oo 

D 

03 



Digitized by 



Google 



Digitized by 



Google 



ANNALS 



—OF— 



GYNAECOLOGY AND PEDIATRY. 



DEPARTMENT OF P-^EDIATRY. 



Remarks Bearing on the Surgical Treatment of Intussusception in the 
Infant. Two Successful Cases.^ 



BY HENRY HOWITT, M. I>., 
ouELPH, oirr. 



The term infant, as used in this 
paper, is employed in a modified sense, 
being restricted to the nursing epoch 
of life, or, more definitely, to the child 
under one year of age. 

Intussusception plays an important 
role at all periods of life in the causa- 
tion of intestinal obstruction. Ac- 
cording to Treves and* Leichtenstem, 
when we class all varieties of bowel 
obstruction together, it forms more 
than one-third the whole number. 
The same and other excellent author- 
ities aver that no less than one-fourth 
of all cases of intussusception occur 
during the first year of life. 

Although as a rule, the diagnostic- 
ation of it in the infant is not by any 
means difficult, few, who have given 
the matter attention, will differ from 
me when I state that more instances 
of the malady are overlooked in early 

1. Bead before the American Association of Ob- 
stetricians and Gynsecoloffists, Toronto, 1894. 



infancy than at any other age ; and a 
review of the literature pertaining to 
it comfpels one to believe that when 
the subject is better understood, 
especially by the general practitioner, 
the above estimate of its frequency 
will be found to be below the mark. 
At this age the flaccid condition and 
the loose attachment of the mesen- 
tery, the proneness on slight irritation 
to irregular intestinal muscular ac- 
tion, and the common occurrence of . 
catarrhal affections in the alimentary 
tract, probably account for its greater 
frequency than at other periods of 
life. 

Taking all forms of intussusception 
together, the general mortality is 70 
per cent ; but, if we confine our obser- 
vations in this line to the infant at 
the breast and exclude professional 
assistance, the mortality percentage 
leaps with a bound to almost, if not 
to, 100 per cent. Ordinary treatment, 

Google 



Digitized by ^ 



76 



HENRY HOWITT. 



including mechanical distention of 
lower bowel with gas, air or liquids, 
does not materially affect the death 
rate. 

This calamitous outlook is ascribable 
to the act that in infants, as a rule, to 
which there are few exceptions, the 
invagination is so acute that the 
efforts of nature are powerless, and, 
after the lapse of a few hours, ordinar}^ 
measures of treatment cannot succeed 
on account of the oedematous and 
other changes in the intussusceptum. 
At other ages spontaneous reduction 
of the displaced bowel and spontane- 
ous elimination of the portion causing 
the obstruction are factors to ward off 
a fatal termination ; but here, in at 
least the recognizable cases, spontane- 
ous reduction never takes place and 
elimination only in 2 per cent.; even 
then it does not by any means indi- 
cate recovery. 

If we exclude the extremely un- 
common varieties, and the pseudo 
ones, which happen immediately be- 
fore death, in brain and other dis- 
eases, the invagination found is either 
ileocaecal or ileo-colic, the former is 
generally, and the latter, in my opin- 
ion, always beyond the reach of any 
treatment short of coeliotomy. 

It is impossible to differentiate dur- 
ing life between the two varieties, nor 
will even inspection on exposure of 
the involved portion of bowel before 
reduction reveal which of the two 
varieties you have ; for the reason 
that in the ileo-colic variety, shortly 
after the lower few inches of the ileum 
became prolapsed into the caecum, 
the tenesmic efforts induced force the 
caecum into the colon, and its after 



course exactly resembles that of the 
ileo-ceecal. 

Now, it is not difficult to under- 
stand that by trusting to distention 
of colon by gas or liquids, a serious 
mistake may be made. For example, 
in a given case the distention may 
reduce the caicum and portion of 
colon involved, while the most impor- 
tant and acute part of the invagina- 
tion, the prolapsed end of ileum^ 
remains, and on account of its small 
size is apt to esca{>e detection, and 
thus lead to false security, which is 
very sure to be disastrous. Reduc- 
tion by distention of colon, if admiss- 
able at all, should only be attempted 
in the early hours of the attack and 
in the absence of marked tympanites. 
If used early it does not exclude in 
event of its failing an operation after- 
wards, but if employed later, or when 
the abdomen is distended with flatus, 
it is liable either to rupture the 
intestine, or lead to arrest of respira- 
tion from pressure on the diaphragm ; 
the latter alarming accident, as will 
be seen below, happened twice in one 
of my cases. 

I am fully aware that the leading 
authorities on the subject more or 
less strongly advise repeated and pro- 
longed trials at disinvagination by 
distention and taxis; at the same 
time it is my firm belief that just so 
long as the advice is followed by the 
profession, the mortality will remain, 
as in the past, appalling. 

To my mind, in the whole line of 
modem surgery, with its vast strides 
on the road to light, there are few 
human ailments which demand more 
prompt surgical aid than do the ma- 



Digitized by 



Google 



SURGICAL TREATMENT OF INTUSSUSCEPTION. 77 



jority of these cases ; and, under favor- 
able circumstances, there is little valid 
reason why in competent hands the 
mortality should^ be greater than the 
average major operation. Moreover, 
the operation is an ideal one, being 
restorative and free from mutilation, 
and its successful accomplishment ful- 
fills two of the noblest aims of our 
profession — the alleviation of pain 
and the prolongation of the sum of 
human life. 

At the annual meeting of the 
Ontario Medical Association in June, 
1889, I read a paper on "Miscellan- 
eous Laparotomies " which was shortly 
afterwards published in the Canad- 
tan Practitioner. The article con- 
tained a brief and hun'iedly-written 
report of my first operation for in- 
tussusception in the infant. In part 
from it, but chiefly from my notes 
taken at the time, allow me to state 
the following facts in regard to the 
case, namely : 

The exact age of patient, a male 
child, was at the time of operation 
2 months and 28 days. He had had, 
though fairly well nourished, almost 
constantly from birth, considerable 
catarrhal irritation of bowel, mani- 
fest by frequent loose stools, often 
containing mucus tinged with blood. 

The onset of intussusception in 
this case was sudden, being announced 
by an unnaturally piercing cry, which 
was soon afterwards followed by par- 
oxysmal attacks of colic, accompanied 
with vomiting and tenesmus. Blood 
and mucus were passed, but no faecal 
matter nor gas. A dose of castor oil, 
administered by the mother, aggra- 
vated symptoms, especially the vom- 



iting, which now (a very unusual 
occuiTcnce in infants) became ster- 
coraceous. After this he refused the 
breast ; in fact to swallow anything. 
The paroxysms of pain continued to 
grow more frequent and prolonged, 
and the intervals of freedom less. 
No medical man saw the case till the 
afternoon of the second day, when he 
was can-ied to my office. The child 
was then in a very critical state, tem- 
perature 102, pulse 135, and abdomen 
greatly distended. During the par- 
oxysms he, now, owing to weakness, 
merely moaned in a piteous manner. 
An oval lump was detected in right 
ide a little above line of umbilicus, 
swliich was extremely tender to touch- 

Under complete chloroform, narco- 
sis with pelvis elevated, the distention 
method, aided by taxis, was tried, but 
when a pint or more of liquid had 
been forced slowly into the bowel 
the child suddenly ceased to breathe. 
Escape of the fluid and artificial 
respiration accomplished our aim — 
resuscitation. Believing at the time 
that this untoward event was due to 
careless administration of the anaes- 
thetic, another attempt at disinvag- 
ination by the method was made, but 
the result, except more alarming, was 
the same. On examination, after 
second resuscitation, the lump was so 
much smaller in size that its detection 
by hand externally was very difficult ; 
and it occupied a lower position in 
the side. 

With as little delay as possible an 
abdominal section was made. The 
incision extended in the median line 
from half an inch above the umbili- 
cus downward as far as the bladder 



Digitized by 



Google 



78 



HFXRY HO WITT. 



would permit. No attempt was made 
to prevent escape of the distended 
coils of intestines, nor could this have 
been successfully accomplished. On 
the contrary, eventration was hastened 
by hand until the invaginated portion 
came into vieAv. It was easily 
brought out through the incision. 
The exposed intestines were pro- 
tected by suitable cloths wi-img out 
of hot water, applied in layers, the 
outer of wiiich were changed fre- 
quently. The intussuscept'on proved 
to be the lower three or !our inches 
of ileum prolapsetl tino.; ^h the ileo- 
C8Bcal valve. The caecum and colon 
were collapsed, and the former and 
the greater part of the ascending por- 
tion of the latter presented unequivo- 
cal evidence of having recently been 
involved in the invagination. No 
doubt the reduction of them had 
been brought about by the previous 
efforts in the way of distention. 

The prolapsed part of ileum proved 
by far to be the most difficult step in 
the operation, and it refused to yield 
until a plan similar to that commonly 
advised for paraphimosis was adopted. 
Immediately after relieving it, some 
gas and liquid contents of upper 
bowel entered colon, and in a few 
minutes flatus was expelled from the 
rectum. The passage of contents of 
small intestines into large was helped 
by gently grasping the former be- 
tween two fingers and running them 
along it towards the colon in such 
a manner that they were forced 
through the ileo-caecal valve. 

The bowel that liad been 
involved in the intussusception was 
dark in color, oedematous and in 



places furrowed. On the ileum 
close to the caecum, and again foiu* 
inches from it, there were clear 
indications of ruptured adhesions 
and several small abrasions of ,the 
peritoneal coat. 

When the intestines were replaced, 
the wound was quickly closed with 
silk-worm sutures, which included all 
layers and a continuous, superficial 
one of silk. 

My notes do not tell how long it 
took me to complete the operation, 
but they do show that within two 
and a half hours from the time the 
child entered my office, I was sitting 
by his cot at the (Juelph Hospital, 
and hearing explosions of flatus. In 
a less interval of time after the oper- 
ation, his bowels moved freely. He 
had no more paroxysms of pain, nor 
did he even vomit. Took the breast 
several times before morning. On 
the second day his temperature was 
normal. Recovery was rapid, and 
his mother took him home before the 
end of the second week. Date of 
operation, 4th of July, 1888. 

After the operation he was en- 
tirely free from his old complaint, 
dysenteric diarrhoea. I am sorry to 
relate that, in the early months of his 
fifth year, he contracted diphtheria 
and died. 

My second operation for intussus- 
ception in an infant took place last 
Spring. 

Frank L., bom October 25, 1893. 
The child from birth till he entered 
his fourth month had been fat and 
rugged; after this, up to time of 
operation, was troubled with frequent 
passages of loose stools, and also in- 



Digitized by 



Google 



SURGICAL TREATMENT OF INTUSSUSCEPTION. 



79 



c lined to vomit what he had nursed 
more than he formerly did. The motions 
were in other respects natural, and the 
act of defecation free from pain and 
tenesmus. Although his weight fell 
off a little, he was still a fairly well 
nourished child, and was neither ill- 
tempered nor restless. 

On the morning of the 20th of 
April, his mother earned him out for 
an airing ; on her return she nursed 
him and he slept quietly for two 
hours. When he awoke, his sister 
rocked his cradle and othei-wise 
amused him. Suddenly he gave an 
agonizing scream and apparently 
fainted. When the mother, who ran 
immediately to his ci-adle, picked him 
up, he was pale and limp. The sur- 
face of the body became cold and 
covered with a clammy sweat. A 
hot bath, mustard plaster ani^ friction 
were resorted to ; then after con- 
siderable time the child vomited and 
reaction sloAvly commenced, and, as 
it became established, paroxysms of 
pain came on, accompanied with fur- 
ther vomiting and tenesmus. Dur- 
ing these attacks, which were becom- 
ing more frequent and severe, the 
child Avrithed and screamed. 

About two hours after the com- 
mencement, a medical man from a 
distance who happened to be in the 
village where the parents resided, was 
requested to see the little one. The 
doctor, after an examination, remarked 
that the temperature was normal ; 
still he feared the patient had a 
touch , of inflammation of bowels. . 
He gave an anodyne mixture and 
ordered a dose of oil and hot applica- 
tions to abdomen: the oil to be re- 



peated in five hours if necessary. An 
hour after the doctor left, the mother 
gave an enema, and dark blood slime 
and a little faecal matter came away. 
The oil was repeated in five hours, 
but it only increased the straining 
efforts and the amount of blood and 
mucous, but except these no bowel 
movement occurred. The anodjTie 
mixture^ which was frequently re- 
peated, by evening relieved the pain, 
and quieted very much the tenesmic 
efforts. The child slept occasionally 
during the first part of the night, but 
after midnight the medicine seemed 
to lose its effect, and in consequence 
the intermissions between the parox- 
syms became shorter as time ad- 
vanced. He nursed frequently, but 
always vomited it, and occasionally a ' 
yello^vish colored material. 

On the . following day the parents 
became alarmed and called in their 
family physician, Dr. Robinson, of 
Guelph, who arrived at noon, about 
twenty-four hours after the com- 
mencement of the attack. The doctor 
at once correctly diagnosed the true 
condition of affairs, and, beside the 
symptoms given above, made a note of 
the following, najnely : Temperature 
104, pulse 140, face pinched with 
anxious expression ; except a little 
fulness in lower abdomen, no tympani- 
tes, and the presence of a lump in 
right iliac region, deeply seated and 
only reached by firm pressure, which 
caused much pain. 

When the doctor returned to town, 
he related the history of his case to 
me, and I concurred with the diag- 
nosis. The result was that his child 
arrived at the hospital at 5 P. M. that 



Digitized by 



Google 



80 



HENRY HOWITT. 



day. He was now so extremely low 
that I became chicken-hearted, and 
refused to attempt any active measure 
of treatment until urged by the par- 
ents, who said that no matter what the 
result might be, no blame would be 
attched to us. They also added that 
on the way from home they hardly ex- 
pected him to reach the hospital 
alive. 

Meanwhile preparations had been 
completed to carry out Senn's plan of 
disinvagination by rectal insufflation 
of hydrogen gas, and in event of its 
failure to perform a coeliotomy. Pal- 
pation of abdomon under chloroform 
on the operating table revealed the 
lump by this time to be high in right 
side ; in fact partly under the ribs. 

Although we had Senn's apparatus, 
as supplied by Shores & Co., of Mil- 
waukee, the gas failed to- have any 
effect whatever. I admit it is pos- 
sible our manner of using it may have 
been defective. 

A three-inch incision was now made 
in the median line, through which a 
large portion of the small intestines 
were drawn out and protected, as in 
my first case. The evisceration al- 
lowed me in less than a minute to 
reach the seat of invagination and to 
bring it into view. 

To the eye the ileum appeared to 
enter the right extremity of the 
transverse colon, with an enlargement 
of the latter commencing at the junc- 
tion of the two, and extending along 
the large bo^el for three or four 
inches. Consequently the lower por- 
tion of ileum, cajcum and ascending 
-colon were invaginated. 

Now came the difficult step in the 



operation, and which, excluding that 
spent in the attempt to relieve by in- 
sufflation, occupied more time than all 
the others. After failure by repeated 
trials of different methods, I wag seri- 
ously considering whether to resect 
the part, or to exclude it from the 
faecal circulation, by making an anas- 
tomosis with a Murphy button be- 
tween the ileum above the obstruction 
and the transvei*se colon below, when, 
pressure being made on the apex of 
the intussusceptum while the intussus- 
cipiens near the neck was pulled in 
the opposite direction, it yielded, 
slowly at first, then suddenly gave 
way. The parts were (Edematous, 
furrowed and dark in color. The 
oedema made the coats of the caecum 
nearly a quarter of an inch thick, and, 
owing to the same condition, the end 
of ileum for two inches to touch felt 
solid. On the colon, near what had 
formed the neck of the intussusception, 
were patches of abraded peritoneum ; 
one on the outer side was larger than 
a 25-cent piece, which bled quite 
freely for a ie^v minutes. The 
affected gut was irrigated and re- 
turned to the abdomen. It was now 
fortunately observed that the dis- 
tended ileum had not emptied itself 
into colon. The bowel was brought 
out again, and an examination led to 
a pull being made on the ileum, when 
something appeared to yield and the 
obstruction at this point, was over- 
come. By running the fingers along 
the ileum toward the colon, the dis- 
tention of small bowel was soon com- 
pletely relieved. All the intestines 
were replaced, the omentum spread 
over them and the wound closed. 



Digitized by 



Google 



SURGK AL TREATMENT OF INTUSSLSCEPTION. 



81 



The child did not vomit after the 
operation, nor, in short, had he a single 
bad symptom. The bowels moved 
the same evening. From the first 
(hiy he could not have felt much pain, 
for when awake and lying on his back 
he spent much of the time in endea- 
voring to put first one and then the 
other foot into his month. His par- 
ents took him home on the eighth 
day. Although he recently has had 
an attack of scarlet fever, he is to- 
day a rugged and healthy child. 

What to me appears worthy of note 
is the fact that in both cases the 
operation evidently did more than 
relieve the obstruction. The chronic 
and troublesome irritability of bowel 
at once and permanently ceased after 
it Avas done, though in the one the 
diseases had existed from birth, and 
in the other for fully two months. 
This should lead one to infer that 
possibly the cause of the irritation 
had its commencement in the peri- 
toneal coat. 

I have photographs of the patients : 
No. 1 taken thirteen days, and No. 
2 four months after operation, Avhich 
in each ca»se fairly well shows the 
site and extent of incision. 

In order to emphasize the import- 
ance of noting the sudden and severe 
nature of the initial symptoms in a 
diagnostic point of view, to shoAv the 
lump cannot always be detected and 
also to make known the possibility of 
an operation being successful as late 
as the foui-th day, the following brief 
notes are given : 

About the middle of July, 1893, in 
consultation with a medical friend, I 
saw a case on the third dav of the 



attack, but could not induce the 
family to allow an operation. The 
child, a male, aged five and a half 
months, had never previously been 
ill. The onset occurred suddenly 
during sleep, causing the infant to 
awake Avith a scream. He then 
turned pale, and the surface of his 
body became cold and clammy. Re- 
action w^as followed by the usual sym- 
ptoms. At the time I saw him the 
abodmen Avas distended and no lump 
could be detected. 

Death took place on the fourth day, 
and a post-mortem examination veri- 
fied the diagnosis and revealed that 
the lower end of ileimi, the caecum 
and all the colon to the upper end of 
the descending portion Avere invagi- 
nated. The distention of the small 
intestines had forced the part upAvards 
and backwards so that it pressed 
against the left kidney. This 
accounts for the reason Avhy the lump 
had not been felt during life. There 
Averenio noticeable adhesions, nor any 
evidence of sloughing, and reduction 
was easily accomplished by merely 
pulling the ileum. 

I Avill noAv present to you for con- 
sideration and judgment, a fcAV re- 
marks and suggestions, the knowledge 
of Avhich, in my opinion, is important, 
if not to some extent necessary, in 
order to obtain success in the treats 
ment of invagination* in the infant by 
surgical means. 

1. The diagnosis in infancy is not 
difticult, for the reason that obstruc- 
tion of boAvei by any other cause is 
extremely uncommon, and when it 
does exist is sure to be owing to con- 
gen tial defects, or as readily recognized 

Digitized by LjOOQ IC 



82 



HKNKY HO WITT. 



ailments. Hie sudden and pro- 
nounced nature of the onset, the pres- 
ence of more or less evidence of shock, 
followed shortly by vomiting, parox- 
ysmal colic and marked tenesmic 
efforts, which give rise to non-fa?cal 
passages of blood and slime in a child 
previously healthy, or who has a 
catarrhal affection of bowel, render 
the diagnosis for all practicable pur- 
poses complete. If in addition to 
tliese we can detect an oval tumor in 
line of colon no room for doubt is pos- 
sible. In consequence of the pliable 
condition of abdominal walls at this 
early age, a lump the size of a pigeon- 
egg can, in the absence of tympanites, 
be readily felt by the educated hand. 

2. The operation should be per- 
formed early, and not when the powers 
of life are ebbing away. Within 
twenty-four hours of the commence- 
ment of attack, and in the absence of 
marked tympanites, an attempt at re- 
duction under chloroform probably 
should be made by distention and 
taxis ; but this trial should be neither 
forcible, prolonged nor repeated, and, 
failing, an abdominal section should 
immediately follow\ In the second 
day and later the operation should be 
done without a moments unnecessary 
delay. The operator shoidd have a 
practicable knowledge of the details 
of aceptic surgery as applied to ab- 
dominal work. * 

8. The incision should be made in 
the median line, either above the 
umbilicus or lower, according to posi- 
tion of lump. When the tumor can- 
not be defined, let the middle of 
incision be at the umbilicus, for 
through this, the part after (eviscera- 



tion, no matter where situate, may 
be reached and brought into view. 
The wound need not be more than 
from three to three and a half inches 
in length. The pliable nature of the 
abdominal walls and the smallness of 
cavity render complete exploration 
with fingers quite easy. 

4. Evisceration will be found not 
only to save time, but to aid very 
much in facilitating the aft^r steps of 
the operation, for it allows more 
room, and permits the large bowel to 
be readily brought out. I differ from 
those who state that it is more dan- 
gerous to expose the intestines in 
infancy than later in life. The evis 
cerated contents of abdomen should 
be protected by suitable cloths wrunjjr 
out of hot water and applied in layers, 
the outer of which are changed wher 
necessary ; or the heat maintained h\ 
imgation with water at a tempera- 
ture of 92 degrees. 

5. Reduction is probably best ac- 
complished by making pressure on 
the apex of the intussusceptum, while, 
at the same time the intussuscepiens 
are pulled in an opposite direction. 
In some instances it is better to break 
^vith a probe or other instrument tho 
adhesions at neck, and then to mako 
firm pressure on the intussusceptnii» 
by grasping the whole mass with the 
hand before an endeavor is made to 
reduce it. 

6. Before the reduced portion ik 
returned to abdomen the operator 
should not only demonstrate that the 
obstruction has l)een completely re- 
moved, but should also empty the 
contents of ileum into large bow^el. 
The last may easily be done by gently 

Digitized by VjOOQ IC 



REVIEW OF im:diatry. 



83 



stroking the ileum dovm wards with a 
soft sponge, or after tlie fashion 
adopted in my operations. The re- 
moval of the material from above the 
place where the obstruction existed 
performs important work for an organ, 
the function of Avhieh is sadly im- 
paired; and it also greatly hastens 
the expulsion of offensive and septie 
matter from the body. 

7. The replacement of the small 
intestines may be facilitated by the 
surgeon and assistant hooking two 
fingers of their left hands into oppo- 
site sides of the wound, and then lift- 
ing the loAver portion of body from 
the table. Should the intestines be 
unusually distended with gas, it is 
my opinion that there is no objection 
to multiply punctures with clean 
hypodennic needles. 

8. A point which also applies to 
most abdominal operations is re- 
arrangement of omentum. By spread- 



ing the omentum over the bowels, it 
certainly prevents adhesion of the 
gut to the line of incision. The 
lymphatics of it are admitted to be 
endowed with more than ordinary 
poAver of absorption, and by extend- 
ing to seat of impairment may in no 
snuill measure prevent trouble. The 
omentum may also haply become at- 
tached to a weak point on the affected 
portion of bowel, and thus be an 
agent in preventing perforation. 

9. 'ilie wound should be sealed in 
such a manner that the uriiu^ of the 
child cannot possibly reach it. 

In conclusion, allow me to add that, 
in all, six causes of intussusception 
have come under my personal obser- 
vation, four in the infant and two in 
the adult. Three were treated by 
abdominal section and recovered, and 
three by non-operative means, with 
one result — death. 



REVIEW OF PEDIATRY. 



Antlsepsis IX Mkaslf:s. 
Belloiu. 



By Dk. 



The following is the treatment as 
to antiseptics, carrie<l out in the ser- 
vice of Dr. Siredey. It is well known 
that the principal danger in measels 
is secondary' infections produced by 
the miero-oi-ganlsms of the buccal and 
naso-phanangeal cavities, causing the 
ela.ssical complications of broncho- 
pneuniania and stitis. To avoid these. 
Dr. Sireilev orders all his cases of this 



disease to undergo a systematic irriga^ 
tion of the above named cavities with 
a very dilute antiseptic solution such 
a« coiTOsive sublimate at 1-10000, per- 
inanganote of potassium at 1-5000 or 
one of the following solutions : 



R 



Thymol. 
Acid carbolic, 
Aq. pent, 
Mophtol B 
Aq. font., 



15 centigrammes. 
5 grammes. 
1 litre. 

20 centigrammes. 
1 litre. 



( La Prene 3feJieale. Sept. 8, 1894.) 

Digitized by VjOOQ IC 



84 



REVIEW^ OF P.EDIATRY. 



Hysteria ix young Boys. A clin- 
ical Lfx^ture delivered by Dr. 
Simon. 

Hy8t(»ria in boys is sufficiently fre- 
quent that it should be seriously 
considered in cases presenthig abnor- 
inal nervous symptoms. The author 
mentioned the following cases. The 
first, a boy aged 12, who had a para- 
plegia of six weeks duration. He was 
taken Avith sharp pains in the knees 
with flexion of the leg on the thigh 
and some one said before him that he 
would never be able to Avalk. This 
produced a deep emotion and from the 
following: dav he could not walk. Dr. 
Simon concluded after examination of 
the case that it w^as one of hysterical 
paraplegia and announced that a cure 
would be affected in fifteen days, and 
by this suggestion cure was complete 
after that lapse of time. In this case 
the cause was the great emotion pro- 
duced on a soil prepared by a partic- 
ular condition of the cerebellum. The 
second case was a boy about the same 
age as the first patient, who was sent 
to the hospital at Berck for some 
slight ailment. He was greatly moved 
at the sight of the different apparatus 
for the sick and the patients and one 
day arose with a severe pain in the 
thigh, which lasted for some time and 
simulated a coxalgia. He was sent 
home walking Avith crutches. Dr. 
Simon saw the child and had suspic- 
ions as to the natm-e of the case and 
tried suggestion as above with result 
that the crutches were abandoned and 
all pain soon disappeared. These 
pseudo-paralytic or painful symptoms 
are very common in the hysteria of 



young children, but more rarely, queer 
movements may be obseiwed whose 
nature it is difficult to explain ; the 
author mentions two cases aged about 
nine years, Avho entered his service 
and Avhose arms were in a state of 
singiUar contractions like a mill-wheel. 
One of these patients Avas cured after 
havmg a sharp pain, the other Avas 
put in with his companion and soon 
was cured by imitation. Other inter- 
esting, but similiar cases and cures are 
reported. F'or treatment the bromide 
of potassium does not work well. 
The root of valerian in infusion is 
more useful. The valerianate of 
ammonia may also be given for 15 
days; belladonna, camphor or hyos- 
cyamus are fairly good. The author 
advises not to employ iron or nux 
cvomica, thej^ being generally contra- 
indicated. (Jouraal de Med. et de 
Chii-. pratiques. Sept. 10, 1894). 



Treatment of Feeble Heart dur- 
ing INFECTIOUS Diseases in 
Children. By Dr. Sevestre. 

When the lieai-t is Aveak during an 
infectious disease and to avoid col- 
lapses when the cold bath is used 
the author employes cafeine, either 
in subcutaneous injections of 20 centi- 
gi-ammes, twice daily or in a potion 
composed as follows : 



R Caffeine. 
Sodje bcnzciat 
Syr. Tolut. 
Spt. vini gall. 
Vanillin. 
Aq. dest. 



aa 1 gram. 60 centigram. 
50 grammes. 
10 grammes. 
5 centigrammes. 
60 grammes. 



M, D. S. A tablespoon twice daily. 
(La Presse Medicale, Sept. 22, 1894) 



Digitized by 



Google 



ANNALS 



—OF— 



GYN/ECOLOGY AND PEDIATRY. 



Vol VIII. 



NOVKNIBER, 1804. 



No. 2. 



Report of Four Cases of Appendicitis Surgically Treated in Thirty-seven 

Consecutive Hours. 



BY G. S. PECK, M. D., 



Consulting Surgeon^ Youngstoivn City Hospital, 

YOUNOSTOWN, O. 



Within the past few years many 
articles have appeared m the various 
medical journals concerning the diag- 
nosis and treatment of appendicitis, 
and while the views regarding the 
symptomology and diagnosis of the 
disease have become almost fixed, the 
same can not yet be said of the treat- 
ment, concerning which there are 
many and widely different ideas. 
These differing opinions, however, do 
not reflect discredit or inefficiency 
upon any of the various classes of 
observers, but rather indicate a lack 
of statistics, which eventually alone 
should determine which plan of treat- 
ment is the safer to follow. I myself 
believe that we obtain the best results 
from the early surgical treatment. 

The cases which I intend to present 
at this meeting are of different char- 



1. Read b<»fore the American Assoeiation of Ob- 
-tetrlcians and Gyns^logists, at Toronto, Sept. *94. 



acter and type, though all were treated 
surgically, with results as you will 
notice. But believing that there 
might be advocates for a different 
treatment than that pursued, you have 
my apology for presenting a paper on 
a subject so frequently discussed, 
though at present lacking, I believe, 
sufficient statistics from which to draw 
more definite conclusions. 

CASE I. 

Operation during interval between 
attacks. Obstruction of bowels on 
sixth day. Second operation. Re- 
covery. 

Miss L. H., suigle, age 26 years, 
residence, Warren, Ohio, was re- 
ferred to me for examination by Dr. 
T. M. Sabin, July 19, 1894. The 
following brief history was obtained : 
In the early part of May, she had an 



Digitized by 



Google 



82 



G. S. PECK. 



attack of appendicitis, lasting some 
three weeks, during which time she 
was very ill; an operation was sug- 
gested, but, on account of a sudden 
favorable change, all operative pro- 
cedure was postponed, and she was 



m 



regard to operative treatment. 
Upon our advice she entered the 
Youngstown City Hospital, July 23d, 
1894, and after three days thorough 
preparation, at 11 A. M., July 26th, 
assisted by Drs. Zimmerman and 



I. APPFNDTX IN RITU. VIEWED FROM POSTERIOR. 




1. CsBCum. 

2. Appendix, held beueatli ilium and ctecum by adhesions. 

3. Ileum, three feet above its terminus 4. 



advised to have the appendix removed 
in the interval between attacks. I 
could easily map out a small tumor in 
the right iliac region, near the Mc- 
Bumey point, wliich was very tender 
upon deep pressure. T confirmed the 
diagnosis, and agreed with Dr. Sabin 



Montgomeiy, Drs. Clark and Sabin 
being present, I made an incision four 
inches long, directly over the cecum. 
Upon opening the abdomen I found 
the appendix very much enlarged, 
buried in a mass of strong adhesions 
between the ileum and cecum, and 



Digitized by 



Google 



FOUR CASES OF APPENDICITIS. 



83 



containing a large fecal concretion. 
The adhesions were soon broken up, 
the ileum returned, and the appendix 
removed by the flap method. The stump 
was invaginated and covered with 
peritoneum. The abdomen was then 
closed with silk-worm gut, and the 
patient put to bed in good condition ; 
pulse 80. On the evening of July 
26th, the temperature was 99 2-5° ; 
pulse 82 ; July 27th, 8 A. M., tempera- 
ture 99 3-5°, pulse 82 ; 7 P. M., tem- 
perature 100 2-5°, pulse 102 ; she had 
passed flatus freely per rectum, and 
was given saline carthartics. During 
the night she had three large move- 
ments. July 28th, 8 A. M., tempera- 
ture 100°, pulse 84 ; 7 P. M., tempera- 
ture 101°, pulse 106. During the 
afternoon and evening she had seven 
lai^e watery passages. July 29, 8 A. 
M., temperature 100 3-5°, pulse 104 ; 
had two watery passages and com- 
plained of pain in the abdomen, due to 
a collection of gas. During the after- 
noon she vomited twice a material 
resembling bile. At 7 P. M,, tem- 
perature 100°, pulse 100. July 30th, 
8 A. M., temperature 99 1-5°, pulse 86. 
She vomited a small quantity of 
bilious matter at 5 A. M., but passed 
a very comfortable night. RocheUe 
saltswere ordered to be given, a drachm 
every hour until bowels moved. At 
7 P. M., temperature 99 2-5°, pulse 90. 
July 31, 8 A. M., temperature 
98 1-5°, pulse 90. Vomited a large 
quantity of brown material; ordered 
an enema containing RocheUe salts, to 
be repeated every four hours until 
bowels moved. During the entire 
day she was troubled greatly with 
flatulency and nausea, and at 2.30 



P. M. vomited about a pint of brown 
material. A third attack of vomiting 
occurred at 3.30, and a fourth at 5.20. 
No results followed the two enemas 
given during the day. At my visit, 
7 P. M., I detected in the material 
vomited at 5.20 a decided fecal odor, 
and then realized that I had an ob- 
struction of the bowel to deiil with, 
and that prompt action was necessary. 
Seven p. M., temperature 99 3-5°, pulse 
104. Realizing the gravity of the 
case I asked for consultation, and Dr. 
Rosenwasser, of Cleveland, was sum- 
moned. 

At 2 A. M., August Ist, Dr. Rosen- 
wasser confirmed my diagnosis. She 
had not vomited since the early even- 
ing, but there was considerable tym- 
panities, nausea and restlessness ; pulse 
120, temperature 100°. 

We decided to reopen at once ; at 
4 A. M. the patient was again ether- 
ized, and, assisted by Drs. Rosen- 
wasser, Zimmerman, Montgomery and 
my student, Mr. Lichty, I reopened 
the incision. The large intestines 
were very much distended with gas, 
the small intestines collapsed and con- 
siderable serous fluid escaped from the 
abdominal cavity. Upon lifting the 
cecum I foimd everything at the seat 
of former operation in good condition. 
After a somewhat tedious search I 
discovered, about three feet from the 
ileo-cecal valve, a complete obstruction 
of the ileum by bands of old, dense 
adhesions (as represented in drawing 
No. 2). After thoroughly breaking 
up the adhesions, thereby liberating 
the obstruction, that portion of the 
ileum was brought out into the in- 
cision, and the opening into the 



Digitized by 



Google 



84 



G. S. PECK. 



abdominal cavity packed with iodoform 
gauze. T did not feel that my patient 
would permit of ideal surgery, and 
was content to do no more than was 
absolutely necessary to save life. 
The patient was put to bed at 5 A. 



to 160. Vomiting of fecal matter 
continued at frequent intervals. 
Tympanites increased. She com 
plained of pain in the left iliac region 
and was very restless. At 7 P. M., 
with the above symptoms present and 



IT. APPENDIX REMOVED.- (FIRST OPERATION) 




1. Caecum. 

2. stitches through peritonium of inteatlne. 

3. Ileum, released from caecum and appendix. 



M., with a pulse of 134. External 
heat was applied, and hypodermics of 
strychnia, gr. 1-20, and digitalin, 
gr. 1-100, were ordered every two 
tours. During the entire day of 
August 1st her pulse ranged from 140 



becoming worse every hour, I felt as 
though my case was growing more 
desperate, and that other obstructions 
had possibly been overlooked. As a 
temporary expedient I made a small 
opening in the ileum. Fecal matter 



Digitized by 



Google 




Digitized by 



Google 



Digitized by 



Google 



L L - 

Cas£ Nq.Y 



^^*^^ In 



r^f«>f^r/pv 




y 









APPENDICITIS. 
Case of Dr. Peck. 

(See page 85.) 



Digitized by 



Google 



Digitized by 



Google 



FOUR CASES OF APPENDICITIS. 



85 



and flatus came away in largjB amount, 
the vomiting ceased, and tympanites 
almost entirely disappeared. 

Thursday, August 2, 8 A. M., tem- 
perature 99 3-5°, pulse 126 ; had a 
fairly good night's rest ; 7 P. M., 



M., temperature 98°, pulse 114 ; T 
p. M., temperature 99°, pulse 118; 
August 5th, 8 A. M., temperature 99°» 
pulse 110 ; 7 P. M., temperature 99°, 
pulse 108. August 6th,' 8 a.Jm., tem- 
perature 98 1-2°, pulse 104 ; 7 P. M. 



m. ADHESIONS BROKEN TO REMOVE OBSTRUCTION IN ILEUM.- (SECOND OPERATION). 




1. Cflscnm. 

2. Stitches through peritoneum. 

3. Ileum, freed from adhesion. 

temperature 99 3-5°, pulse 132 ; 
vomiting entirely ceased and 6very 
symptom improved. Friday, August 
8d, 8 A. M., temperature 99 4-5°, pulse 
120; 7 p. M., temperature 98 1-2°, 
pulse 120. August 4th, 8 a. 



temperature 98 1-2°, pulse 118. From 
August 6th to 14th, the temperature 
remained normal ; pulse ranged from 
104 to 118. Since August 1st she 
has passed a large amount of fecal 
matter through the artificial anus, at 



Digitized by 



Google 



86 



G. S. PECK. 



first liquid, but later more solid. Her 
•food has been liquid and semi-solid. 
From August 1st to 11th she has 
passed flatus per rectum but twice, 
and then but a very small quantity. 
August 11th, after given an enema 
containing Rochelle salts she passed 
well-formed fecal matter from the 
rectum for the first time since the 
second operation — eleven days before. 
During the day she had six good 
natural passages and passed flatus 
freely. August 12th, bowels moved 
twice, naturally, and the amount dis- 
charged through the fecal fistula was 
greatly diminished. August 13th, the 
nineteenth day, the temperature com- 
menced to rise, and there had been 
considerable fluctuation up to the pre- 
sent time, as you will observe by the 
charts on page 88, 89. The integu- 
ment around the fecal fistula for a 
distance of some two inches was so 
painful from excoriation that, against 
my better judgment, I attempted to 
close the fistula, August 2 2d, the 
twenty-eighth day. For three days 
she was very comfortable, when, upon 
the thirty-first day, a small amount of 
fecal matter came through the fistula. 
On the thirty-fifth day I made a 
second unsuccessful attempt to close 
the fistula. From the thirteenth day 
to the present time she has had from 
one to three daily passages per rectimi, 
and the amount coming through the 
fistula diminished rapidly. She sat 
up for the first time on the thirty- 
third day ; walked about the room on 
the thirty-eighth day; and has been 
out doors every pleasant day since 
September 3d. The temperature 
reached normal on the fifty-first day, 



and continued so up to the present. 
From the forty-sixth to the fifty-first 
day the fistula has been dressed once 
every thirty-six hours. From the 
fifty-first to the fi%-fifth day fistula 
was dressed every forty-eights hours. 
The diet during the entire fifty-five 
days has been liquid and semi-solid. 
She is gaining strength every day and 
left the hospital September 18th, fifty- 
five days after the first operation. 

CASE NO. n. 

Operation during the fourth day. 
First attack. Recovery. 

Mr. D. McN., aged 32, married, 
and a resident of Youngstown, Ohio ; 
occupation, peddler. 

Previous History. — With the ex- 
ception of diseases incidental to child- 
hood, he has enjoyed perfect health. 

At 3 A. M. Monday, July 23rd, 1894, 
while preparing for work, he was 
seized with severe pain in the region 
of the stomach, extending over entire 
abdomen. After taking some break- 
fast and a dose of Jamaica ginger he 
went to work. The pains soon be- 
came griping in nature, and the stom- 
ach irritable, but he was unable to 
vomit. He continued his work about 
an hour, when the pains became so 
severe that he was obliged to quit, 
and was removed to his home. Dur- 
ing the morning he had three scant, 
watery stools. After trying the usual 
home remedies without success. Dr. J. 
J. Thomas was called, about 7 P. M. 
July 23rd. Upon examination he de- 
tected all the symptoms of appendi- 
citis. Temperature 100°, pulse 96. 
He advised Rochelle salts in drachm 
doses every hour until bowels moved. 



Digitized by 



Google 



FOUR CASES OF APPENDICITIS. 



87 



During the next two days, July 24th 
and 25th, the patient had 15 watery 
discharges. July 26th, 8 A. M., there 
being no improvement in symptoms, I 
was asked to see him in consultation 
with Dr. Thomas. Upon examina- 
tion I found a mass in the right iliac 
region, which was exquisitively sensi- 
tive upon the slightest pressiu'e. 

I confirmed the doctor's diagnosis,and 
advised an immediate operation. Dur- 
ing the afternoon he was seen by Dr. 
A. M. Clark, who (independently of 
Dr. Thomas and myself) confirmed 
the diagnosis. He was at once re- 
moved to the city hospital, and at 5.30 
p. M., July 26th, assisted by Drs. 
Thomas, Zimmerman and Booth, and 
in the presence of a number of local 
physicians, I made the usual oblique 
incision into the peritoneal cavity, 
and removed a very large appendix 
containing pus, and a large fecal 
concretion, together with a portion 
of thickened adherent omentum. 
The opening into the peritoneal cavity 
was packed with sterilized gauze. 
Upon further examination I ruptured 
an abscess sac (extra peritoneal), con- 
taining about two ounces of pus. The 
cavity was well irrigated with a bi- 
chloride solution, a large drainage tube 
placed in position, the lower part of 
the incision and the peritoneum closed 
with silk-worm gut, and the abscess 
cavity packed with iodoform gauze. 
The patient made an uninterrupted 
recovery, and left the hospital Thurs- 
day, August 23rd, four weeks after 
operation. The highest temperature 
reached was 101°, during the second 
day, pulse 100. Since the second day 
temperature and pulse gradually de- 



creased until the seventh day, when 
they reached normal and so con- 
tinued. 

CASE NO. in. 

Operation on third day of third at- 
tack. Recovery. 

July 27th, 1894, I was asked to 
see, in consultation, G. H., a painter 
by trade, aged 27, married; residence, 
Youngstown, Ohio. 

Previous History, — Has had dis- 
eases incidental to childhood. Usually 
constipated, and was obliged to take 
laxatives frequently. Was troubled 
with indigestion at times and occa- 
sionally had attacks of dian-hcea. 

Some eight years ago he was taken 
sick with what he now thinks was 
appendicitis, presenting the following 
symptoms : Pain in region of stom- 
ach, after two days, becoming local- 
ized in the right iliac region ; pain 
was excessive. While in bed the 
limbs were flexed; vomited frequently, 
and was constipated. The attack 
lasted one week, no physician having 
been called. 

Two years ago he had a similar at- 
tack, with pain and vomiting as before, 
lasting three or four days. This time 
a physician was called ; he was given 
saline cathartics, and after bowels 
moved freely he steadily improved. 
He thinks he was not so strong since 
the last attack, being more constipated 
and having had frequent slight pains 
in the abdomen and back. 

Tuesday, July 24th, 1894, after 
eating a hearty supper he complained 
of pain in the abdomen, much like the 
pain of two years previous. From 8 
to 12 p. M. he drank half pint of 



Digitized by 



Google 



88 



G. S. PECK. 




Digitized by 



Google 



FOUR CASES OF APPENDICITIS. 



89 



«1 



o o o o o 

o Q OB CO rx cc 

^ T *? 1 tp t^ 



M5 




Digitized by 



Google 



90 



G. S. PECK. 



whiskey and vomited frequently. At 
2 A. M., July 25th, the pain becoming 
more severe, Dr. A. M. Clark was 
summoned. The doctor recognized 
the possibility of an appendicitis, and 
at once prescribed Rochelle salts, 
drachm doses every hour until the 
bowels moved. Morning temperature 
100°, pulse 91. During the day he 
had three large watery movements. 
Pain was relieved temporarily, but 
at 9 p. M. it returned and became 
localized in the right iliac region, not 
being severe except upon pressure. 
Evening temperature 102°, pulse 100 ; 
vomiting ceased. Thursday, July 26th, 
8 A. M., temperature 101°, pidse 100 ; 
7 p. M., temperature 102°, pulse 104. 
Had a very comfortable day, pain not 
being present except when moving 
about. 

Friday, July 27th, 10 A. M., tem- 
perature 102 3-5°, pulse 100. Upon 
examination I could detect a small 
mass in the right iliac region at the 
McBumey point, which was very 
tender to touch. The diagnosis of 
appendicitis was confirmed, operation 
advised, and he was at once sent to 
the city hospital. At 4.30 p. M., Fri- 
day, July 27th, assisted by Drs. Zim- 
merman and Booth and in the pres- 
ence of the staff, I made the usual 
oblique incision four inches long di- 
rectly over the mass, and opened the 
peritoneal cavity. After packing the 
cavity with gauze I removed a very 
large appendix, which contained about 
half a drachm of pus. At its attach- 
ment to the cecum the appendix was 
very large and ulcerated, so much so 
that my ligature cut through, making 
it impossible to invaginate the stump. 



After cutting away the appendix, I 
touched the stump and a spot on the 
cecum with pure carbolic acid. After 
irrigation, I inserted a small drainage 
tube in the lower angle of the incision, 
extending down to the cecum, and 
closed the opening with silk-worm 
gut. The patient made a good re- 
covery, and 'left the hospital August 
23rd, 27 days after operation. High- 
est temperature since operation was 
102 2-5°, pulse 90, the afternoon of 
second day. Temperature reached 
normal on seventh day, and so con- 
tinued. 

CASE NO. IV. 

Operation during tenth day. Death 
from septic peritonitis sixty-five hours 
after operation. 

G. L., female, aged 13 ; residence. 
Brier HiU. 

Left home to visit at Niles, O., 
July 9th, 1894, apparently well, al- 
though for some little time before, 
she had complained of some pain 
across the lower part of the bowels, 
which her parents called "growing 
pains." During her visit she com- 
plained of being unusually tired. 
During the night of Thursday, July 
19th, the pains became very severe 
and vomiting set in. Friday, July 
20th, the pains having subsided, she 
walked about a mile to visit a friend, 
and while there she was obliged to 
lie on a couch the greater part of the 
day. The pain, which had been gen- 
eral, now became localized in the right 
iliac region. She had some fever, the 
tongue was heavily coated and she 
vomited frequently. 

Saturday, July 21st, she felt some- 



Digitized by 



Google 



FOUR CASES OF APPENDICITIS. 



91 



what better, had no fever, but her 
stomach was still irritable. She was 
up and about all day, and seemed well 
in the evening ; in fact well enough 
to walk three or four blocks. 

Sunday, Jidy 22, she was much 
better all day and went to church in 
the evening; after church she ate 
hickory nuts and blackberry pie. A 
restless night followed, but the next 
day (Monday, July 23rd) she vras 
better, the pains having almost en- 
tirely subsided. 

Tuesday morning, July 24th, she 
felt quite well, but in the afternoon 
the pain in the right iliac region re- 
appeared. 

Wednesday, July 25th, she returned 
to her home at Youngstown, having 
carried her valise, about a mile to the 
depot before taking the train. She 
appeared well, and during the even- 
ing attended a party, where she ate 
cake and watermelon. 

Thursday, July 26th, she washed 
the breakfast dishes, and was up and 
about the house the greater part of 
the day. Her parents noticed that 
she looked sick and seemed tired. In 
the evening she was much worse, and 
at 11 P. M. Dr. H. E. Blott was 
summoned. He found her suffering 
intense pain in the right iliac region 
and with a temperature of 100, pulse 
112. He at once suspected appendi- 
citis and advised saline cathartics. 

Friday morning, July 27th, tem- 
perature was 100 1-2°, pulse 112. 
During the night she had a severe 
chill, and the bowels had moved 
freely ; pain was greatly relieved, but 
there was much tenderness in the 
right iliac region. 



I was asked to see her in consulta- 
tion with Dr. Blott at 10 P. M., July 
27th. I found her with a temperature 
of 102 1-2°, pulse 120 ; face flushed 
and somewhat restless. Upon exami- 
nation I detected a. fluctuating tumor 
in the right ileac region, but a little 
above the McBumey point, which 
was extremely painful when touched. 
Examination per rectum was negative. 
I confirmed Dr. Blott's diagnosis, and 
advised immediate operation. The 
parents were anxious to wait until the 
next morning, but I insisted upon do- 
ing it at once, telling them that the 
case was desperate, and that only im- 
mediate action would give her any 
chance of recovery. She was at once 
sent to the hospital, and at midnight, 
assisted by Drs. Zimmerman and 
Booth, and in the presence of the staff, 
I made an incision over the tumor, 
running obliquely downwards and for- 
wards, and removed nearly a quart of 
pus. Unfortimately I opened the 
peritoneal cavity, which I hurriedly 
packed, in order to prevent the escape 
of pus into the cavity. Upon exami- 
ning the pus cavity I found a long 
gangrenous appendix, which was de- 
tached and removed by irrigation. 
Upon further examination a large 
gangrenous mass was found upon the 
posterior surface of the cecum. After 
again washing the cavity, a drainage 
tube was inserted, and the cavity 
packed with iodoform gauze. The 
patient was put in bed very much 
shocked, with a pulse of 160. Ex- 
ternal heat was applied, and hypo- 
dermics of strychnia grain 1-20 and 
digitalin grain 1-100 were ordered to 
be given every two hours. 



Digitized by 



Google 



92 



G. S. PECK. 



My prognosis given to the parents 
immediately after the operation was 
unfavorable. July 28th, 8 A, M., 
temperature 102°, pulse 120 ; 7p. m., 
temperature 101 4-5^ pulse 120. 
During the day the pulse was imper- 
ceptible at times. About 18 hours 
after operation she seemed to rally 
from the shock and the hypodermics 
were discontinued. 

July 29th, 8 A. m., temperature 
101 4-5°, pulse 120 ; 7 P. M., tempera- 
ture 102 1-3°, pulse 150 ; she had a 
very comfortable night, but a 7 A. M. 
became delirious, and remained so 
until her death from septic peritionitis, 
at 5 p. M., July 30th, sixty-five hours 
after the operation. 

At the autopsy by Mr. Lichty, four 
hours after death, we found extensive 
recent adhesions throughout the peri- 
toneal cavity, and old, firm adhesions 
in the right ileac region. Around the 
incision quite an amount of inflamma- 
tory material was thrown out, beauti- 
fully illustrating nature's attempt , to 
protect the peritoneal cavity. The 
omentum was bound down by recent 
adhesions, especially in the right iliac 
region. On the posterior surface of 
the cecum there was a large gangren- 
ous patch. The pelvic cavity con- 
tained from four to six drachms of 
free pus. I must confess that the 
opening into the abdominal cavity was 
particularly unfortunate to the patient 
and, although I made every effort to 
prevent pus entering the cavity, I was 
not successful. But if my patient 
had not died from septic peritonitis I 
think the gangrenous patch in the 
cecum would undoubtedly have pro- 
duced death. 



CASE NO. V. 

Perforating Appendicitis. - — Opera- 
tion during the third day. Death 
from septic peritonitis in twenty-seven 
hours. 

L. L., aged 33, a large muscular 
man, weighing 220 pounds; occupa- 
tion druggist and postmaster of Girard, 
Ohio. With the exception of a slight 
headache he was in his usual good 
health Sunday, August 26, 1894. 
While attending his duties, about 10 
A. M. Monday, August 27th, he com- 
plained of pain in the abdomen, which 
he attributed to some fruit eaten during 
the morning. The pain becoming 
more severe and the stomach irritable, 
he, druggist-like, took a large dose of 
some cholera mixture. Not obtaining 
the necessary relief, he resorted to a 
large dose of chlorodyne. At 4 P. M. 
the pain was very severe and located 
in the right ileac region. Dr. Brooks, 
of Girard, was called. Dovers powd- 
ers, 10 grains every four hours, and 
hot applications, were ordered. 

Tuesday, August 28tli, passed a very 
restless night, vomited several times^ 
pains increasing in severity. The 
physician was again called at 3 A. M..^ 
temperature 102 4-5°, pulse 96. He 
ordered phenacetine, 6 grains, quinia 
sulph., 2 grains, every four hours. Had 
a fairly comfortable day until 5 P. M.» 
when suddenly the pain in the right 
iliac region became intensified. A 
hypodermic morph. sulph., grain 1-4, 
was given, hot applications continued 
and an enema of hot water given 
without effect. 

Wednesday, August 29th, slight 
delirium during the night, tongue red 
and dry. While quiet in one position 



Digitized by 



Google 



FOUR CASES OF APPENDICITIS. 



93 



pain not so severe. A second enema 
was given and a small amount of fecal 
matter came away. Patient was more 
restless, and delirium more marked. 
I saw him in consultation with Dr. 
Brooks at 8 P. M. Wednesday, Au- 
gust 29, temperature 99 1-5°, pulse 
116, expression anxious, tongue dry 
respiration somewhat accelerated and 
some slight delirium. Upon exami- 
nation I found a moderately flat abdo- 
men on left side, some fullness and 
exquisite tenderness on the right, 
especially marked at the McBurney 
point. I diagnosed appendicitis and ad- 
Tised an immediate operation. I told 
the friends I feared perforation, and 
if such was the case my prognosis 
would not be favorably. He was at 
once moved to the city hospital. At 
midnight (Wednesday, August 29), 
assisted by Drs. Zimmerman and 
Welsh, I made the usual oblique in- 
•cision, and removed the appendix, 
which was found situated at the outer 
side of the meso-cecum and meso 
colon. It was intra-peritoneal, and 
had a mesentery of its own about 
three inches long. It was very 
much inflamed, enlarged, and perfor- 
ated about midway between the ceca- 
and distal end, containing a fair-sized 
fecal concretion near its proximal end, 
and at its distal end, pus. A cavity 
•containing about four ounces of pus 
was opened. The cecum was dark in 
spots presenting the appearance of 
early gangrene. The vitality being 
«o poor I was unable to invaginate the 
«tump. 

After a thorough irrigation of the 
general peritoneal and pus cavity, I 
passed a rubber drainage tube down 



to the stump of the appendix, and 
packed the incision with iodoform 
gauze. Pulse after operation 116. 

Thursday, August 30th, 8 a. m., 
temperature 99 2-5°, pulse 116. 
Vomited about an ounce of dark- 
colored material. Tongue, dark- 
brown and dry. Delirium increasing, 
and abdomen tympanitic. Vomited 
dark-colored material at 3.30 p. M. 
At 4 p. M., an enema with rectal tube 
was given; no results. At 5 p. u, 
vomited bilious material. At 6.15 
vomited dark-colored material. At 6 
P. M. ordered a glycerine enema. 
Small movement, and passed some 
flatus. Eight P. m., temperature 
100 2-5°, pulse 128, very restless and 
delirium continuous. I advised re- 
opening, and asked for consultation, 
and Dr. C. B. King, of Pittsburgh, 
was called. 

At 2 A. M., August 31st, Dr. King 
saw him in consultation, and at 2.30 
A. M. the patient was again etherized 
and the incision reopened. Not being 
able to reach the obstruction, we were 
obliged to make a median incision. 
A band of recent adhesions was foimd, 
producing a complete obstruction of 
ileum.. This was soon liberated and 
flatus passed freely into the collapsed 
small intestines. The abdominal 
cavity was thoroughly irrigated with 
distilled water. While placing a 
drainage tube, with my two fingers, in 
the hollow of the sacrum a* a guide, a 
pus sac was discovered deep in the 
pelvis in the recto-vesical pouch, con- 
taining fully a pint of pus, which had a 
distinctly garlic odor. The cavity 
was again irrigated, a drainage tube 
placed in position and the incision 



Digitized by 



Google 



94 



MARCUS ROSENWASSER. 



closed with silk-worm gut. The first 
incision was packed with iodoform 
gauze. The shock was too much for 
the patient, and he died at 3.30 A. M., 
Aiigust 31st, twenty-seven hours after 
the first operation. 

Autopsy immediately after death 
revealed an extensive peritonitis, the 
omentimi being adherent to the cecum. 
The obstinictive band in the ileum was 
found to be twenty inches above the 
ileo-cecal valve. The ileum was dark 
and gangrenous six inches immediately 
below the seat of obstruction, and 



gangrenous in spots from thence on to 
the ileo-cecal valve. The cecum was 
dark, inflamed, and with thickened 
coatings. The sutures at the stiunp 
and in the peritoneum were fovmd in 
good condition. No extra peritoneal 
pus cavity could be found, and there 
was no evidence of any remaining pus, 
either extra or intrar-peritoneal in the 
right ileac region. After a very 
thorough search, we were unable to 
find the pus sac, ruptured while plac- 
ing the drainage tube in position. 



Supplementary Paper on Abdominal Section in Intra-pelvic Haemorrhage.* 



HY MARCUS ROSENWASSER, 

CLEVELAND* O. 



The implied disapproval and the 
fear lest it be a step backward, ex- 
pressed by a number of the Fellows 
who kindly discussed my paper at our 
last meeting at Detroit, are my apol- 
ogy for again bringing this subject 
before you. I ventured an argimient 
against the dogma " When you find 
an extra-uterine, early or late, remove 
it." I attempted to prove that vig- 
ilant delay imder definite limitations 
was more safe than immediate opera- 
tion and was based on authority 
" more positive than the vaporings of 
fancy." Experience with a limited 
number of additional cases has served 
to strengthen my conviction that the 

IKead before the Amer. Assoc, of Obstetricians 
and fiyn8ec<»loirist8 at Toronto, Ont , Sept. 21, 1894. 
The fiirmer paper was published in the Annals of 
Gynsecology and Psediatry. Vol. VI., p. 162, Aug., 
1893. 



position advocated is one in advance, 
and not backward. 

My plea for vigilant delay at oAso- 
lute rest in circumscribed hcemorrhage 
is based on the fact that there is no 
immediate danger, and that active 
surgical interference is proper only 
for definite indications, or when vig- 
ilance and rest are not practicable. 
At the time of my writing I was not 
aware of the demand for these indica- 
tions made by Prof. R. H. Fitz in his 
annual oration before the Medical and 
Chirurgical Facidty of Maryland.* 
Permit me to quote : " It seems, 
therefore, not unprofitable to consider 
the subject of intra-peritoneal hsem- 
orrhage from a general point of view. 



• " Intra-peritoneal Hsemorrhage.*' 
Med. Journal, Jane 17, 1893. 



Maryland 



Digitized by 



Google 



INTRA-PELVIC HEMORRHAGE. 



95 



especially bearing in mind the exper- 
ience of the past, with the hope that 
the indications for its medical treat- 
ment may be made conspicuous and 
the existence of limitation for its 
surgical treatment be emphasized." 

In the past fifteen months I have 
met with nine cases of intra-pelvic 
haemorrhage. There is no stronger 
proof of the inefiicient teaching of the 
past and of the necessity of further 
missionary work on our part than the 
fact that the diagnosis was not made 
in a single instance — barely sus- 
pected in two. Two* of the nine 
were due to free haemorrhage and 
were operated without unecessary de- 
lay. The accompanying table is lim- 
ited to the seven cases of circum- 
scribed haemorrhage, and is arranged 
to correspond with that published 
last year. 

I did not see case one during the 
attack, which had taken place eight- 
teen years before, but T found the 
encysted skeletal remnants while oper- 
ating for ovarian cystoma. In case 
two the mass was absorbed in two 
months and the patient has continued 
well since. After resting in bed three 
months, case three was allowed to 
leave the hospital, a mass of the size 
of an orange still remaining. She 
has attended to her household duties 
all summer, but recently there is more 
tumor and some pain. The necessity 
for operation may yet arise. I do not 
consider her well. Cases four and 
five were in hospital ten weeks and 
three weeks, respectively, before oper- 
ation ; the latter was not in my care. 
In cases six and seven there was no 

•Cleyeland Med. Gar^ette, Feb. and Sept., 1894. 



delay, because the indication for inter- 
ference was imperative when first 
seen. The last four cases, therefore, 
were operated for cause with or with- 
out delay. The causes were : Growth 
of tumor, two, recurrent haemorr- 
hage, two. There were two deaths 
after operation. Case five, in wliich 
the writer assisted, died of shock. 
Case seven was having active, recur- 
rent bleeding for three days with 
failing pulse, when first seen ; she was 
operated at once, but died septic. 

I have here described imvarnished 
facts that we, as specialists, cannot 
ignore. Our ideal is early recogni- 
tion and early operation — before the 
loss of blood has proved fatal, before 
dangerous adhesions have formed, be- 
fore sepsis has set in, and while the 
operation is comparatively simple and 
safe. But when the case has con- 
tinued for some time unrecognized, 
when a tumor has formed, and ad- 
hesions have become organized, the 
possibility of absorption is so great 
that it ought not be discarded. 
The operation, on the other hand, has 
become proportionately more difficult 
and dangerous, and ought not be done 
except for cause. We are confronted 
by two factors, the average practi- 
tioner and the average operator. To 
the former the symptoms of intra- 
pelvic haemorrhage must be made so 
plain that its early diagnosis will be 
as assured as that of any other com- 
mon disease. To the latter the indi- 
cations for surgical interference must 
be so clear cut that he can distinguish 
between cases that require immediate 
operation and those that can bear 
vigilant delay, with reasonable hope 



Digitized by 



Google 



-96 



MARCUS ROSENWASSER. 



of ultimate recovery without opera- 
tion. 

In three of the cases reported it 
was impossible to remove the sac 
entire on account of numerous dense 
intestinal adhesions. These consti- 
tute the chief element of danger. The 
attempt to enucleate the sac is often 
followed by serious lesions, or even 
death. T have elsewhere* advocated 
non-interference with such adhesions. 
It is better to incise the sac, evacuate 
the contents, stitch edge of incised 
sac to parietal wall and drain. The 
question whether it woidd not be 
more safe to operate by vaginal in- 
cision when the tumor bulges into the 
vagina, and thus avoid interfering 
with the adhesions above is still an 
open one. In a careful study of the 
literature and statistics,! I found the 
advantage in favor of abdominal sec- 
tion to be but a fraction of one per cent. 

Thesq additional cases serve to 
corroborate : 



* *' A contribution to the Technique of Intra-llga- 
mentary Operations.*' Annals of GynsBcology, 
March, 1881. 

t " Comparative merits of Abdominal Section and 
Vaginal incision in Extra-peritoneal Hematocele.'* 
^Annals of Gynaecology, September, 1890. 



1. The ease of recognizing intra- 
pelvic hemorrhage. 

2. The feasibility of distinguish- 
ing between urgent cases requiring 
immediate operation, and cases that 
can safely bear vigilant delay until 
their recovery, or until some definite 
indication demands operative inter- 
ference. 

3. The danger attending the oper- 
ation ; and, consequently, 

4. The propriety of crying "halt" 
to the furore for indiscriminate cut- 
ting for every blood clot to be felt in 
the pelvis. 

If I were to amend the conclusions 
arrived at in my former paper, 
namely : To operate in all cases of 
unruptured tubal pregnancy ; in all 
cases of free haemorrhage ; in circum- 
scribed hemorrhage complicated by 
recurrence, or by suppuration, or 
growth of foetus, or interference of 
vital functions by pressure, I would 
add novrahsorption as a possible final 
indication. 
722 Woodland avenue. 



Digitized by 



Google 



INTRA-PELVIC HAEMORRHAGE. 



97 



m 

O 

I 

M 
o 



Q 
S 

o 
o 



o 

m 

o 






^^^ a^QjijaviH 



i 






'jcoixrandO 



^ o a « c 

c « 4^ t-HB^: 

J a c § e 

e Jl ^ » A 






^2« 






c*«g 



s? 



"^■■i^ fc_l 
** *J el * "1 

? — 1 6 o 






IH. 






-^oi:&<s?^ 









I 



c1 



111 









1_ 

|5«1 



IS BB a Q -^ 



^ ^ "* t:^*: i 









^1 J*,— s— * 









^ > - S - § 
EC _ 



£ d e ffi 
F » - ■y 



Hill 

■< 









X^i 






« r 2 

S ^ d Bi 

£ ii. E W 






i. i ; = « ^ 



S-5 



1-^ 



3P. 



a£? 



5^ 
5*- 









wflvaTuia «o -oac 



-guy 






mm^sgMUK. 






£ = = * 

1^ {« ^ OD 



\ g^ 






1 Si 



-3^ 



m _ 



Digitized by 



Google 



98 



MARCUS ROSENWASSER. 





m 






« 






" s . 


^ q i=i.c o 


m 
ic 




ill'! 


g 


*g5g 


■S£*S^5 


fi< 


■3025 


stf -SH-g 




=^lw § 










S.aSi 




Is!-* 


Is*? 


*<raxHo^ 


•r« - 




-SH XHXHJiaraqa 




§ 


& 






>> 


ja 


S 


1 


1 


xsYxna 




Si" 

llgi 
^11 


JO Moixvaaa 




ei 


ei 


-MoiXTirado 


S 


^ 

s 




^ 


^ 




SBSs 


•^**i . 


'KOIXYVXdO 


©•85 


aoJ MOIXYOIOKI 


S»8| 




^i-ifl h 




nil 

11 2 is 




ii 


lal-JSf 










1^ 




2t ! 

15 1 


^5 


•* 


i 


'KXvaiiHD JO ox 


i 


u 






^ 


s. 


•aov 


^ 


a 




Hi 


aodsS 

S|=5d 


< 


qCOS 


qO;;)"^ 




'HaHK.l^ 


** 


t- 



Digitized by 



Google 



HYDROSALPINX. 



99 



Hydrosalpinx/ 

BY A. H. CORDIEK, M. D., 

Lecturer on Abdominal Surgery^ Kansas City Medical College, 

KANSAS OITT, MO. 



To the illustrious membera of this 
great society a discussion of the pa- 
thology and treatment of hydrosalpinx 
will doubtless seem a work of super- 
erogation on the part of the essayist. 
Many prominent writers and opera- 
tors, who, from sentiment or desire to 
make a '* grand-stand " play, are writ- 
ing and talking along this line, in 
tones of so-called conservatism, but are 
operating as usual in many instances. 
Their utterances have engendered a 
retrogressive tendency on the part of 
many lesser lights over the land, and 
a marked increase of mortality from 
subsequent operative procedures will 
be noticed as a result of the complica- 
tions arising in close and distant 
organs as a sequence of procrastination 
and tinkering. 

A desire to assist in correcting these 
false ideas, and to establish the truth, 
has prompted me to write this short 
paper, giving my personal observation 
and experience with cases of hydro- 
salpinx. 

I am fully aware that this, above all 
other diseased conditions of the Fallo- 
pian tubes, has been the one that 
many gynecic surgeons have looked 
upon as the least hazardous to life, but 
when one views the history of a case 
of hydrosalpinx from its inception, it 
will be found, in the majority of in- 

1. Read before the American Aesocfation of Ob- 
stetricians and Oynseoologists, at Toronto, Ont., 
Sept. 20tb, 18M. 



stances, to be that of some old hiflam- 
matory disease (pyosalpinx often) as 
a predecessor, and the case presents 
itself as an offspring of a virulent dis- 
ease, the ravages of which have left 
permanent and irreparable injury to 
the delicate structure of the tube, and 
with no microscopical appearances of 
the affected oi^an or its contents to 
indicate whether or no the transition 
from a virulent to an innocent condi- 
tion has been compfete. 

That a true dropsical condition of 
the tube is occasionally found no one 
will doubt, but such a find is, in the 
great majority of instances, in the na^ 
ture of a surprise at the time of the op- 
eration, and not diagnosed beforehand* 

Nosologically, it would be incorrect 
to classify hydrosalpinx as retention 
cysts. The surgeon sees these cases^ 
as a rule, as a sequela of some well 
marked pathological condition, and 
the fluid found in them is not the 
normal fluid secreted by the glands in 
the tube, as is the case in ranula, 
pancreatic cysts, etc., but the remains, 
often, of a fluid changed from a puru- 
lent to a watery by the death or dis- 
appearance of the septic micro-organ- 
isms, primarily the stailers of the dis- 
eased condition of the tubes. 

The Fallopian tubes are ova-bearing 
canals. Some authors claim that a 
menstnial fluid is thrown off by the 
tubes. 



Digitized by VjOOQ IC 



100 



A. H. CORDIER. 



I do not believe that all cases of 
hydrosalpinx originate as a result 
of a suppurative disease of the tubes, 
and the mild cases, those presenting 
few severe symptoms during their 
long period of existence, and few ad- 
hesive bands and little injury to the 
ovaries, are cases that probably have 
their origin in a catarrhal salpingitis 
or a subinvolution of the tube follow- 
ing a septic " getting up " after a full 
term labor, or a miscarriage. These 
cases are rarely diagnosed prior to 
operation, hence the fallacy of any one 
advising catheterization as a relief or 
cure. 

I have noticed that in examining a 
thin-walled tube filled with a watery 
fluid, the sensation to the examining 
finger was that of a large varicocele 
in the male, a squirrel-gut feel, with 
less resistance and pain than that 
noticed and produced in examining 
pus-filled tubes, but a positive 
diagnosis can not be made from these 
alone. The adhesions, as a rule, are 
less firm, and the uterus more move- 
able than in pyosalpinx, but it must 
be remembered just here that we 
never see an acute hydrosalpinx. 

In two of my cases the beginning 
of the symptoms have dated back to 
a childbirth, followed by a poor 
" getting up " and subsequent steril- 
ity. In both the tubes were sealed 
at abdominal and uterine ostia. 

In none of my causes are the women 
unmarried, and all are mothers of one 
or more children, but in not a single 
case where symptoms of diseased tubes 
had existed any length of time, had 
conception taken place after the de- 
velopmeu;^ ,i^f45i4i3;ltiC)ns of tubal dis- 



ease. In most of the cases this 
period of sterility had extended over 
a period of several years. 

Occasional gushes of a watery dis- 
charge from the vagina have been 
mentioned by some writers as a diag- 
nostic evidence of the presence of a 
hydrosalpinx. Sutton says, "there 
is no trustworthy pathological evi- 
dence that these discharges escape in- 
to the uterus by way of the Fallopian 
tubes. The discharge of watery fluid 
from the uterus in gushes is as yet 
without an explanation." I can not 
quite agree with Mr. Sutton on this 
point, as I believe that it is possible, 
and that occasionally a hydrosalpinx 
does partially empty itself into the 
uterus. , This as a method of cure is 
a problematical proposition, for even 
though a cure symptomatically, the 
tube will remain functionless, and a 
lasting symptomatic cure is hardly to 
be expected. 

The diagnosis in these cases being 
doubtful, we can not prognosticate, 
(admitting a probable cure of a case 
of hydrosalpinx by drainage through 
the uterus) in any given case, the 
outcome of any procedure that is as 
imcertain in its results as the diag- 
nosis is fallible. Nature's surgery is 
not the surgery that assists the un- 
surgical in his incomplete methods. 

A Fallopian tube filled with a 
serous fluid, no doubt, in rare in- 
stances, has ruptured, the patient was 
none the worse for the accident, and a 
symptomatic cure resulted, but how 
many surgeons of to-day would recom- 
mend rupturing these cases into the 
peritoneum as a procedure of cure? 
The mere knowledge of the possibility 



Digitized by 



Google 



HYDROSALPINX. 



101 



of a ruptui'e of these cases makes an 
operative procedure for their removal 
imperative. 

In some cases the fluid has seemed 
to be of the most innocent nature, 
while in one case I am sure that my 
patient was saved only by a thorough 
irrigation and drainage. The micro- 
scope and culture 'tubes are the only 
means of classifying the fluid in cases 
in which the microscopical appearance 
makes its character doubtful at time 
of the operation. The narrowest part 
pf the tube, the uterine end, is espe- 
cially contracted in this, as in all 
inflammatory diseases. This is due to 
the abundant muscular arrangement 
surrounding the uterine end of the 
tube during the passage throiigh the 
walls of the uterus. This anatomi- 
cal fact would in a measure seem to 
negative the probability of introducing 
a catheter into the tube from the 
uterus, and would doul^tless result in 
the closure of same after the catheter 
was removed, thus preventing per- 
manent drainage. I have endeavored 
on several occasions, with the tube in 
my hand, to intl-oduce the smallest 
probe into its calibre, but have failed 
on each occasion. I have asked some 
of the advocates of tubal catheteriza- 
tion to make similar efforts under like 
circumstances, and they, too, have 
always failed. 

I have noticed that the ovaries are 
not so often injured in these cases as 
in "the more acute suppurative proc- 
esses of the tube. They are usually 
found bound down with adhesions. 
This would seem to imply that when 
hydrosalpinx is a late stage of a 
pyosalpinx the latter must have 



been a mild foi-m of the disease. 
Such I believe to be true. The 
abdominal ostium has in every case 
been closed, and in only one speci- 
men did I find the fimbriae attached 
to the ovary. I firmly believe that 
a tube when once closed is from that 
time on useless as an ovarbearing 
canal, let the source of the closure be 
what it may. I have in one speci- 
men noticed two or more strictures in 
the tube, all being due to cicatricial 
bands on outside of the tube acting as 
a compressing agent, as is so often 
the case in intestinal strictures from 
like causes, differing from the strict- 
ures usually ^foimd in pus-laden tubes, 
where the narrowing is due to inflam- 
matory new products within the tubal 
walls. I have seen a specimen that 
measured twelve inches in length, and 
with walls so thick and vascular that 
at first suggested the idea that a coil 
of bowel was being ligated and re- 
moved. This rare specimen of a 
hydrosalpinx was in a young married 
woman from whom a large parovarian 
cyst was removed, the tube encircling 
the growth two thirds of its circum- 
ference. This specimen, unfortu- 
nately, was lost. 

Hydrosalpinx has been a complica- 
tion of uterine fibroids in two or three 
of my abdominal hysterectomies. Pus- 
filled tubes have also been noticed a 
nimiber of times as complications of 
these neoplasms. Many writers as_ 
sert that the disease is unilateral, but 
in all of my cases both tubes have 
been affected. In one case I found a 
pyosalpinx on one side, and a hydro- 
salpinx on the other. 

Simple catarrh of the tubes run- 



Digitized by 



Google 



102 



A. H. CORDIER. 



ning a short mild course, may not 
seal the tubal ostia, and in such cases 
a cure is the rule, but where the in- 
flammatory process is so severe and 
persistent as to close these openings, 
a permanent damage is wrought, and 
nature is not, as a rule, a competent 
surgical guardian to look after and 
remove the pathology. 

Several cases have been reported 
where death took place as a result of 
a twisted pedicle and strangulation of 
a tube filled with a watery fluid. If 
the theory that the mucus membranes 
of the tubes bleed monthly is true, 
this makes the removal of a distended 
tube imperative, for with closed ends, 
thinned walls and filled with fluid of 
a doubtful character, with the likeli- 
hood of a rupture from a rapid 
menstrual distention, there are dangers 
of a serious nature, and to be averted 
only by the removal of the tube. A 
fatal haemorrhage may occur as a se- 
quence to a rupture of a hydrosalpinx, 
a condition often stimulating a rupt- 
ured tubal pi-egnancy, both in its con- 
stitutional manifestations and local 
physical signs on examination. I have 
in the last year had two such cases in 
my practice. In one of the cases I 
diagnosed, before operating, extra- 
uterine pregnancy with rupture. She 
was in collapse from intra-peritoneal 
haemon'hage at my first visit. She 
was 29 years old, youngest child six 
yeai"8 old, menstrual history one of ir- 
regularity for last three months. 



sudden severe pain in region of left 
tube, followed by symptoms of internal 
bleeding. Operation revealed a belly 
full of blood and a ruptured tube near 
its distal end. The tube was very 
thin, and its inner walls perfectly 
smooth, with no evidence of placental 
attachments at a single point ; calibre 
large enough to admit two fingers. 
Abdominal ostium completely closed. 
The pathology in this case demon- 
strated two truths : First, that all 
haemorrhages into the peritoneum, of 
an alarming character, taking place 
from a ruptured Fallopian tube, are 
not of necessity of extra-uterine pr^- 
nancy origin ; and, second, that a dis- 
tended Fallopian tube filled with any 
fluid may rupture from any rapid dis- 
tention, and cause death either from a 
septic peritonitis or from loss of blood. 
In one case the uterine extremity 
of the tube was largely dilated and 
filled with a clear fluid, while in the 
ampulla there existed a collection of 
pus separated from the clear fluid by 
a complete and closed structure. This 
state of affairs may exist in any case, 
and a knowledge of this fact should 
admonish all to lay aside the vaginal 
vault trocar and tubal catheters and 
do surgery. Any procedure that ap- 
proaches the surgical, if not done in a 
surgical manner, will bring disap- 
pointment and disaster to both the 
patient and the doctor. Incomplete . 
work is always unsatisfactory to all 
parties concerned. 



Digitized by 



Google 



CLAMP FOR THE OBSTETRIC FORCEPS. 



108 



A Clamp for the Obstetric Forceps. 



BY HUGH H. HAMILTON, M. D., ENGLISH-SPEAKING SECRETARY OF THE PAN- 
AMERICAN MEDICAL CONGRESS, 
Harrlsbnrgb, Penn. 



The success attending the use of 
the Tamier forceps in accommodating 
itself to the curves of the obstetric 
canal is the result of two facts : 

Fir^ft^ the fixing of the blad(»s so 
they do not slij). 

Serond^ the double line of traction. 




Evei^" one using the forceps knows 
that at least one-half, if not more, 
strength is necessary^ to grasp the 
handles firmly enough to prevent them 
slipping ^w-hen pulling. 

NoTur the Tamier fulfills this con- 
dition of fixedness, but all have not 



Tamier's forceps, but many Hodge's, 
Wallace's, etc., etc. This little clamp 
accommodates itself to any forceps. 
If moved and fixed toward the handles 
it can be made to compress the head 
so as to deliver in slightly narrow 
pelves. It relieves the hand from 
prolonged (franp. Most hands are ir- 
regular in their tena<?ity and tire — 
of coui*se one must use judgment and 
not compress a head to death. This 
is not for crushing. 

Should one desire to apply to his 
forceps the Reynold's hooks, he has a 
Tamier to all intents and purposes. 
A long forceps is the most desirable. 
A short forceps is sometimes very 
short. 

This clamp weighs (it may be made 
a little light) 45 grammes, 3 ounces, 
measures 85x80 cm.; 3 1-2x1 1-4 
inches. 

It is upon the principle of the 
" gun-spring vise " furnished with the 
rifles in the war of 1861. 



Digitized by 



Google 



104 



SOCIETY PROCEEDINGS. 



SOCIETY PROCEEDINGS. 



Proceedings of the American Association of Obstetricians and Gynaecolo- 
gists. 

(CONTINUED FROM OCTOBER NUMBER.) 



Dr. E. W. CusHiNG, of Boston : I 
think there is one point in the paper 
to which exception can be taken. I 
understand the essayist to refer to 
sexual immorality as being an in- 
creasing factor of our civilization, and 
that diflScult labors were largely re- 
sults of it. A hundred years ago 
there was more sexual immorality 
than there is now. I do not think 
the statement should go out from this 
Aissociation that where a woman has 
a diflScult labor it is probably owing * 
to previous sexual immorality. The 
woman who has diflBculty in labor is 
the one who is too much civilized, so to 
speak, where the sexual development 
has been stunted, and she gets a nar- 
row, long cervix which splits, an ante- 
flexed uterus which does not properly 
take care of itself. It seems to me our 
women are reforming themselves in 
their mode of living, but that the 
profession is not keeping up with 
them in regard to taking care of them. 

Dr. William P. Jones, of Roch- 
ester, N. Y., wished to object to 
considering a pregnant woman as be- 
in a pathological state, and to what 
he understood was the author's true 
idea, that a woman having become 
pregnant should thereafter frequently 
seek advice and an examination. The 
examination of the urine was all right, 
but unless there was haemorrhage, al- 
buminuria, or something else to indi- 
cate a pathological condition, he be- 
lieves a great deal of harm will be 
done if the woman is not let alone. 
If the physician upsets her, he does 



worse than the old women referred to 
by Dr. Price, because the doctor has 
more influence upon his patient. He 
was still engaged in general practice, 
and if all those women who came to 
him to engage his services in labor 
were required to submit to an occa- 
sional examination, he is afraid he 
would have calls from their husbands. 

Dr. Longyear: I will say that 
the majority of deaths I have seen 
from albuminuria incidental to labor 
have not been attended with eclamp- 
sia. We look for eclampsia, but they 
do not always die from it. They 
oftener die from uremic poisoning 
without convulsions. In some cases, 
there has not been a sign of convul- 
sion. 

Dr. Dewees, in closing, desired it 
to be understood that in his paper he 
stated that the beauty of our women 
was on the increase rather than de- 
creasing. 



INFLAMMATORY DISEASE OF THE UT- 
ERUS AND APPENDAGES AND OF 
THE PELVIC PERITONEUM. (AB« 
STRACT.) I. INTRODUCTORY RE- 
MARKS. BY WILLIAM WARREN 
PORTER, M. D., BUFFALO, N. Y. 

What I shall have to say will be 
of a general character, leaving the 
several special branches of the subject 
to be presented by the referees whose 
names appear under the respective 
headings. 

In the writings of Bemutz and 
Goupil, about 1860, was the first 



Digitized by 



Google 



SOCIETY PROCEEDINCiS. 



105 



challenge that ihe old pathology, 
described by M. Nonat under the 
head of periuterine phelgmon, had 
received. But it was strange that 
the profession was so slow to accept 
a pathology based on such sound 
anatomical principles as was that of 
Bemutz. 

But it was not until Mr. Tait, 
some ten or twelve years ago, began 
to publish his views, that the doctrine 
of pelvic cellulitis was first weakened, 
then overthrown, and finally periand 
parametritis were driven out of the 
pathological vocabulary of modem 
abdominal surgeons. 

Let me further remind you in this 
connection that in 1843 Bennett as- 
serted that inflammation of the cer- 
vical canal was the cause, for the 
most part, of the diseases of woman. 
He declared that from cervicitis came 
ulceration, displacements, leucorrhoea, 
menstrual derangements, and even 
ovarian disorders ; and he further 
asserted that by the application of 
strong caustics to the offending os 
and cervix all these could be cured. 
Strange how quick such an absurd 
doctrine was accepted and how imi- 
versely it was taught I For ten years 
this dogma ran riot until Sims ar- 
rested its mad career by addressing 
himself to repairing the damage caus- 
tics had done by teaching the useless- 
ness and danger of such treatment. 

In the early seventies Emmet be- 
gan to announce the doctrine of 
pelvic cellulitis, and it was not long 
before almost all sexual diseases of 
women were diagnosticated as pelvic 
cellulitis as cause or effect, and treat- 
ment addressed to the relief of inflam- 
mation of the pelvic connective tissue 
was about the total of gynaecologickl 
work. 

To-day we know that it is impossi- 
ble to separate the inflammation of 
serous and cellular tissues in the pel- 
vis either clinically or histologically ; 
that pelvic cellulitis is a very rare 



condition; and that pelvic inflamma- 
tion is in almost every instance peri- 
tonitis caused by disease of the ovaries 
or tubes, or both. We know, too, 
that a frequently recurrent pelvic 
peritonitis is strongly suggestive of 
leaky tubes. 

The newer pathology under which 
we are working to-day further teaches 
us that pus originating outside of the 
tubes or ovaries in the non-puerperal 
state is a very rare condition ; that is 
to say, pelvic abscesses are, speaking 
generally, pus tubes. 

By far the largest number of 
women in our consulting rooms to-day 
are those suffering from pelvic inflam- 
mation in some form, in either its 
primary or secondary stages, and who 
justly demand relief from an acute 
attack or expect a cure from the resi- 
dues that are mercilessly ravishing 
their pelves. Tumors, cystic or solid, 
malignant growths, tubercular disease 
and the like, that constitute grave and 
undisputed reasons for surgical relief, 
though observed with a surpassing 
frequency, are in smaU minority as 
compared with the myriads who suffer 
from inflanmiatory diseases of tubes, 
ovaries, and pelvic peritoneum. 

Within the past seven or eight 
years, however, a greater uniformity 
of opinion on this subject has prevailed 
among physicians who may be classi- 
fied as weU informed. They are 
agreed that in all pus cases — and 
these constitute the majority — ex- 
cision and drainage should be the rule ; 
that leaky tubes causing recurrent 
pelvic peritonitis should be removed ; 
that tentative measures are of little 
avail and are only to be employed 
where radical methods cannot be in- 
voked ; and especially that electricity 
not only does not cure but is capable 
of doing positive harm. 

Under this increasingly satisfactory 
state of imiformity of opinion many 
women have been cured who other- 
wise would have been lost to the corn- 



Digitized by 



Google 



106 



SOCIETY PROCEEDINGS. 



munity either in death or chronic 
invalidism. 

Hardly have we become settled 
down to a policy that is yielding the 
largest measure of favorable results 
when there comes a mandate from un- 
expected sources, like a thunderbolt 
out of a clear sky, crying : ••^ Halt ! " 
"Cease your radical, even though 
they be curative, measures, and adopt 
conservatism in the management of 
these conditions." 

The application of the word con- 
servative in this relation is so mislead- 
ing that mucli harm comes from its 
use. Every gynaecologist and abdom- 
inal surgeon believes in true conser- 
vatism. We all believe that every 
organ in the body should be preserved 
when it can be done without a menace 
to health or life. We believe in re- 
sorting to the knife only after it 
becomes apparent that through the 
knife lies the surest, safest, and 
quickest avenue to restored health. 

When, therefore, men talk about 
tinkering with diseased organs that 
ure rendered useless for procreation or 
utterly destroyed in function and 
structure, menacing health and life in 
their progressively destructive disease, 
it cannot be called properly conser- 
vatism. To asseverate that such cases 
can be restored to health through the 
employment of rest, massage, electric- 
ity, a general building-up of the whole 
system, and by topical treatment, is 
to presume upon the credulity of the 
poor patients, but it scarcely will con- 
vince an enlightened and wary pro- 
fession. 

In the majority of women suffering 
from these inflammations or their 
sequelae there is inability to meet the 
financial demands of a residence of six 
months or a year in a fashionable 
private hospital. This kind of con- 
servatism is an expensive toy that the 
wealthy may play with, because their 
very wealth accords them privileges 
that perforce must be denied the poor. 



The woman who earns her bread in 
the sweat of her face demands the 
highest exercise of that skilful con- 
servatism which, through the most 
perfect surgery, may give her the 
quickest restoration to health by the 
removal of organs that are not only 
themselves already destroyed, but 
which in a progressive destructiveness 
are invading neighboring tissues and 
threatening even life itself. 

Another very plausible argument 
that the so-called conservative gentle- 
men are advancing is that in doing 
operations on the pelvic organs women 
are being unsexed. It is stated that 
not only does sterility follow the com- 
plete extirpation of the uterine ap- 
pendages, but that the woman also 
loses all sexual desire. Were this 
latter absolutely true — which is not, 
however, the case — it would hardly 
be a tenable argument. But when- 
ever extirpation becomes necessary, it 
is for diseased conditions that have 
already caused sterility and obliterated 
sexual desire. 

But there is another side to this 
question that is fraught with serious 
import and that is productive of great 
harm. I have observed, and so, I 
doubt not, has every one here present, 
the medical journals throughout the 
country are taking up this so-called 
conservative treatment, reprinting its 
plausible literature and commenting 
favorably upon it m their editorial 
columns. It is a fetching phrase, and 
the argument is so taking in its 
method as to win favor with the mul- 
titude. Many physicians, especially 
the younger ones who do not look be- 
neath the surface or fail to compre- 
hend the motives of these men, accept 
their teachings and promulgate their 
dangerous doctrines to their clients on 
every and all occasions. 

The result of all this it is not diffi- 
cult to comprehend. Deserving 
women who need surgical operations 
for their cure are frightened away 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



107 



from the operating rooms of skilful 
surgeons, hence are prevented from 
obtaining relief, and thus go on from 
bad to worse until the end. 

Now, must we go all over the argu- 
ment again m view of these so-called 
conservative doctrines that are being 
preached on eveiy occasion and pub- 
lished to the foui- winds ? Must the 
ground all be fought over again in 
order to let these suffering women 
understand, as they had already meco 
very largely so to do, that then- only 
safety lies in submitting themselves 
to the careful hands of skilful pelvic 
surgeons who are the true conservators 
of their health and lives ? I hope not. 

I trust that this Association will on 
this occasion so put the stamp of its 
disapproval on the clever but danger- 
ous teaching of these clever though 
dangerous men as to counteract its ill 
effects and to stem the tide of erron- 
eous, misguided, and hazardous doc- 
trines that are springing up therefrom 
in the columns of the medical press. 



n. CLINICAL HISTORY. — BY CHARLES 
A. L. REED, M. D., CINCINNATI, 
OHIO. 

We have heard this morning of the 
erroneous doctrine of Fenwick, and 
the erroneus doctrine of Bennett. 
There is a soul of truth in the doctrine 
of Bennett — namely, that nearly, 
all cases of pelvic inflammation have 
their origin at the cervix. Whether 
we shall call these cases by the term 
of endocervicitis or cervicitis, or what- 
ever you may see fit, nevertheless the 
symptomatology with which I am to 
deal — and I am warned not to tres- 
pass upon the pathological field — be- 
gins with a previous history of cervical 
leucorrhoea. Following this there is 
generally some perturbation of the 
menstrual function. Ordinarily the 
symptoms are those of unobstructed 
dysmenorrhea; yet in a number of 
cases this particular symptoip is not 



manifested. Later, however, the 
premenstrual pain occasioned by the 
periodical afflux of blood to the pelvis 
prior to the onset of the menstrual 
flow occasions an increase of distress 
which forces itself upon the conscious- 
ness of the patient. After a while 
this pain becomes localized to either 
side of the uterus. There is a heavi- 
ness, a dragginess, amounting at 
times to a shai'p and lancinating pain ; 
but after this has been experienced, 
perhaps through some months, sud- 
denly the patient feels a chill, has a- 
slight sweat, perhaps, and then she 
experiences her first medication in the 
form of quinine given for the relief of 
malaria. But this malaria is intrac- 
table. It recurs \vithout reference to 
that definite periodicity characteristic 
of the duration of malaria organisms, 
and after a period, more or less pro- 
longed, of this futile treatment, the 
patient has been subjected perhaps to 
an examination. At this time we 
come in contact with the objective 
features of the disease. Upon exami- 
nation the practitioner experiences — 
what? There is generally more or 
less tenderness to either side of the 
uterus, and there may be tumefaction. 
The patient occupying the semi-prone 
position with the thighs well flexed, 
giving every possible relaxation to the 
abdominal wall, will not even then 
permit the examiner to definitely out^ 
line the position of the ovaries and 
tubes in many of these cases, for the 
reason that there is at this time a very 
considerable amount of general pelvic 
engorgement. The leucorrhoea of 
which she has complained, and which 
comprised the prominent symptom, be- 
comes perhaps purulent and becomes 
offensive, and with the manifestation 
of this change in the uterine discharge 
there is a certain relifef of pain to 
either side of the uterus. After a 
while there is a repetition of previous 
experience, of intense degree. The 
chill comes now with unmistakable 



Digitized by 



Google 



108 



SOCIETY PROCEEDINGS. 



severity, the fever is of the most pro- 
nounced character, and then come the 
aggravating and exhausting sweats. 
This experience is again repeated 
within a short period. Then follows 
an increase of pelvic tenderness. 
Later on there will be lassitude, ex- 
haustion, and all the pronounced 
features of anemia become manifest. 
The timiefaction within the pelvis is 
now most pronounced. There is no 
repetition of this gush of purulent 
leucorrhoea. Then comes the culmi- 
nating sweat following the chill and 
the fever, and later prostration 
amounting to collapse. Then comes 
abdominal distention leading to a fatal 
infective peritonitis. 

There is another type of cases. I'he 
young married woman, or the courte- 
san, experiences a sudden discharge of 
a purulent character. She finds pelvic 
tenderness at once occupying the 
entire cavity. This increases in a few 
days until there are manifest evidences 
of progressive invasion from the cer- 
vix through the mucous tract, until 
infection reaches not only the uterus, 
the endometrium, and the lining mem- 
brance of the adjacent Fallopian 
tubes, but the peritoneum, and active 
symptoms become manifested, which 
lead to a speedy fatal result. 

We have another type of cases — 
those subjected to curettement follow- 
ing a miscarriage. The patient has 
been effectually vaccinated on the in- 
side of the uterus by curettement for 
the relief of so-called purulent endo- 
metritis. A sharp curette has been 
used, and the endometrium fairly 
well scraped, the lymph channels 
have been opened, and there has been 
invasion of them imtil we have diffuse 
tumefaction of the pelvis, not localized 
or lobulated, but that general diffuse 
tumefaction which indicates general 
invasion. This is the dangerous form 
of pelvic inflammation, and when left 
to itself results in that serious form of 
pldegmon which may give rise to the 



liberation of septic elements into the 
general circulation and a fatal sep- 
ticemia may result. 



Ur. CAUSATION AND PATHOLOGY. 
BY L. S. MCMURTHY, M.D., 

I shall use the term pelvic inflam- 
mation to embrace all those inflamma- 
tory diseases which involve the Fal- 
lopian tubes, ovaries, and pehdc peri- 
toneum. The uterus is almost invari- 
ably involved in the process, its carity 
being, as a rule, the point of departure 
of access of the inflammation. The 
inflammatory process, beginning in 
the uterine cavity, extends along 
contiguous mucous surfaces through 
the Fallopian tubes to the peritoneum, 
often destroying tissues and invading 
parenchymatous structures. The 
salpingitis, peritonitis, ovaritis, exuda- 
tion, adhesions, pyosalpinx, hemato- 
salpinx, hydrosalpinx, ovarian abscess, 
and lesions of the bowel are but result- 
ant factors in the disease, correspond- 
ing to the intensity and stage of in- , 
flammation and structures involved. 

Pelvic inflammation originates 
from septic infection, which may be 
specific or traumatic, includii^ the 
wounds of childbearing and abortion. 
Puerperal infection exceeds all other 
etiological factors, in this disease. The 
open surface left by separation and 
extrusion of the palcenta is peculi- 
arly liable to infection, as is also the 
intrauterine surface after abortion. 
The enlarged lymphatics and hyper-^ 
trophied blood vessels, torn across and 
gaping, the process of degeneration 
following the completed term of preg- 
nancy, offer a most receptive surface 
for absorbing, developing, and diffus- 
ing the slightest contamination by 
septic matter. An amount of septic 
matter will suffice to infect a woman 
under these conditions, which would 
be resisted and overcome by the nor- 
mal non-gravid uterus. Moreover, the 
retention of portions of placenta par- 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



109 



iially detached and deprived of circula- 
tion renders infection even more easily 
accomplished. There is abundant 
evidejxce that many puerperal women 
.are infected with gonorrhoea, and that 
ibath tiie puerperal and specific cause 
may coexist in the same individual. 
The conjunction of specific infection 
with the traumatism of labor has been 
termed mixed infections, 

A different class of traumatic infec- 
tions is surgical operations and manipu- 
lations upon the uterus. Such are 
the injury and contamination of 
sponge tents, of steel dialators, and 
operations upon the cervix and with- 
in the uterine cavity. The traumat- 
ism by which tissues rich lymphatic 
.distribution are exposed to infection- 
by foul discharges, and dirty instru- 
ments is often the initial step in 
severe grades of pelvic inflammation. 
It is not the traumatism per 8e which 
begets the inflammatory process ; it is 
the admission of septic material. 

When a woman becomes infected 
with gonorrhoea the vagina is at first the 
seat of specific inflammation. There 
is a continuous membrane by which 
the inflammatory process can spread 
to the peritoneal cavity, and the virus 
often traverses this entire membrane 
with amazing rapidity, producing sup- 
purative salpingitis and peritonitis in 
a brief period. As a rule, the inflam- 
mation exhibits itself in recurrent 
attacks, and the protec^ting peritonitis 
limits and encloses the infected area 
through long periods of subacute and 
chronic disease. Modem pathological 
researches have combined with the 
disclosures of modem pelvic surgery 
to demonstrate the active agency of 
gonorrhoea in the causation of pelvic 
inflammation in women. My studies 
do not lead me to concur with the 
view held by some that an attack of 
gonorrhoea is never cured. I believe 
that in numerous instances both men 
and women make perfect recoveries 
from this disease — tliat is, get well 



without extension to the membranous 
uretha and bladder in the one, and 
without invasion of the Fallopian tubes 
in the other. It is, however, a most 
serious disease in both sexes, and plays 
a conspicuous part in the causation of 
pelvic inflammation. No virus to 
which the female genital tract is 
exposed is so active and destructive 
as the gonorrhoeal. It traverses the 
mucous membrane with rapidity, in- 
vades the peritoneum, destroys tissues, 
forms sacs of pus, and often termi- 
nates fatally. 

The ovaries and Fallopian tubes 
are situated on the posterior surface 
of the broad ligaments, and the fact 
that adhesions and exudates are more 
commonly found posteriorly than 
anteriorly shows that the mode of 
invasion is by continuity of membrane 
rather than by vascular routes from 
cervix to broad ligament. Syphilitic 
ulcers of the cervix may be the cause 
of pelvic inflammation by transmit- 
ting infectious products along the 
mucous tract or lymphatic channels. 

Tubercular salpingitis deserves men- 
tion among the causes of pelvic in- 
flammation; and the eruptive fevers, 
especially scarlatina and variola, are 
believed by some to be accompanied 
by salpingitis. A sudden suppression 
of menstruation is one of the rare 
causes of pelvic inflanmiation. 

In a certain proportion of cases 
pelvic inflammation appears as a 
complication of other morbid condi- 
tions. Such are the cases wherein 
inflammatory lesions are associated 
with neoplasms of the ovaries and 
uterus. Rupture of cystic growths, 
the irritation of solid tumors from 
pressure, and obstruction of the Fal- 
lopian tubes with retention and ex- 
trusion of secretions, with hypertrophy 
of epithelial and interstitial elements, 
are conditions commonly associated 
with localized peritonitis complicating 
neoplasms of ovaries and uterus. Im- 
perfect development and malforma- 



Digitized by 



Google 



110 



SOCIETY PROCEEDINGS. 



of the uterus and appendages may 
sustain a causual relation to pelvic 
inflammation. 

At the outset there is congestion, 
followed by effusion. The effusion is 
from the surface of the mucus mem- 
brane and into the underlying con- 
nective tissue. The rapidity and 
extent of this process depend upon 
the virulence of the attack and the 
condition of the parts. The tubes 
become filled with serum, which may 
drain into the uterus or discharge 
through the fimbriated extremity into 
the peritoneum, or it may be retained 
by closure of both these openings. 
The exudation into the tissues varies, 
making the tube walls more or less 
thickened by infiltration with cells, in 
some instances penetrating the walls 
and directly involving the peritoneum. 
The tube becomes adherent to the 
uteinis and ovary, the broad ligament 
is matted down and the fimbrise 
covered over. Should Nature's ef- 
forts avail to confine the effusion by 
sealing the fimbriated extremity of 
the tube, a hydrosalpinx wOl be 
formed. In some instances the in- 
flammatory process is characterized 
by haemorrhage, forming hematosal- 
pinx. Resolution may take place later 
on, either to a complete or incomplete 
degree. If the process terminates in 
suppuration a pyosalpinx will be 
formed. Should the contents leak 
through the fimbriated opening into 
the peritoneum, whether pus has 
formed or not, active peritonitis will 
be established. This process is con- 
servative, Nature endeavoring by ad- 
hesions to shut off the general peri- 
toneum and limit the inflamed area. 
The characteristic inflammatory prod- 
ucts of a serous membrane are depos- 
ited ; later the serum may become ab- 
sorbed, and the exudate remain to un- 
dergo organization or suppurate. When 
this process is characterized by ex- 
treme virulence, tissues are infiltrated 
and destroyed by the very intensity 



of the process, the involved tissues 
being so friable as to break down 
under slight manipulation. Thi& 
process may involve not only the 
tubes but the uterus and contiguous 
portions of intestines, causing the 
uterus to slough and the walls ,of the 
intestine to give way. 

The proximity of the fimbriated 
extremity of the tube to the ovary 
involves the latter organ, and it 
becomes attached by adhesions to the 
tube. The infection is thus trans- 
mitted to the ovary, and when sup- 
puration occurs ovarian abscess is 
conjoined with pyosalpinx. Nature, 
always prolifix here in her resources^ 
throws out layer after layer of exu- 
date in her efforts to limit the sup- 
purative area, and in time an immense 
thick sac is formed, enclosing the 
abscess cavity, originating in tube and 
ovary. The breaking through this 
wall is signalized by an outbreak of 
peritonitis corresponding in gravity 
to the area invaded, or by a discharge 
from bowel or bladder, or externally 
through the abdominal wall, as the 
place of rupture may happen to occur. 
In the progress of the chronic in- 
flammatory process changes take place 
in the walls of the tube, known as 
chronic interstitial salpingitis. These 
changes consist in infiltration of the 
walls of the tubes with cells, and 
degenerative changes. When this 
advances to suppuration the walls 
become soft and cheesy. In a certain 
proportion of cases of long-standing 
inflammation, especially when char- 
acterized by repeated abscesses, the 
tubes and ovaries may be destroyed, 
leaving only vestiges of noi'mal struc- 
tures in the form of a membranous 
band. 

In acute inflamation the effusion 
may consist largely of serum with 
varying additions of lymph ; the serum 
being absorbed, the inflammatory area 
is covered with thick deposits of 
lymph. This exudate forms the ad- 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



Ill 



hesions, which may be soft or firm 
as the inflamation may be acute or 
chronic. Advancing infection may 
break down these deposits. Partially 
broken-down lymph is very commonly 
associated with acute suppurative sal- 
pingitis. The lymph may break 
down at different points, thus forming 
pockets of pus. The pockets formed 
may vary in size from the smallest to 
a universal pelvic abscess, bridged over 
above by the omentum and intestines. 
The limitation of suppurative force 
by firm organized exudate, and bur- 
rowing of pus along intermuscular 
cellular spaces in seeking an outlet, 
has caused close observers to mistake 
this condition for an extraperitoneal 
cellular abscess. 



IV. DIAGNOSIS AND PROGNOSIS BY 
J. F. W. ROSS, M. D., TORONTO, 
CAN. 

The diagnosis of acute inflamma- 
tory disease of the uterus is not diffi- 
cult to make. Usually the patient, 
after some mechanical injury for the 
production of miscarriage, or the in- 
troduction of sepsis f6llowing mis- 
carriage or labor, or through gonor- 
rhoeal infection, is siezed with a chill, 
rise of temperature, increased pulse, 
and in many cases with severe pain 
in the pelvic region. In some of the 
cases, however, the pain may be al- 
most entirely absent, -and in cases in 
which this inflammatory condition 
follows labor I have looked upon this 
absence of pain as a bad omen. The 
cases of phlebitis affecting the uterine 
sinuses are usually the ones that 
prove most rapidly fatal by the pro- 
duction of secondary abscesses, and 
pain is usually wanting. 

With tte invasion pf the tubes and 
pelvic peritoneum there is an acces- 
sion of pain, and if the inflammatory 
condition spreads the entire abdomen 
becomes tender. In some cases the 
bladder is secondarily implicated and 



we have painful micturition ; in 
others the rectum is secondarily im- 
plicated and we have painful defecar 
tion. In many cases of acute metritis 
following gonorrhoeal infection I have 
observed a sudden onset of what 
cannot be looked upon as a menstrual 
flow, because it frequently appears in 
an intermenstrual period. In some 
cases this discharge may last for two 
or three weeks, and if the inflamma- 
tory condition becomes chronic the 
flow may at a later period become 
excessive. In fact, in many cases of 
inflammation of the uterine appen- 
dages, one of the important symptoms 
is menorrhagia. 

I meet with a large number of cases 
of progressive salpingitis in fallen 
women who come under my care in 
the different hospitals. The temper- 
ature in such cases usually runs a 
somewhat erratic course, and inter- 
mittent rises will be observed if the 
cases are watched for a considerable 
period of time. These elevations may 
last only for twenty-four or thirty-six 
hours, and the temperature will then 
drop to about 99°. The patient com- 
plains of pain, and this pain is inter- 
mittent in its character. In some 
cases dysmenorrhoea is present; in 
other cases the diagnosis is quite easy. 
The floor of the pelvis feels hard and 
boggy, and the uterus is fixed. In 
other cases the uterus may be to a 
certain extent movable and masses 
will be felt on one side or the other of 
it or behind it. In many of these 
cases, in which there are large pus 
tubes within the peritoneal cavity, 
there may be no particular rise in 
temperature. 

The diagnosis of the cases in which 
there is but little to be felt in the 
pelvis, is difficult, and are likely to be 
mistaken for so-called ovarities and 
for eases in which the ovaries are 
tender, owing to some anemic or other 
condition. Neurotic women and 
anemic girls frequently suffer from 



Digitized by 



Google 



112 



SOCIETY PROCEEDINGS. 



this ovarian tendeniess. Such tender- 
ness exists without the presence of 
any actual disease, and these cases 
should never be operated upon. Ob- 
served closely for a time, no accelera- 
tion of pulse or rise of temperature 
will be noticed. 

The pus tube may be mistaken for 
a uterine fibroid. I have made this 
mistake in one case myself. There 
was no pus in the interior of the tube, 
but its wall was enormously thickened 
and itself was a solid fleshy mass. 
The pus tube may be mistaken, if ad- 
herent to the anterior abdominal 
wall, for a growth arising from the 
rectus muscle. I have one such case 
convalescing after operation, from 
whom I took a large pus tube that 
had become adherent to the anterior 
abdominal wall, and from which pus 
had burrowed into the sheath of the 
rectus muscle. 

During the development of pus 
tubes patients are usually supposed to 
be sufEering from typhoid or malarial 
fever. The diagnosis in such cases 
should be made with an expert finger 
in the vagima. 

Prognosis. — Many cases of disease 
of the uterus and appendages become 
entirely well without operative inter- 
ference. A large number of cases 
progress, and require for their relief 
surgical measures. There is an inter- 
vening class in which the disease 
«eems to be in a state of abeyance, but 
likely to be lighted up again at any 
minute. In the cases that suffer from 
•relapses nothing will relieve them but 
^he removal of the tubes and ovaries. 
In cases suffering from large pus tubes 
cure is dependent upon the removal 
-of such tubes. The drainage of pus 
tubes I consider to be bad practice. 
What applies to the pus tube applies 
equally well to the septic hematoma 
of the ovary and ovarian abscess. 

In speaking of the prognosis of such 
cases it is impossible to do so without 
.considering the subject of treatment. 



For pus tubes interfering with 
health and causing intermitent attacks 
of inflammation there is but one treat- 
ment — namely, removal by sui^cal 
means. The results after this opera- 
tion are perfect, but the operation is 
attended with considerable danger. 
The dangers certainly are much dimi- 
nished if the patients are placed in 
experienced hands. The patients do 
not grow fat and ugly, nor become 
insane, nor lose sexual vigor when it 
has been present before operation, nor 
grow a beard or moustache, as is oc- 
cassionally remarked by laymen. 
They leave the invalid chamber and 
become useful members of society. 
They lead active lives and look after 
their homes. 

When inflammation of the uterine 
appendages kills, it does so for want 
of operation, but it kills slowly, and 
before producing death causes an 
enormous amount of suffering. Many 
patients may live long enough to have 
sinuses running forward through the 
abdominal wall or down through the 
pelvic floor, discharging through large 
pus tubes, do not heal, and the pa- 
tients go from bad to worse. A con- 
dition of chronic septicemia sets in 
the patients become emaciated and 
confined to bed, bedsores form, and 
they slowly die. 



V. TREATREMT. BY MARCUS ROSBN- 
WASSER, M. D., CLEVELAND, O. 
1. ACUTE PELVIC PERITONITIS, 
(a) Medical Treatment. — When the 
immediate cause — foreign body, de- 
composing tissue, or germ-laden ma- 
terial — ^has been removed from vagina 
or uterus, the parts cleansed and 
disinfected, and the bowels have been 
well purged, rest in the horizontal 
position, with hot fomentation or ice 
bag to the hypogastrium, is the 
essential feature of the medical treat- 
ment. 

The temperature is not often exces- 



Digitized by 



Google 



SOCIETY procep:i)ings. 



113 



sive, hence seldom requires attention. 
The pulse may, however, be rapid and 
weak, indicating the need of stimu- 
lants and stiyclmia. 

Opiates should be used sparingly 
and should be early discontinued. 

The fact that the inflammation is 
more or less limited to uterus, ovary, 
or tube does not in itself imply the 
use of local applications. Hot vaginal 
douches may be used when well-borne, 
not othenvise. Small blisters to the 
inguinal region are of no value. Fre- 
qtient repetition of saline laxatives is 
followed by relief of pain. The bro- 
mides serve a good purpose in allaying 
reflex nervous manifestations. 

Giving iodides and mercurials with 
the idea of dissolving exudates is 
decidedly wrong. Nature thi'ows out 
plastic material as a bulwark against 
peritoneal invasion. 

(i) Sunjical Treatment, — Curet- 
ting and free diainage of the uterine 
cavity, befme infection has spread to 
the tubes or beyond, will in many 
cases limit or abort the inflammation 
within the utenis. But the utility is 
questionable, nay, it is often positively 
harmful, when the appendages have 
been drawn into the inflamed area. 
Nature is then busy sealing the tubes 
and repairing leaks and overflow. 
To disturb and pull down the uterus, 
and thus to sever the web and meshes 
of adhesions in process of formation, 
is to invite general peritonitis. 

Abdominal section is called for 
when symptoms point to formation 
of abscess either within a pelvic organ 
or within a circumscribed space in the 
pelvic cavity. Should such abscess 
rupture, section is indicated if it can 
be performed immediately or within 
the first few hours before general 
inflammation has developed. In the 
latter event results are not encourag- 
ing. 

Guided by my own experience 
(after general inflammation has devel- 
oped), I might yield to the request to 



open the abdomen and drain, if the 
pulse were small and rapid and there 
were vomiting and increasing tympan- 
ites. The operation would, of course, 
be a forlorn hope. On the other 
hand, if neither tymanites nor vomit- 
ing was present, despite small, rapid 
pulse, I would prefer to stimulate and 
push strychnia to the point of tolera- 
tion; because, while such symptoms 
indicate, shock, tjiey also indicate con- 
trol of the septic process. To inter- 
fere by the additional shock of oper- 
ation, and by disturbing protecting 
plastic foraiation, is not rational. I 
believe the chances of recovery in 
such event are better bv medical than 
by surgical treatment. 

2. Chkokic Pelvic Peritonitis. 
(a) 3IeJical Treatment, — During 
the subacute period, as also early in 
the chronic stage with lingering ten- 
derness, masses of exudate, and oc- 
casional rise of temperature, rest in 
bed with attention to bowels, to feed- 
ing, and to hygiene, is still the essen- 
tial factor; and rest, in its broadest 
meanhig, continues the elementary 
principle of treatment even after the 
patient is about. Boroglyceride or 
ichthyol tampons of lamb's wool, by 
supporting the pelvic diaphragm and 
depleting the blood vessels, hasten 
recovery in some cases. Gentle pelvic 
massage may be of value in softening 
adhesions, and may thus aid in the re- 
position of fixed organs. Tonics, 
cod-liver oil, and general massage 
and electricity will aid in restoring 
faded blood, weakened nerves, and 
wasted muscles. Local electricity 
may be of temporary benefit. As a 
resolvent of exudates it has proved 
a dismal failure at my hands after 
faithful and patient trial. Repeated 
blisters or other counter-irritants over 
the hj^gastrium serve the good pur- 
pose of temporizing. 

There are some cases whose condi- 
tion is uninfluenced by medication or 



Digitized by 



Google 



114 



SOCIETY PROCEEDINGS. 



treatment. They remain chronic 
invalids, fluctuating between fair 
though feeble health and spells of 
pain and nervous reflexes. They are 
comfortable for a time, but break 
down on over-exertion, exposure, or 
violent emotion. 

(6) Surgical Treatment, — Curet- 
ting the uterus was at one time con- 
sidered unsafe when tubal inflamma- 
tion was a complication. Experience 
has since taught that, carefully done, 
it may be a means of improving womb 
and appendages. The improvement 
is often preceded by increased tume- 
faction and tenderness of the append- 
ages, which are slow in subsiding, 
sometimes many months, but whicli 
ultimately do disappear, leaving the 
patient symptomatically cured, the 
backache, dysmenorrhoea, leucorrhcea, 
painful locomotion, and nervousness 
all gone. 

Even in pyosalpinx curetting has 
been advocated and practised with a 
view to establish drainage by the 
uterine route. A study of the path- 
ology of suppurating appendages Avill 
stamp the procedure as^one partaking 
more of tlie empirical than of the 
scientific. 

Abdominal section is to-day the 
recognized treatment for removal of 
suppurating appendages, either singly 
or bilateraUy, or together with the 
uterus, if the latter is also infected or 
honeycombed with pus. Section is 
indicated for thickened, enlarged, or 
cirrhotic appendages that cause pro- 
longed dysmenorrhoea, local suffering, 
or aggravated reflex disturbances. 
Firm adliesions causing much distress 
. by displacing pelvic organs can be 
relieved more safely by section than 
by other more crude methods. If 
there be good grounds to suspect that 
sterility is due to displacement or 
constriction of appendages by adhesion 
or bands, section will best accomplish 
release and cure. Finally, the sinuses 
and fistidae that remain after the dis- 



charge of so-called pelvic abscess, and 
resist efforts to cure by drainage and 
injection of irritants, may be cured by 
removing the cause, located in the 
remnants of suppurating tube or 
ovar\\ 



VI. TliEATMENT BY A. VAN DKR VEEK, 
M. I). ALBANY, N. Y. 

The ground of treatment has been 
very- well covered by Dr. Rosenwasser. 
We should make an earnest effort in 
all of these cases to learn the cause of 
the inflammatory trouble. A young 
girl is brought to us, or a young 
woman, who has been an invalid for 
five years. She is compelled to give 
up school. In such a case we must 
carefully inquire into the condition, 
learn as to what may be the actual 
cause of the inflammatory condition 
that exists about the pelvis. The 
question will occur to you : Has she 
had for three or four years a persis- 
tent leucorrhoea? Has she become 
infected in some manner with a puru- 
lent discharge, not necessarily specific, 
but by some form of abscess or sinus 
that has existed? I have found in 
one case a well-marked inflammatory' 
condition of the pelvis due to an iin- 
cured ischio-rectal abscess that one 
time discharged into the vagnia. 
This condition should be looked into 
with the utmost cai'e and caution. 
Irritations about *the rectum should 
be carefully looked for in young girls 
who present a condition of this kind. 

As to the condition of the appen- 
dages in a young girl in early life, we 
sliould ask ourselves the question : 
Has Nature accomplished her work 
well ? Has she developed the uterine 
appendages in a proper manner ? Has 
the girl, from the time the menstrual 
act was noticed, had a normal men- 
struation? In many cases we will 
find that menstruation has been irreg- 
ular; that the patient has always 
suffered; that she has had perhaps 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



115 



an abscess, an isehio-rectal abscess or 
an ovarian abscess, which has escaped 
through one of the lymph channels, 
through which Nature will often make 
an exit for the pus. She may have 
an undeveloped ovary tube on one 
side. These causes should be looked 
into carefully before cairying out an 
intelligent line of treatment. 

As to the cases occurring in the 
adult, the married or immarried 
woman, these nmst also be examined 
witli the utmost care. If the patient 
has borne children the condition of 
the cervix should be examined with 
great care. That noble man — Dr. 
Emmet — has done great work for us 
in reference to the lacerated cervix. 
The condition we seek may rest 
witliin the cavity of the uterus while 
the tubes are absolutely free from 
disease. There may be no trouble 
outside of the cavity of the uterus. 
But you begin with your tincture of 
iodine, with your various applica- 
tions; you begin curettement, and 
perhaps then you light up an inflam- 
matory condition, and the patient is 
finally made worse by the line of treat- 
ment carried out. Make a careful ex- 
amination, and, if the cause be a lacer- 
ated cerv^ix, it must be repaired. 

There are cases, as has been stated 
by some of the previous speakers, 
which present conditions that are 
extremely difficult to diagnosticate. 
The patient has gone along fairly 
well and has had two or tlu'ee attacks 
of a mild form of pelvic peritonitis. 
During the next attack an exudate 
is thrown out. We feel when we 
see these acute cases that they present 
some difficulties. It is not an easy 
matter to tell whether the hard 
masses we meet with are benign or 
malignant. These cases should be 
carefully classified as to treatment. 

I must say I do not feel like con- 
demning the curette entirely, for I 
believe it is of service in some cases. 
When we have a high temperature 



with a rapid pulse we should not go 
inside the uterus with a sharp curette. 
Do a gentle form of curetting, then 
pack the uterine cavity with iodoform 
gauze, and the patients will be bene- 
fited. In two or three days you may 
have a case of pyosalpinx that needs 
a more radical operation. You need 
not ignore the use of the curette 
entirely. It may be used in cases of 
endometritis. In the submucous form 
of polyp you can perhaps use the 
shai*]) curette. No one can cover the 
conditions present in these cases by 
one simple examination. The cases 
should be carefully studied and then 
the line of treatment selected. 

When a case comes to us with an 
inflammatory condition of the pelvis* 
I do think we are justified always in 
sjiying to the patient that the uterine 
appendages must be removed. The 
condition must be outside, when oper- 
ation is not necessary. On the other 
hand, how many of you have seen 
those cases that have passed from 
office to office and from city to city, 
where there has been absolutely no 
relationship for years and years on the 
pail of the husband and wife, perhaps, 
the husband having spent his hard 
eaniings from week to week in going 
to this and that doctor, they telling 
him they could cure his wife without 
operation; and finally the case goes 
into the hospital with all the compli- 
cations, with all the sorrowful con- 
ditions present of immense pus tubes 
opening into the rectum — the saddest 
of all conditions. Then we are to 
operate. It is unfortunate that we do 
not get these cases earlier. 

There are cases where the comu of 
the uterus is in a thickened condition, 
bimanual examination will not cause 
the woman to complain, and the uterus 
is somewhat fixed. In these cases I 
believe we can do some good by local 
thorough douchings, putting the 
woman under a sensible, cautious line 
of treatment. The old suppository of 



Digitized by 



Google 



116 



SOCIETY PROCEEDINGS. 



lead and lK41adoniia, to be held there 
and renewed, the patient being kept 
absohitel}^ quiet, will materially bene- 
fit these patients. Furthermore, we 
must look into tlie condition of the 
bowels ; see that they are thoroughly 
emptied every day. We have patients 
that come to our office for examina- 
tion and we find that the bowels have 
not moved in two or three days, and 
they (expect a careful examination of 
the pelvis to be made. The condi- 
tion of the bowels, therefore, nnist 
be studied carefully, as well its the 
bladder. We may be able to carry 
some of these cases through success- 
fully by this line of treatment witliout 
removal of the appendages, but the 
vast majority of cases of pelvic uiflam- 
mation will ultimately necessitate sucli 
an ojMM-ation. 



Vll. TKKATMENT. BY JOSEPH PKICE, 

M. D., PHILADELPHIA. 

It is argued by the conservative 
camp to take away just as little as 
possible, leaving adhesions if neces- 
sary to simplify the work. This, to 
the thorough surgeon, is not per- 
missible. His aim is to remove 
disease, and to bring the parts not 
diseased mto as near their normal 
anatomical relation, and by so doing 
conduce more certauily to the ulti- 
mate well-being of the patient. Under 
this point of view the operation that 
would remove a diseased tube and 
leave an ovary bound down by ad- 
hesions to the pelvic wall or to the 
intestine or omentum is not surgerj^ 
at all ; it is only experimental dilly- 
•dally, which, if it results well, is no 
credit to any one. 

'J'he same may be said if the 
method is applied to the conservation 
•of a useless tube, because it is hard to 
remove. To know that in these 
•cases women get well if we leave 
them when we have opened the abdo- 
men to find them, puts our conserva- 



tism in the light of doing a useless 
operation, and becoming at once con- 
servative because it is the easiest 
thmg to do. To leave a tube full of 
pus or blood simply because it is hard 
to remove, is like building a bridge 
till we get into deep water and then 
completing it with a ferry-boat. 

To say that many ovaries have 
been removed which ought to have 
been saved is to say what we all 
know, namely, that cures by opera- 
tion have been sought when the idea 
was not justifiable, and we know' that 
such errors were a part of the pioneer 
work, accidentally of the best men, 
designedly of the seekers after noto- 
riety. But this does not answer the 
sm*geiT of to-day, neither is it a fair 
accusation nor a plea. It is simply 
special pleading in the line of popu- 
larity. It' is a fad which, like electric- 
it}% tickles the popular ear, the un- 
critical eye, and the easily satisfied 
imagination. 

The surgery that leaves pus tubes 
and abscesses to get well of them- 
selves, and afterwards find pregnancy 
occurring, is so fabidous and mystical 
that I prefer simply to wonder with- 
out caring to understand or believe. 
What we have here referred to in- 
cidentally leads to a broader refer- 
ence to pelvic pathologj' . To under- 
stand the limitations of conservatism, 
especially as applied to subsequent 
conception, it is necessary to consider 
the complexity of the pathological 
processes which militate against every 
chance of the organs regaining their 
physiological fimction. Pus tubes 
are not simple. It is the rule to find 
them with multiple constructions, and 
with the tube simply a wire line, its 
lumen a wreck.. 

Many of the operations now success- 
fid were formerly failures because of 
the insufficient knowledge of hovr to 
deal with the wounded gut, ho'w to 
make an anastomosis or do a bowel 
resection. Hence it is to be put 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



IIT 



(lovni as a postulate in pelvic surgery 
that no man has a right to attempt it 
who does not know how to ileal with 
all the complexities of intestinal sur- 
gerj-. To know when and when not 
to stitch intestine is as necessary- as to 
know when and when not to operate. 

I cannot here refrain from paying 
my compliments to the Trendelen- 
burg position, and to say that I find it 
just as useless in all abdominal sur- 
gery as it is for the operation of 
suprapubic cystotomy, for which it 
was invented. 

The varioius modes of treatment 
that have ever been suggested are 
scarcely to be noticed. They must 
stand or fall in their results. It is 
fair to assume that where great re- 
sults have been claimed, where the 
means have been problematical, the 
disease has been slight or imaginary ; 
and so where some mechanical pro- 
cedure, such as the Trendelenburg 
position, is ssiid to have simplified and 
rendered easy all the difficulties of 
pelvic siu-gery, I must allow others to 
believe it who find the need of it, and 
say, "Credat Judaeus Apelles, non 
ego." I put it down that the long 
incision and elevated position are not 
necessary, because with a minimum 
of incision and a real surgical care 
the conditions that demand them 
presumably do not exist, and the 
advantages they offer are therefore 
mvthical. 

Just a word with reference to the 
assertion that with the Trendelenburg 
position there is no escape of fluid into 
the abdominal cavity. If there Ls a 
collection of any kind in the tube not 
over-distended, and the pavilion is 
attached to the ovary, it is an easy 
matter to enucleate the mass without 
nipture; but if the pavilion is at- 
tached deep down on the pelvic wall 
or to an intestine, what is to become of 
the dischai^ing fluid ? It is very easy 
to manufacture reasons that will not 
explain at all the actual condition of 



things. Any operator or set of o|)er- 
ators who argue from a condition of 
affairs different from the above are 
taking a stand upon insufficient data. 
Akin to all these undemonstrated 
claims are the tentative methods in 
certain conditions, such as gauze 
packing and vaginal puncture for 
tubal abscess. Now, it is a demon- 
strated fact that gauze does not drain 
anything but mere fluid matter ; the 
debris of any sort whatever remains 
behind, and in the cheesy conditions 
which obtain in pus collections it is a 
matter of entire impossibility to clean 
out the cavities by such packing. 
Then, again, the vaginal puncture is 
as uncertain as any procedure can be 
that does not go to the bottom of the 
disease. We do not know primarily 
the extent of the disease, nor its sur- 
roundings nor its complications, and 
therefore we cannot drain it certainly 
by any one given puncture or 
method, except by enucleation. 

After the enucleation is made the 
general cavity can be tlrained and the 
results are in nowise questionable. 

What are we to say as to the re- 
moval of the entire uterus in the 
presence of tubal and ovarian disease ? 
I take it that if all the pathologists 
who have ever examined uterine 
structure which is purely muscidar — 
or, to be more exact, in great part 
muscular — were to make a report, 
there would be a general concensus of 
opinion that an abscess condition of 
the uterine walls, apart from broken- 
down fibroid, is the rarest condition 
imaginable, except at the cornu in 
case of pyosalpinx. 

Now, the disease here is strictly de- 
finable and removable. It is there- 
fore an unproven assertion to assume 
that the uterus is diseased and is the 
cause of the failure of cure in certain 
women whose appendages have been 
removed. To remove, therefore, an 
organ which in a great majority of 
cases is not even remotely diseased is 



Digitized by 



Google 



118 



SOCIETY procep:dings. 



a seeking after means to obviate bad 
results that should otherwise be ex- 
plained. 

In conclusion, we are to remember 
that enough has been done of all kinds 
of pelvic work to decide what Ls the 
general drift of results, how far they 
are satisfactory and how far disap 
pointing. The end here should jus- 
tify the means, not in the hands of 
the disappointed experimentalist, but 
in the careful, painstaking surgeon. 



PERSONAL EXPERIENCE WITH VUH 
TUBES: W^HEN TO OPERATE; HOW 
TO OPERATE; AND THE RESULTS 
OF OPERATION. BY J. F. W. ROSS, 
M. D., TORONTO, CANADA. 

The operations such as those I am 
about to set before you are a terrible 
tax upon the nervous system of the 
operator. They are, without excej)- 
tion, the most terrible of all surgical 
operations. I have seen a great deal 
of surgeiy in my short career, but 
have never yet seen any operations to 
compare with operations for the 
removal of pus tubes and ovaries fi*om 
delicate women. I refer to cases in 
which the operator is walloAving in 
pus, where enormous abscesses of 
tubes and ovaries tliat have perforated 
into the bowel and into the bladder 
have to be peeled out from among 
dense adhesions of such delicate 
structures a« the intestines — cases in 
whicli the operator is compelled to 
leave well enough alone, cease work 
after the removal of one side, wash 
out and close tlie abdomen, and go 
back after the other side on some sub- 
sequent occasion. Naturally a time 
arrives in an operator's existence* 
when he does not care to sustain such 
a terrible strain. If he has a large 
hospital dependent on him it is only 
natural that he should suddenly 
become conservative — that is what 
they call it, conservatism. He goes 
back to his old routine treatment, in 



which there is no anxiety, the hot- 
water douche, the vaginal tampon — 
and he will neither operate himself 
nor let others operate if he can help 
it. I believe there is a time when a 
man should not operate on such cases, 
but he has no right to prevent others 
from doing what they know and he 
knows is best for the patient — namely 
the enucleation of such pus sacs. 

In my own experience I have met 
with four different varieties — namely, 
intratubal abscess, intraovarian ab- 
scess, intraligamentous abscess, and 
extraperitoneal abscess (that is, an 
abscess entirely outside the tissues 
forming the pelvic contents). The 
latter variety may be cured by punc- 
ture and drainage. The third variety, 
or intraligamentous abscess, must be 
opened and dinined, but if accom- 
panied by a pus tube that is not 
removed the abscess may remain 
uncured until the pus tube is re- 
moved. The second variety will 
occasionally cure itself by perforating 
downward and dischargmg its con- 
tents, but the patient will not rem am 
well while the contracted and dis- 
organized ovary is left in i<ltu. The 
intratubal abscess should always be 
treated by removal of the tube. We 
have all been frequently amazed to 
find such large collections of })us in 
women who are not emaciated, but 
who are suffering from intermittent 
attacks of pain. 

In looking back over my reconls I 
find that the fatal cases were chiefly 
tliose in whom gonorrhoea had been 
contracted but a shoit time before. 
I now believe that it is not wise to 
operate* on tliese cases to soon after 
the primary infection. It is better to 
wait until tlie pus has become to a 
certain extent sterile and until the 
poisonous germ has become attenuated. 
The first case that died was one on 
whom I performed my second abdom- 
inal operation, and, not knowing the 
best nu^thod of procedure, I unfortu- 

Digitized by VjOOQIC 



SOCIETY PROCEEDINGS. 



119 



nately tore one ureter, and finally 
elosed the abdomen without bemg 
able to complete the operation. After 
more mature experience, and after 
having made a pilgrimage to the old 
country, such a case would now be 
readily completed. The second case 
that died had gonorrhoea, but a few 
months before. The third case that 
died was operated on over a butcher 
shop in the country, in the mid- 
dle of summer, with the flies thick 
about the place and stagnant water in 
the yard, llie fourth case that died 
was very septic at the time of opera- 
tion and had suffered from high fever 
for five weeks, and the abdominal 
cavity was studded with tubercular 
deposit. It would have been wiser in 
this case to have closed the abdomen 
and to have done nothing. The next 
case that died was saturated with 
sepsis at the time of operation, and 
was operated on after nine weeks of 
high temperature ; the operation was 
done as a last resource. The next 
three cases that died were operated 
on after a recent infection with 
gononhcea; two of them were prosti- 
tutes. The next case that died had 
been operated on previously, and one 
enormous pus tube had been removed, 
but owing to her weak condition I 
was forced to desist and operate a 
second time. She died after the 
second operation, perfonned nine or 
ten weeks after the first. The gon- 
orrhoeal infection in this case was 
remote — that is, occurred two years 
before operation. The next fatality 
occurred in the case of a young 
woman, a prostitute, recently infected 
with gonon-hoea. The next death 
occurred in a woman who was in the 
last stages of septicemia and very 
much emaciated from her long-con- 
tinued illness. In the next fatal case 
the death was attributable to an acci- 
dent. A piece of omentum escaped 
through the opening from which the 
glass drainage tube had been removed. 



and remained out beneath the diiess 
ings all night. The patient's vomit- 
ing was attributed to the anaesthetic, 
and I was amazed in the morning, on 
renaoving the dressings, to find the 
extruded mass black and gangrenous • 
Peritonitis set in and the patient died 
on the ninth day. The next death 
occurred as a result of rupture of the 
intestine and escape of fecal matter at 
some time after the operation. The 
outer coating of the intestine had 
evidently been injured during the 
enucleation of an enormous abscess of 
the left ovary, and a perforation oc- 
curt*ed subsequently. She died on 
the second day. 

The remaining sixty cases recov- 
ered. Some of them made an easy 
convalescence, others only recovered 
after a desperate illness. 

The history of these cases previous 
to operation would fill an enormous 
volume. There would be in the vol- 
ume many tales of woe. There would 
not be much in the volume that would 
be flattering to the so-called "treat- 
ment" received by these patients 
before surgical measures were resorted 
to. One woman has begun to live 
her life over again. She was for 
fourteen 'years bedridden; she gi'ew 
old as the to\vn grew up about her. 
The operation was very difficult, but, 
contrary to the expectations of all, 
she never had a bad symptom after 
its completion. She is at present 
enjoying life and in perfect health. 
Many of the other cases had been 
through other hands and had been 
under the care of various physicians, 
imtil at last they reached the care of 
the more enlightened y6ung men of 
the rising generation and were trans- 
ferred to me for surgical mterference. 

We must conclude, then, that there 
is a danger in operating on these cases 
at too early a period after the primary 
infection, and there is certainly a want 
of wisdom in deferring operation be- 
yond a certain point. No case should 



Digitized by 



Google 



120 



SO( IKTV PROCEEDINGS. 



be operated on during tlie first acute 
atbick, except under very exceptional 
circumstances. They will fretpiently 
ling(»r for weeks with high fever, the 
fever will then to a great extent dis- 
app(»ar and the general health will im- 
prove up to a cei-tain point. Opera- 
tions done at this time will be at- 
tended with a much lower mortality. 

Jn obtaining tlie history of many of 
these cases I iind that they have had 
an attack of inflammation of the bow- 
els follo^ving either labor, miscarriage, 
gonorrhoea, an intra-uterine application 
or instrumentation, or some severe in- 
jury. Following this inflammation 
they have had, what has been called, 
low fever or tyjjhoid fever. This 
fever has continued for some weeks ; 
they have then apparently conva- 
lesced, but have never regained their 
strength. But a few cases never lose 
this fever and must be operated on to 
save their lives. The majority, conva- 
lesce, to a limited (*xtent,and suffer from 
relapses, which ctnne on at varying in- 
tervals. Jn each attack there is pain, 
tenderness, rise of temperature, and, in 
some of them, vomiting. A large 
number of women suffer from inflam- 
mation of the boAveLs and convalesce 
readily and completely. It is a for- 
tunate thing for the human race that 
this is so. These seventy-three cases , 
must be looked upon as exceptions to 
the general rule ; and the exceptions 
are the cases for whom our skill is re- 
quired, because the other cases recover 
so perfectly that no treatment is needed . 

In giving the cause I have done so 
only after careful mquiry. Jn five of 
the cases the cause was not known. 
In thirty-six cases the cause was gon- 
orrhoeal infection. In some of these 
cases this was not ascertained until 
after the operation had been per- 
formed, and the information fre- 
quently reached me in a roundabout 
way, oftentimes through some profes- 
sional brother who had attended the 
husband during the attack. 



In three cjises the disease was pro- 
duced by tubercular deposit ; in one 
case from {>eritonitis due to the pres- 
ence of a uterine fibroid ; in one from 
peritonitis following a fall from a car- 
riage ; in one case from inflammation 
following an intrauterine application ; 
in one from the passage of a sound 
into a utcMUs that was supposed to 
contain an ovum impregnated about 
two we(»ks before. Some of the cases 
suffered from metrorrhagia, so that 
they closely simidated cases of fibroid 
tumor; many of them suffered from 
menorrhagia; and a large majority 
suffered from dysmenorrhoea. The 
length of time the disease was pro- 
gressing varied from a few months up 
to fourteen years. Many cases were 
mistake^n for |)elvic lia^matocele or 
fibroid tumor, and many of them were 
looked upon as cases of pelvic cellu- 
litis. 

I am firmly convinced tliat none 
but those who have had the advantage 
of a special training in this depart- 
ment of surgery should imdertake the 
operations for the relief of cases such 
as those under discussion. 

There is a certain method of pro- 
cedure that should be followed in 
each of these cases. In the fii^st 
place, it is necessary to draw up the 
anchored omentum and to do so 
rapidly. The portion from which an 
anchored omentmn lias been peeled 
will not bleed, but the proximal por- 
tion of the omentum itself will bleed 
freely, and this bleeding should be 
carefully attended to. If, after it has 
been placed temporarily to one side, 
wrapped in a sponge, while the rest 
of the operation is being carried out, 
it is found that it still bleeds, no time 
should be lost, but fine ligatures 
should be applied around the bleeding 
portion and the rest should be cut 
away beyond the ligatures. The 
omentum should never be tied with 
coarse silk ; the very finest silk should 
be used for this purpose. I f re- 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



121 



quently tie off a shred of the omentum 
to prevent intestinal obstruction by 
the constriction that may be produced 
by the tags that are left after the 
anchored portions have been detached 
from the parts to which they are 
adherent. The enucleation should 
always be begun at the uterine comu. 
The uterus should first be found 
before any peeling is commenced; 
after this has been located the opera- 
tor has a valuable landmark. The 
line of cleavage between intestine and 
tube can only be made out by the 
tips of the index and middle fingers, 
and must be made out in the dark 
recesses of the pelvis. The peeling 
must always be made from the centre 
outward and forward up against the 
posterior layer of the broad ligament. 
The operator who begins his enuclea- 
tion at the infundibulo-pelvic ligament 
or from the front of the broad liga- 
ment will soon find that he has made 
a terrible mistake ; large veins will be 
opened and the haemorrhage will be 
severe, the cellular tissue will be in- 
vaded and damage will be done to 
important parts. 1 find I receive a 
great deal of assistance from a small 
laryngoscopic mirror fitted with a 
mouthpiece, as used by Tait, that it 
may be held between the teeth. With 
the aid of sponges to hold back the 
constantly prolapsing intestine, the 
operator may view from time to time 
the field of operation, and may thus 
frequently avoid injury to a portion of 
adherent intestine. The haemorrhage 
can usually be controlled, if the opera- 
tion is done with the precautions 
above mentioned, by sponge pressure. 
But if the broad ligament and cellular 
tissue of the pelvis have been invaded, 
sponge pressure will not be sufficient 
to control the haemorrhage. In a 
recent case I injured a small branch 
of the internal iliac vein. This was 
readily discovered by means of the 
mirror and the bleeding points tied. 
It is much better not to attempt to 



remove a tube or ovary, filled wdth 
pus, intact, if such removal is fi-aught 
with danger to any portion of adherent 
intestine. At times it will be found 
by the aid of the mirror that the outer 
coat of the intestine has been injured, 
and when this is so I believe it wise 
to draw the serous coat together with 
a few Halsted sutures. 

Drainage and Flushing, — In the 
list of cases it wiU be found that 
drainage was used in sixty-one cases, 
and thirty-nine cases were flushed. In 
the cvuses that died two were not 
flushed, while eleven were flushed 
thoroughly. All the fatal cases were 
drained. I am firmly convinced that 
a prolonged drainage is the correct 
procedure in such cases. Among my 
earlier cases I used prolonged drain- 
age. In the intervening period, when 
there was such an outcry tigainst 
drainage, I attempted to shorten the 
length of time that the drainage tube 
was left in, and I found that the cases 
did not do as well. A secondarj^ rise 
of temperature took place, some in- 
flammatorj^ action set in at the bottom 
of the sinus from which the drainage 
tube had been removed, and this de- 
layed convalescence. In my later 
days I have returned again to pro- 
longed drainage, and intend to pursue 
that course in future. The method I 
adopt is about as follows : The drain- 
age tube is inserted and left in situ 
for about six days, being drained at 
intervals and packed with iodoform 
gauze after about the second day. I 
never use iodoform gauze packing until 
all danger of secondary haemorrhage 
is over. On one occasion I packed 
the tube, and on removing it a couple 
of ounces of blood were drawn up 
from the pelvis by means of the 
sucker, and yet this haemorrhage did 
not show through the gauze. Had 
there been no gauze it would have 
been readily discovered. 

About the sixth day a rubber drain- 
age tube is passed down through the 

Digitized by LjOOQ IC 



122 



SOCIBiTY PROCEEDINGS. 



glass one (to act as a guide when the 
glass one is reintroduced), and the 
glass one removed, thoroughly washed, 
and replaced for a day or two longer ; 
by doing this I can more readily keep 
it aseptic. At the end of the eighth 
day a rubber drainage tube is placed 
in the sinus and the glass tube re- 
moved. The rubber tube is kept 
packed with iodofoim gauze, removed 
and replaced two or three times a day, 
and shortened daily. In this way a 
sinus is kept open down to the seat of 
operation, and if any d<3bris left be- 
hind during the peeling off of friable 
and poisonous tubes, should become a 
focus of suppuration, the pus will find 
the readiest exit through the old drain- 
age-tube sinus. If the abdominal wall 
is completely closed over and firmly 
healed together, any such pus can 
only find an outlet by burrowing 
downward, and a sinus may thus be 
left that cannot readily be closed. 

The danger of the infection of the 
peritoneum through the drainage-tube 
track is a myth. After a very few 
hours adliesions form of intestine to 
intestine around the tube and prevent 
any such infection. 

Hernia is cei-tainly more liable to 
occur as a consequence of drainage, 
but such a hernia is only a slight mat- 
ter when compared with the life of 
the patient. It may be practicable, 
in some institutions where there are 
numbers of assistants, and assistants 
trained in bacteriological research, to 
examine the pus from a pus tube or 
suppurating ovaiy with the micro- 
scope at the time of the operation, 
but such examination is certainly not 
practicable in my work. I therefore 
think it is best to adopt drainage in 
all doubtful cases. 

Flushing, to be of any service, must 
be thorough, and a large quantity of 
water should be used. It will be 
found to produce an alteration in the 
pulse as soon as it is begun, but after 
it has been continued for a few mo- 



ments the pulse again slows doVn. 
The pulse is at first raised by the 
application of the hot water to the 
peritoneal cavity, and the respiration 
is increased in frequency. Such a 
stream of water should be used as 
will float out clots and pieces of debris, 
as well as remove pus. 

It is advisable during operation to 
ascertain the exact condition present 
by going slowly. If the operator is 
uncertain he should pack the intes- 
tines back with sponges, and proceed 
step by step until he is convinced 
regarding the condition with which 
he is dealing. I have seen an opera- 
tor remove a large |K)rtion of the 
rectum ; it was peeled out from among 
adhesions and tied off. Such a mis- 
take, it seems to me, can only occur 
as a consequence of too great haste. 

The ligation of the pedicle is a 
matter of very great importance. In 
his anxiety to remove all diseased 
tissue the operator scoops out the 
inside of the tube with his scissors, 
and in doing so is very liable to di- 
minish the bulk of the tissue beyond 
the ligature, and in this way the ligar 
ture may become loosened. I have 
seen a pedicle bleed as a consequence 
of this procedure, but the bleeding 
was fortunately noticed before the 
abdomen was closed and a second 
ligature applied. The tissue of a pus 
tube, like the tissue of a fibroid 
tumor, has a tendency to shrink ; the 
ligatures should therefore be applied 
very tightly. I have been forced on 
one or two occasions to ligate a portion 
of thickly adlierent tissue in the 
neighborhood of the infundibulo-pelvic 
ligament, owing to the fact that the 
mass was densely adherent to the 
rectum. During the process of peel- 
ing one is veiy liable to produce a 
tearing at the outer end of the tube 
in the edge of the infundilo-pelvic 
ligament, and, as this torn portion 
is beyond the seat of ligature, it is 
liable to bleed. I was forced on one 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



123 



oc'CHHion to reopen a case for hsenior- 
rhjige from this source, but fortu- 
nately she made a good recovery. 

To test the amoimt of hsemorrhage 
a drainage tube should be hiserted 
during the hiterval of time that is 
occupied by passing the sutures. The 
amount of oosing can thus be judged, 
and if excessive the bleeding points 
should be brought into view by 
means of the mirror and sponge. 
Sometimes a large vein will be found 
torn and the blood will be found run- 
ning from it very freely. On such a 
point a small ligature should be 
placed ; this can be done without diffi- 
culty, and the operator will feel much 
more comfortable for the rest of the 
day. In some cases, however, a con- 
tinual oosing may keep up and the 
patient may lose a large quantity of 
blood. 

Another difficulty to be met with 
sometimes is prolonged hfemorrhage 
from enucleation of a large mass such 
as that in one of my cases, where the 
hoemorrhage was terrific. I worked as 
rapidly as possible and used as much 
sponge pressure as possible during the 
operation, endeavoring all the while 
to reach the j>edicle. (^wing to dense 
adliesions around, it was impossible to 
reach this until the very last. It was 
feared in the interval that the patient 
would die on the table before the 
haemorrhage could be checked.' The 
abscess of the ovary ruptured and 
flooded the abdomen with pus, and 
this complicated matters. The omen- 
tum was nearly as thick as the palm 
of a lady's hand and firndy adherent 
to the enormous abscess of the right 
ovars-. The patient was so low that 
those standing by could not feel the 
])ulse, and I was advised more than 
once to close the abdomen, with strajv 
puig, so that she would not die on the 
table. Arms and hands were ban- 
<lage(l during the operation to keep 
enough blood in the head to nourish 
the brain. v\s soon as the pedicle 



was reached and the loss of blood con- 
trolled, the completion of the opera" 
tion did not apparently mcrease the 
gravit)^ of her condition. We felt 
that it was not wise to remove her 
from the opemting room, and she 
was left there until the next day. 
To those who have not done these 
operations such statements may ap- 
pear incredulous, but there are many 
of my friends ready to verify them. 

Another case was operated on dur- 
ing an acute attack of peritonitis pro- 
duced by escape of pus from a pus 
tube. The pulse was 160 when she 
was placed on the table, and nobody 
expected her to recover. She made a 
someAvhat prolonged convalescence. 
In this case the dramage tube was 
used, and removed on the fourth day. 

There is a class of cases in which 
nothing can be reached except one 
dense plain of matted tissue covermg 
over the inlet to the pelvis. In such 
cases it would be necessary to remove 
bladder and rectum in the attempt 
to remove tubes and ovaries. I 
have operated two or three such 
cases, have endeavored through a pro- 
longed period to get some opening 
into the adhesions, and have been 
forced to close them up without re- 
moving anythmg. One such case had 
been ill a long time. I peeled off 
thickened, cartilaginous-looking omen- 
tum and removed it, but even then it 
was impossible to distinguish between 
intestines, tubes, and ovaries. After 
working for considerable time the 
pulse began to rise until it reached 
120, and I came to the conclusion 
that my only course was to desist. 
The patient has been under my obser- 
vation ever since. She has been ill 
off and on, suffering from distension 
and vomiting, together with symj^- 
toms of obstruction of the bowels. 
After the attacks of inflammation she 
passes bloody urine. 1 presume the 
absorption of the ptomaines from the 
inflamed peritoneum produces in some 

Digitized by VjOOQ IC 



124 



SOCIETY PROCEEDINGS. 



way a congested condition of the kid- 
neys. In the intervals no blood, 
casts, or albumen are to be found. 
It is now two and one-half years since 
the operation ; the patient is able to 
go around and do light work, but I am 
afraid is a confirmed morphine-eat^r. 
I have noticed iu many of these cases 
the unusual color of the fat lining 
the abdominal cavity ; it is of a deep 
yellow color and looks like the fat of 
a dead chicken. In several cases I 
have found small cysts of the perito- 
neum. They are not so infrequent as 
we might suppose. Frequently there 
is a large cyst, filled evidently with 
fluid that has collected during some 
attack of inflammation. After a seri- 
ous peritonitis this fluid has been left 
between the intestines, absorption has 
not taken place, and the cyst has re- 
sulted. Other similar collections 
between other folds of the intestine 
had temporarily united by adhesive 
inflammation. By the vermicular 
action of the bowels these eventually 
become detached and pendulous, and 
hang like grapes from some portion of 
the peritoneum. I have tapped them 
and left the sac behind without per- 
ceiving any difference to the patient. 
I have removed them by fine ligature, 
owing to the fact that the grape-like 
cysts have a tendency to bleed if cut 
off without having been previously 
ligatured. After the pus tubes have 
been removed the previous existence 
of this conditio^ has no influence 
whatever on the convalescence. 

In these operations the sponges 
should be very carefully counted. 
This should of course be done before 
any abdominal operation, but should 
be carefully done in such cases as 
these, because during haemorrhage 
sponges are frequently being put into 
the pelvis to control the bleeding 
while the rest of the enucleation is 
proceeded with. In this way a 
sponge becomes coated with pus and 
blood, and after the fingers have been 



peeling off adhesions for some time 
their sensitiveness is to a certain ex- 
tent lost and such a sponge is very 
apt to be overlooked. 

If fecal fistula? occur and feces are 
passed through the drainage tube the 
patients should be let alone ; the less 
they are interfered with the better 
will be the result. Adhesions will 
form, and though feces be passed out 
through the drainage tube the patient 
will frequently recover. These fistulae 
are not the result of the presence of 
the drainage tube, but are due to 
injury of the outer wall of the intes- 
tine. When a very firmly adherent 
rectum has been peeled from pus 
tubes it is unwise to give rectal 
enemata early after operation. One 
patient, I think, died as a consequence 
of an enema finding its way, through 
a perforation in the rectum, into the 
abdomen. In another case the nurse 
was giving an enema, and Avas amazed 
and frightened to see the fluid coming 
out through the drainage tube; the 
patient, however, made an excellent 
recovery. These fecal fistulse have a 
tendency to heal, or they may be 
operated on at a subsequent date and 
closed. There is a peculiar bile- 
colored stain to the fluid drained from 
the peritoneal cavity that is met with 
occasionally. I am imable to state the 
precise cause of this staining. The 
fluid does not give the biliary reac- 
tion. In two or three cases in which 
I have seen this deep yellow tinge the 
patients have died; in one case it 
was accompanied by intense jaundice. 

RemiltH of Operation, — In some 
cases the menstrual flow ceases. 
There is usually a slight flow, coming 
on a few days after operation. In 
some cases this may return no more. 
I have one patient who has been 
menstruating regularly ever since her 
operation nearly four years ago. I 
was at a loss to know why this was 
until I looked up my record and 
found that both tubes were removed, 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



125 



Wthat one ovaiy could not be found, 
owing to the fact that the tube on 
*liat side had burst into the broad 
lament and produced an abscess of 
^^ broad ligament that was drained. 
Jiis proved conclusively to my mind 
tht the removal of the tubes did not 
have much influence on the function 
of menstruation. The patients pass 
through the usual symptoms of the 
menopause. Those who have become 
emaciated by the long-continued su|>- 
puration rapidly put on flesh. When 
dyspareunia has existed before oper- 
ation, it disappears after convales- 
cence, and the patient is much less 
ansexed in this respect than she was 
before. The patient who before 
operation has been living in her bed- 
room is now enabled to live in the 
outer air and is transferred from the 
invalid carriage to her own feet ; the 
doctor is not now so frequently a 
visitor to the house as in fonner 
years, and happiness is restored to 
the home. 



THE PRESENT STATUS OF THE TKE^\T- 
JIENT OF PELVIC lNFLiV>mAT10X ; 
OR, HOW SHALL WE DEAL WITH 
PELVIC rS'FLAMMATOUY TJtOUHLKS ? 
BY WALTER B. IM)HSETT, M. I). 

The following conclusions of the 
author are : 

1. Pus in quantities is hard to deal 
vith doAvn in the pelvis in laparatomy 
cases, and, if possible, should be 
evacuated prior to taking out the 
tub^ and ovaries, either through the 
cul-de-sac of Douglass, or, if between 
the layers of the broad ligament at 
the side of the uterus, do your lapara- 
^nay at some future time. 

2. Pus sacs in the tube near the 
iiterine end of the tube can be evacu- 
ated through the uterus by packing 
^e horn. 

3- Parametritis, or cellultis of the 
^cients, is, except in rare instances, 
a secondary trouble, due to a f eul 



uterine cavity. Clean out the cavity 
and stop tlie source of poison, and you 
do the best thing possible to be done. 
These are my convictions and are 
honestly stated. Take them for what 
they are worth and give us youi*s, 
and let us compare notes. 



ti{Fl\tmp:nt of distention of the 
falu)i»ian tubes without i^pa- 
katomy and removal. by frank 
a. (;u\s(jow, a. b., m. d. 

I present to you to-day an article 
on the modern treatment of distention 
of the Fallopian tubes. 

The question is, can we cure tubal 
disease in any other way ? I say we 
verj" often can. We can learn from 
what Nature unaided can do. We 
have all seen cases of acute pyosal- 
pinx, even accompanied with peri- 
tonitis, recover from their acute symp- 
toms and, after a discharge has taken 
place from the uterus, become per- 
fectly well. AVe have looked for dis- 
tended tubes later on and not found 
them. Those tubes were imdoubtedly 
distended and were em})tied. We 
assist Nature to cure in other loca- 
tions in the body, why not do so 
here ? Catheterization has been tried 
and found impracticable. Very few 
have claimed that they could succeed. 
I doubt if it has ever succeeded in a 
case that needed it. There were 
cases re|K)rted years back in which, 
after a curetting, a discharge of pus 
took place, followed by recovery ; 
yet members of our profession did 
not take the hint. W. B. Dorsett 
was the first to advocate the dilata- 
tion of the uterine cavity with the 
object of opening the uterine end of 
the tube. He advocated this for 
those cases only where the tube was 
enlarged close to the body of the 
uterus, and presented some striking 
cases of its success. He advocated 
packing the uterine comu next to the 
tube. For myself, I doubt if we can 



Digitized by 



Google 



126 



S0( lETY PRO( EEDINGS. 



pack one part of the cavity any more 
than another. Dorsett's idea seemed 
to me good and I tried it, but not in 
exactly the kind of cases for which 
he recommended it. I have always 
noticed that the uterine ends of the 
tubes which I removed were pervious, 
also those wliich I saw removed by 
othei*8. I did not consider gonorrhoeal 
inflammation as an adhesive inflam- 
mation, hence I did not believe the 
generally accepted opinion, viz., ^^ that 
the tubes were closed by adhesion 
after they had been inflamed." I 
consider this a false teaching and 
probably responsible for our neglect- 
ing even trying to open the tubes. 
Knowing that the tubes are more 
generally distended at their distal 
extremity and that the inflammation 
is not an adhesive one, we are natu- 
rally led to look for tlie obstruction. 
We can account for it by swelling of 
the mucous membrane of uterine 
tissue immediately around the uterine 
ends of the tube, which is the narrow- 
est portion. This I believe to be the 
site of the occlusion in the majority 
of cases. The results obtained after 
packing the uterine cavity can easily 
be explained on this supposition. If 
this is so it is not hard to believe that 
we may have an emptying of the tube 
after we have applied antiseptics and 
pressure to the swollen mucous mem- 
brane. I believe another element 
comes to our aid, and that is a stimu- 
lation of the peristaltic action of the 
uterus and tubes. This is not diffi- 
cidt to imagine. 

I do not agree with Dorsett that it 
is the actual distention of the cornu 
which opens the tube, but believe 
that it is a subsidence of the inflamma- 
tion brought about by pressure and 
antisepsis. 

I prepared a number of tents of 
elm bark and sterilized them, some 
by means of heat and others by an 
alcoholic solution of bichloride of 
mercury 1 : 4000. These I have used 



almost exclusively for about nine 
months past. They can be partially 
broken at frequent intervals, so that 
they will easily follow the curve or 
flexion of the uterus. We can use 
them when the uterus is too sensitive 
to permit the use of gauze. We can 
gradually slip in tent after tent, first 
dipping them in glycerine or water 
for a moment, until the cervix is full. 
I now place a wad of cotton, tied with 
string, just against the cervix ; the 
tents are cut off to a length which 
will just permit them to entirely enter 
the OS externum Avithout pressing on 
the fundus ; they have each a short 
string attached to them. This is 
kept up for a nimiber of days, the 
patient being kept in bed. Some- 
times the dilatation causes pain; 
often none. If, when the uterine 
canal is large enough to admit the 
finger, there is no discharge of pus, 
with relief of the symptoms, I anaes- 
thetize and curette. I now pack with 
gauze and repeat for a number of 
days. 

I cannot at present recall a case of 
tubal distention where i did not get 
some discharge after packing \Wth 
gauze or dilating with tents for some 
time. VeiT often a very offensive 
watery discharge comes through the 
packing, even soaking into the bed ; I 
do not refer to the slimy discharge 
fi'om the tents. 

Case I.— October 12th, 1893. 
Complained of much pain in the rigJit 
inguinal region. One week previous 
to entrance had a severe chill. I 
found enlargement of the right tube, 
lacerated cervix uteri and perineum. 
I packed the uterus with iodoform 
gauze, without an8esthesia,for ten days 
without effect. The treatment was 
now interrupted for ten days on ac- 
count of catamenial flow. Three days 
after the packing had been resumed a 
fetid discharge began. The pain dis- 
appeared and the patient sat up next 
day. The second day after there ^vas 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



127 



no sensitiveness, except higli up and 
on firm pressure ; tube infiltrated but 
smaller, and fundus fixed ; patient 
feels tV^ell and went home on Novem- 
ber 6th. She returned on November 
30th, having had a chill, followed by 
fever. I found a hard mass to the 
right of uterus, firmly attached to the 
sacnun. The patient was chloro- 
formed on December 2d, and the ex- 
amination showed the right tube to 
be, near the utenis, of the size of the 
thumb; the fundus attached poste- 
riorly. Left side of pelvis free. I 
cui'etted the fundus and packed. Two 
days later a free discliarge of watery 
fluid took place ; no pain afterward. 
I washed out uterus and packed for a 
few days. Slie was discharged on 
December 20th, not quite well, but 
steadily improving. I heard later 
that the improvement continued. 

( 'ase 11 . — (Jave a history of having 
led a gay life a few years ago, about 
which time she had a miscarriage and 
also a gonorrhoea. .Vfter the gonor- 
rhoea she was attacked with peritonitis 
and was for a long time in a hospital 
in New York. She was warned by 
Dr. Mundd at parting not to allow 
any doctor to examine her, for it 
might cause peritonitis. This was 
about two years before I saw her on 
May 21st. I found her in bed with 
her knees dra^^^l up, suffering in- 
tensely ; temperature 101 1-2° ; ex- 
quisitely sensitive all over abdomen 
and all around the uterus. No satis- 
factory examination could be made. I 
ordered hot douches, hot poultices, 
and a lines, and had to give her a lit- 
tle morphine. The next day she was 
removed to the hospital, where she 
showed a temperature to 104 1-2°. I 
began to use bichloride elm tents at 
once, and continued the hot applica- 
tions and salines. By the second day 
a free discharge of bloody pus came 
away and the pain ceased. Two days 
after I ceased to use tents and ex- 
amined her. I now found the left 



tube small and the right tube the size 
of an egg. The uterus was pushed to 
the left and anterior ; no pain, no fever, 
and little sensitiveness. From now 
on until May 30th there was a bloody 
ilischarge ; at this date both tubes 
were found thickened but apparently 
empty ; there was a little sensitive- 
ness. She left the hospital on June 8. 

This patient became perfectly well. 
On June 2(>th, as she had some 
leucorrhoea, I introduced a single small 
tent. This, I very much suspect, 
interrupted an early pregnancy, for 
three days later she had severe cramps ; 
no tubal distention. The next day a 
fetid discharge took place. There 
was now a bloody discharge until I 
curetted the uterus under anpesthesia 
on July 12th. The tubes were not 
involved. I packed the uterus for a 
few days. She is now probably preg- 
nant again, but perfectly well. 

Case III. — I had one case where, 
after packing the uterus, I got a dis- 
charge, but the patient was not re- 
lieved. I now opened Douglas' cul- 
de-sac, and in separating the gut from 
the posterior surface of the broad lig- 
ament on the right I opened the ab- 
scess, which was in the ligament. I 
packed in a strip of gauze, and, with 
subsequent drainage, patient recov- 
ered completely. This may be con- 
sidered as a fype of cases which the 
advocates of laparatomy would say 
were not suited to such a procedure. 
In many cases it is impossible to tell 
beforehand whether this is the condi- 
tion or not. A good rule is to try to 
empty the tubes, and if we succeed, 
and the patient still does not improve, 
we can then perhaps open the abscess 
from below or perform laparatomy. I 
prefer opening from the vagina, for I 
have never lost a case where I did 
this, nor had hernia result. I have 
never opened a gut but once, and this 
I did carefully, as I suspected it to be 
a gut. I sewed it up and had no 
trouble. 



Digitized by 



Google 



128 



SOCIETY PROCEEDINGS. 



During the last year or so I have 
had more than twenty eases of disten- 
tion of the tubes and have performed 
laparatomy only on one. In this case 
I only broke up the adhesions and 
closed the abdomen. All the other 
cases were either very much improved 
or cured. 

I hope I have said enough to in- 
duce you to make a trial of this 
method of treating tubal distention 
and decide for yourselves what it is 
worth. 



I would also recommend you to try 
slippery-elm tents for the routine 
treatment of endometritis. Make the 
tent as small as a match, or •even 
smaller, and dip it into the medicine 
which you wish to apply to the en- 
dometrium, introduce it, and keep it 
there for sevieral hours with a cotton 
tampon. You will get a mucilaginous 
antiseptic application to the endo- 
metrium, which is far more efficient 
than any application made on an ap- 
plicator. 

(To be Continued.) 



THE INTERNATIONAL SOCIETY OF CONGRESS OF GYNi€;COLOGY 

AND OBSTETRICS. 



The second meoting of this Society 
will take place in Geneva, Switzerland, 
September, 1895. 

The questions for discussion are : 

(1) The Treatment of Eclampsia; 

(2) The Surgical Treatment of Re- 
trodeviations of the Uterus ; (3) The 
Relative Frequence of the Different 
Pelvic Strictures in Different Nations ; 
(4) The Best Methods of Suturing 
the Abdominal WaUs in order to 
avoid Eventration; (5) The Treat- 
ment of Pelvic Suppurations. 



From this programme it Tvill be 
seen that this session will be most 
important to all those interested in 
gynaecology and obstetrics, and, from 
the fact of the congress being held in 
one of the most beautiful cities of the 
continent, it is to be hoped that many 
of the profession of America will at- 
tend. We congratulate our corifrSreB 
Suisses^ and wish them every success 
in their undertaking, which we feel 
sure will be crowned with honor. 

C. G. C. 



Digitized by 



Google 



PHILADELPHIA OBSTETRICAL SOCIETY. 



129 



Chicago Gynaecological Society. 



At the sixteenth annual meeting 
of the Chicago Gynsecologieal So- 
ciety, held Oct. 19, 1894,- the fol- 
lowing officers were elected to serve 
the ensuing year: Dr. Franklin II. 



Martin, President; Dr. A. J.. Foster, 
first Vice President ; Dr. J. C. Hoag, 
second Vice President; Dr. H. P. 
Newman, Secretary ; and |^Dr. T. J. 
Watkins, Editor. 



Philadelphia Obstetrical Society, 



The meeting of the Philadelphia 
Obstetrical Society was held Novem- 
ber 1st, 1894, President Dr. Barton 
Cooke Hirst in the chair. 

A Case of Sudden Death Follow- 
ing Ventral Fixation. By Dk. 
Frank W. Talley. Abstract. 

Sudden death following coeliotomy 
is of sufficient rarity to warrant record, 
especially where the accident occurs in 
cases where there has been little or no 
disturbance of the abdominal contents. 
In the case to be reported nothing 
was done beyond the separation of 
tubercular adhesions and the fixation 
of the uterus. The patient was a 
well-nourished girl, 25 years of age. 
She was admitted to the Polyclinic 
Hospital, October 10th, 1894. There 
was no history of tuberculosis in her 
ancestors and no evidence of pulmo- 
nary or cardiac disease. For three 
years she had suffered from a burning, 
dragging pain in the left ovarian 
region, extending down the left thigh, 
with pain in the back, constipation, 



headache, and nervous debility. The 
uterus was anteflexed, retroverted and 
fixed. Both ovaries were prolapsed 
behind the uterus, large and tender, 
and bound down by inflammatory ad- 
hesions. 

October 11th, the abdomen was 
opened and the uterus and ovaries 
freed from adhesions. The fundus of 
the uterus was then secured at the 
lower angle of the wound by two fine 
silk sutures. The patient did well, 
and on the eighth day the stitches 
were removed. During the next 
three days she seemed entirely con- 
valescent. At ten o'clock on the 
eleventh day she seemed to be in high 
spirits, but two hours later she was 
observed to throw up her hand and 
apparently had an epileptic fit. She 
then became cyanosed and exhibited 
Cheyne-Stokes respiration ; pulse 
eighty per minute. In six minutes 
from the onset of the symptoms, 
respiration ceased. The heart con- 
tinued to beat for some time after the 
cessation of respiration. Artificial 
respiration was kept up for some time. 



Digitized by 



Google 



130 



PHILADELPHIA OBSTETRICAL SOCIETY. 



but witliout avail. An autopsy was 
not permitted, and therefore the cause 
of death can only be a matter of pre- 
sumption. From the rapid onset of 
death with marked respiratorv^ symp- 
toms, one would infer that the respira- 
tory centre had been the seat of some 
rapidly develoving interference. It 
would seem probable that an embolus 
had entered the general circulation 
and occluded an artery supplying the 
respiratory^ centre. Where such an 
embolus could have come from, as no 
vessels were ligated, must be a matter 
of conjee tun*. 

Repokt of a CAvSE of Pueupekal 
Pelvic Abscess, with some Re- 
main ks ON Septic Infection. 
By Dk. George M. Boyd. Ab- 

iSTUACT. 

In speaking of the sites of infection, 
it is convenient to divide the partur- 
ient canal into three }K)rtions, — the 
uterine portion, the cervical portion 
and tlu' vaginal portion. Septic 
infection must develop in one of two 
ways : either the poison is introduced 
from without, or the patient is self- 
inoculated. The uterine portion of 
the canal would seem the least liable 
to primary inoculation, sis it is the 
furthest from external contamina- 
tion. The cervical portion is nearer 
the exterior and is liable to suffer 
from accidental injuries favoring in- 
fection, while the vaginal portion is 
constantly in danger of infection. It 
would seem that this is the most fre- 
quent site of direct inoculation. In 
observing twelve hundred puerperal 
oases at the Philadelphia Lying-in 



Charity, the author had been im- 
pressed with the freedom of the cases 
from symptoms of uterine infection. 

The non-infectious fevers being ex- 
cluded, an occasional elevation of 
temi)erature must be explained by 
wound infection. The milder forms 
of this infection are not difficult to 
combat and are for the most part 
probably due to auto-infection. The 
case to be reported is of interest, not 
only as regards the probable site of 
infection, but also as to the wisest 
method of treating these cases. 

The patient, an Italian, aged 2t> 
years was admitted to the hospital 
March 20, 1894. Six weeks before, 
she had been delivered by a mid-wife. 
She soon developed fever with a tem- 
perature of 100 ' to 102 \ with sjTU})- 
toms of septic infection. On exam- 
ination a mass Avas found filUng the 
right side of the pelvis. A tumor 
could also be felt in the right groin. 

She was operated on March 22. 
Although there was no fluctuation, 
it was deemed wisest to cut down 
parallel to Poupart's ligament, so that 
if tlie accumulation were extra-per- 
itoneal, it could be evacuated without 
opening the peritoneal cavity. In 
this way an abscess was reached, from 
which two ounces of pus were evac- 
uated. The cavity was then washed 
out and an iodoform gauze drain in- 
troduced. The symptoms at once 
improved, and three weeks later she 
left the hospital, well. Three months 
later, examination failed to reveal any 
evidence of the original trouble, and 
she had improved much in flesh and 
strength. This particular case seemed 
to be one of infection through the 



Digitized by 



Google 



PHILADELPHIA OBSTETRICAL SOCIETY. 



181 



vaginal portion of the parturient 
canal, and it seems possible that dur- 
ing the long illness, the uterus never 
became infected. 

abstract of discussion. 

Dr. W. Reynolds Wh^son: — 
Probably Dr. Boyd's conclusions with 
reference to thfe seat of infection may 
be open to discussion. It is probable 
that the endometrium is more fre- 
quently the site of the infection than 
are other portions of the canal. This 
is so for two reasons. In the first 
place the sinuses at the placental site 
are occupied by large clots, which be- 
come readily infected, and from this 
location the putrefactive and septic 
elements are absorbed into the general 
circulation. The lacerated vessels of 
the cervical canal are also liable to be 
plumed by similar clots, but not to 
the same extent, so that infection 
from decomposing material is more 
likely to occur from the placental site 
than from the cervical canal. In the 
second place, the infection is more 
likely to occur higher up in the uterus 
on acrcount of the more active de- 
velopment of the lymphathic tissues, 
and absorbent vessels at this point. 
The lymphatics in the lower portion 
of the canal are not nearly so highly 
developed as those draining the fundus 
of the uterus and accompanying the 
ovarian or spermatic arteries. There- 
fore, as a matter of discussion, I would 
suggest that the infection is more 
likely to occur from the endometrium 
than from the lower portion of the 
uterine canal, owing, in the first place, 
to the formation of clots at the pla- 
cental site, and in the second place to 



the more active development of the 
lymphatics in this position. 

Again; the results of local treatment 
in the early stage of septic infection 
prove that the endometrium is the 
source of infection. When proper 
treatment is properly applied to this 
portion of the canal, the early symp- 
toms are likely to subside at once. 

Dr. a. J. DowNES: — During the 
past year I had a case which, in its 
clinical histoiy, veiy closely resembled 
the one reported. The patient was a 
primipara, confined in December, 
1893, imder circumstances which 
seemed to preclude any chance of in- 
fection. She had a normal puerperium 
and was in good health for six weeks, 
when she began to suffer, and in eight 
weeks she was in bed. On examina- 
tion, I found a small tumor. The 
case had all the clinical features 
of a case of abscess. By the eleventh 
week the mass had become quite large. 
There was no chill, but there was evi- 
dence of tuberculosis. I operated 
eleven weeks after delivery and fomid 
a large tuberculous tube, about three 
times its normal size, and a large 
fibroid mass in the signoid flexure of 
the bowel. This case seen by one 
who had not attended her previously 
would probably have been regarded 
as one of pelvic abscess. As regards 
treatment, I would state that I left 
this tuberculous mesentery, and the 
patient is now in excellent health. 

Dr. J. M. Baldy : — Dealing 
with the subject in a general way, I 
recognize three kinds of pelvic ab- 
scesses. There is often a confusion 
of terms in discussing this matter. 
In the first place we have pus tube^ 



Digitized by 



Google 



132 



PHILADELPHIA OBSTETRICAL SOCIETY. 



and ovarian abscesses ; in the second, 
true intra-peritoneal abscess, and in 
the third, cellulitic or extra peritoneal 
abscesses developing in the connective 
tissue. This is the rarest abscess of 
aU. In my own experience I have 
never run across one of these extra- 
peritoneal abscesses, but I do not 
doubt they occur. My failure to 
meet them is perhaps explained in 
part by the fact that I do not deal so 
extensively with obstetrical work as 
some others. All of the pelvic ab- 
scesses that I have run across in 
opening the abdomen — and that is 
the only way that we can have direct 
proof, by opening the abdomen and 
knowing the exact relations — have 
been cases of the intra-peritoneal 
variety. 

While I do not doubt that extra- 
peritoneal abscess may occur, I 
would rather question the statement 
that the case reported belonged to 
that group. I question its being one 
of these connective tissue abscesses. 
The history is that the case was 
operated on eight weeks after labor 
and only a small amount of pus found. 
The abscess is opened above Poupart^s 
ligament, and there was no chance of 
determining the relations to the pel- 
vic organs. Many of the connective 
tissue abscesses of which I have heard 
have been large accumulations of pus. 
The small amount of pus is what is 
found in the ordinary ovarian abscess. 
The length of time after labor is also 
a factor, although not a prominent one, 
that would go to substantiate this 
opinion. Again, the negative fact 
that all trace of disease has since dis- 
appeared goes to prove nothing at all. 



for we know that in these acute cases 
of pus tubes, if the pus is evacuated 
by any means, such as vaginal punc- 
ture — which is a bad practice — ex- 
amination weeks or months after- 
ward may fail to show any ti-ace of 
disease. The patient is, however, 
always in danger of recurring attacks. 
This fact then does not go far in the 
way of proof that it was a cellulitic 
abscess. 

As far a.s the method of approach- 
ing these abscesses is concerned, if 
one can diagnose that the abscess is 
sub-peritoneal, there is no question 
that the peritoneal cavity should not 
be opened. The abscess should be 
opened through the vagina preferably, 
or if it is pointing toward the abdom- 
inal wall, which is excetnlingly rare, 
it could be opened at that point. I 
conceive, however, that it would be 
impossible to make that diagnosis, 
and therefore, a« a mater of practice 
the operation should always be by 
abdominal section. If this shows that 
the abscess is sub-peritoneal, the abdo- 
men can be closed and the abscess 
approached from the outside. 

I)k. William S. Ashton: — Last 
Spring I had a case occurnng in the 
wife of a physician in the interior of 
the State, with a history much the 
same as that given to-night, and which 
would lead me to rather suspect that 
this was not an extra-peritoneal col- 
lection of pus, but that the ovary 
rather than the tube was the seat of 
the abscess, as it was evacuated so 
readily. The history was as follows : 
Five or six days after delivery the 
patient developed septicaemia. Cu- 
rettement was performed with prompt 



Digitized by 



Google 



PHILADELPHIA OBSTETRICAL SOCIETY. 



133 



relief to the symptoms, but from that 
time on the general condition was 
not very satisfactoiy. There was 
considerable pain in the right iliac 
fossa. I saw her ten weeks after 
confinement and found a condition of 
affairs precisely as described by Dr. 
Boyd, namely, a blocked pelvis on the 
right side, with a distuict mass on 
aupra-pubic examination.* I did not 
make a lateral incision, because I 
agree with Dr. Baldy that it is im- 
possible to determine prior to section 
what we have to deal with. I made 
a section and found that the trouble 
was in the ovary, which contained two 
and a half ounces of pus. This was 
adherent to the abdominal wall, the 
head of the colon and the appendix. 
The operation required the complete 
removal of the uterus and appendages. 
Also had to remove the appendix, 
which was gaugreous and on tlie point 
of rupture, and an opening was left in 
the colon. Had I made a lateral 
incision, I could have evacuated the 
pus, and I am cert am that this, with 
drainage, would have resulted in a 
cure such as Dr. Boyd has described, 
but I think that would have been bad 
practice. In this case the tubes were 
perfectly normal. The infection 
seemed to have come through the 
lymphatics of the broad ligament, 
infecting the ovarj\ 

I think that the ix)int brought out 
by Dr. Wilson, that the endometrium 
is the primary source of trouble in 
these cases, is well shown by the fact 
that in the vast majority of these 
cases of sepsis the early use of the 
curette and flushing gives rapid re- 
lief. 



Dk. Kohert E. Dickinson, of 
Brooklyn: — I have a vague recol- 
lection of certain cases that would 
seem to contradict the statement of 
the laparotomists that most pelvic 
abscesses are Avithin the peritoneum. 
We who are called in consultation in 
cases of puerperal septicaemia seem 
to encoimter more of the cases such 
as have been described to-night. Four 
cases come to my mind, in two of 
which the post-mortem confirmed the 
diagnosis. In both of these case* 
there was extensive burrowing of pus 
from the pelvis up as high as the 
diaphragm, with a thin place in the 
groin, through which an opening iiould 
be readily made and through which a 
large cavity could be treated. One 
•of these cases had well marked ne- 
phritis, and died. The post-mortem 
showed distinctly that the sepsis had 
developed post-partum, and there was 
no trouble in tlie peritoneum to com- 
plicate it. The second case died of 
pure sepsis. 

I had twice opened above Poupart's 
ligament and evacuated collections of 
pus where there seemed to be no 
peritoneal involvement, beyond the 
deposit of lym{)h in the region of the 
abscess cavity. 

Dr. M. Price: — I am a little sur- 
prised at the position taken by gentle- 
men in regard to pus and the ability 
to locate it. I mean to say whether 
it is in one place or another after the 
disease has existed any length of 
time. I can not do it on the living, 
and I have never seen any one do it 
satisfactorily on the dead. I have 
seen probably one hundred cases of 
puerperal peritonitis, and in this num- 



Digitized by 



Google 



184 



PHILADELPHIA OBSTETKK AL SOCIETY. 



bor many cases where the jK^ritoneum 
contained not ounces but pints of pus, 
and where flushing and drainage was 
all that was necessarj^ for recovery, and 
I am positive that in those cases no 
one could say whether the infection 
had come from the tubes, from the en- 
dom(»trium, or whether it had come 
from some injury or violence at the 
time of labor. In nearly all the cases 
the trouble came on too late after labor 
to say that it was from an injury, but 
when it is said that pus can not exist in 
the pelvis without the infection has 
come thi-ough the uterus or append- 
ag(»s, it is a mistake, because I have 
oj>ened abscesses in the groin and in the 
loin which seemed to be intra perito- 
neal, and I know they were not con- 
nected with the uterus, because the 
patients were males. I did not go 
deeper than the abscess cavity and both 
of the (*}uses nuide good recoveries. I 
see no reason why Dr. Boyd's case 
could not have been one of abscess 
outside the peritoneum, having nothing 
to do with the uterus and nothing to 
do with the confinement. There are 
so many labors that we can not say 
that a woman may not have as a 
coincidence an abscess somewhere 
about the pelvic bones, along the 
crest of the ilium or ah)ng Poupaii's 
ligament that has absolutely nothing 
to do with the uterus. Only a little 
while ago I reported a pelvic abscess 
in a boy with a gallon of pus. Had the 
patient been a girl, I should probably 
have said that it was a p(»lvic abscess 
without uterine or tubal involvement. 
We are often too loose in our state- 
ments when we say that we know 
that the trouble is not tubal, but in 



this case, the fact that no sign of 
disease remains is almost proof posi- 
tive that there was no tubal disease. 
I do not believe that these cases will 
get well and remain well if the 
trouble originates in the tube or 
ovaiy. 

In Dr. Ashton's case where he 
states that the tubes were not diseased 
and the head of the colon and appen- 
dix was gangrenous, I should judge 
that the infection had come from a 
preexisting appendicitis. 

Dn. G. Batton Massev : — There 
seems to be two sides to this question. 
One tak(\s the position that the old 
surgical axiom that where you find 
pus it should be let out at the most 
de{>endent and best point for drainage 
is correct, while the other side seems 
to take the position that if it is a 
woman that is suspected of having 
the abscess, you must dig around 
among her vital organs to see if it 
is not something else ; then after prob- 
ably doing untold damage you may 
adopt the old fashioned surgical proced- 
ure and open and drain. And thus illus- 
trates again the saying that has been 
put forward by me that we are apt 
to fall into fads and lose our hold on 
principles. 

It seems to me that in cases of this 
sort the diagnosis ought to be easily 
made before the knife is used, adopt- 
ing Dr. EbedohFs plan of aspiration. 
Surely the presence of pus could be 
discovered before operation. This 
operation has been done by Dr. Ebe- 
dohl a number of times without bad 
results. Of course, as has been said, 
if you have a pelvic abscess of the 
extra-peritoneal kind, or an ovarian 



Digitized by 



Google 



PHILADELPHIA OBSTETRICAL SOCIETY. 



186 



abscess or a typical pus tube, there 
will be agglutination of neighboring 
organs, and if you dig for them you 
will find them, but that is not posi- 
tive proof that you should dig for 
them. 

Dr. Chakles P. Noblk: — I did 
not have the pleasure of hearing Dr. 
Boyd's paper, but since I last ad- 
dressed the Society on this subject, I 
have had two cases in addition to 
those previously reported. Some time 
ago I saw a case on which Dr. Joseph 
Price came near operating. If he had 
opened that case, he would have had 
one case in which there was pus in 
the broad ligament. The patient was 
a Russian Jewess and I saw her some 
time after labor. The labor was fol- 
lowed by sepsis, and in that case the 
broad ligament was riddled with 
abscesses and the omentum was 
adherent. Of course there was sal- 
pingitis, but there was no pus in the 
tube. The broad ligament had the 
omentum fastened to it, but the dis- 
ease was plainly primar\' in the 
broad ligament. 

The second case wjus a patient of 
Dr. Dunn and was seen in East 
Chester. The confinement was fol- 
lowed by sepsis, and some weeks later 
I saw her. She had had a tempera- 
ture of 102° to 103° for some weeks, 
with a large mass in the left groin. 
I opened that without opening the 
belly. The patient recovered and 
Dr. Dunn writes me that he is unable 
to find any pelvic mtiss in the left 
side. In this last case, as the belly 
was not opened, it is impossible to 
speak of the condition of the appen- 
dages, but I have every reason to 



believe that it was a typical broad 
ligament abscess. 

Dr. Baldy : — What reasons have 
you for believing that this was a broad 
ligament abscess? 

Dr. Noble : — If this had been an 
abscess connected with the tube, I do 
not believe that it would have gotten 
well by simply opening it in the 
grom. With a suppurating tube at 
the bottom of the cavity, I think that 
a sinus would have been left. The 
wound closed, the woman feels well 
and the doctor can find nothing 
wrong. 

I have been investigating this mat- 
ter from the standpoint of corres- 
pondence. I find that about ten per 
cent, of my correspondents have veri- 
fied cases of broad ligament abscess 
by abdominal section and a much 
larger percentage have opened ab- 
scesses which they considered broad 
ligament abscesses, but not having 
opened the belly they have been un- 
able to exclude tubal and ovarian 
trouble. 

Dr. George M. Boyd: — The dis- 
cussion seems to have wandered far 
from the subject of extra-peritoneal 
collections of pus. In the case re- 
ported the infection seemed to be by 
way of the vagina, because throughout 
the illness of the patient there was no 
tenderness over the uterus and the 
one labium was timiefied. More than 
that, she had been attended by a 
midwife. I felt that it was an extra- 
peritoneal accumulation of pus, and as 
the woman was very ill at the time 
of operation, it was important to de- 
cide whether it was wisest to make 
a central incision or to attempt to 



Digitized by 



Google 



136 



REVIEW OF GYNECOLOGY. 



relieve by an incision above Poupart's 
ligament. The course that I pursued 
seemed to be the wisest. 

With regard to the amount of pus, 
Dr. Wilson reminds me that there 
was more purulent matter evacuated 



than is indicated in the report. For 
several days pus from the abscess 
drained away. I do not think that 
that is the history of the drainage of 
an ovarian abscess. 
Adjourned. 



REVIEW OF GYNAECOLOGY. 



Intestinal Occlusion After Opeu- 
ATioN. By Dr. Leguen. 
The author reported the following 
case at the Soci^lS Anatomlque of 
Paris. A woman was operated on for 
a unilocular ovarian cyst, tlie laparot- 
omy presenting no difficulties, when 
shortly after, symptoms of intestinal 
occlusion appeared. The sutures of 
the abdomen were removed and the 
incision enlargc^d. The large intestine 
on the right side was found dilated ; 
on the left side it was flatten(»d, and 
consequently the obstruetien should 
be found in the region of the splefni. 
Nothing however could be found and 
the patient dicnl a few hours later. 
The autopsy revea]<'d some hard bands 
at the. postero-inf( rior part of the 
spleen, binding this organ to the 
transverse meso colon. These bands 
were very hard, thick and of old date ; 
a very large one was the cause of the 
flattening of the intestine. It might 
have been thought that the intestinal 
coils had been displaced during the 
laparotomy and had indirectly pro- 
duced this complication, but no lesion 
was found in the interior of the in- 
testine at the site of the strangulation. 
(^Nouvelle% Archives d* Obntetrique et 
de GynScologie^ Aug., 1894.) 



Congenital Colloid Myxosar- 
(X)MA. Br Dr. Massen. 
The author related the following 



case at the Obst(»trical Society of St. 
Petersburg at the meeting of March, 
1894 : A strong woman with a nor- 
mal pelvis came to the Maternity for 
her sixth labor. Vertex presenta- 
tion, position right occipital posterior. 
Spontaneous expulsion of the head 
and upper part of ti*unk, when 
in spite of energetic contractions- 
further expulsion ceased. Trac- 
tion on the shoulders produced no 
result. Chloroform was given and 
the feet had to be first extract- 
ed in order to deliver the child, 
which breathed poorly and died 
shortly. On examination of the in- 
fant, tumors were found on both 
buttocks. The tumors were round 
and covered by smooth, stretch- 
ed skin, containing many dilated 
veins. 

The tumor on the right side wa.s 
as large as two fists, being larger and 
harder than the left one. The largest 
circumference of both tumors together 
measured 40 centimeters, the smallest 
38 centimeters. Autopsy showed that 
the tumors were developed in the 
muscles, each being covered by a 
capsule. Microscopically they were 
found to be myxosarcoma, the left 
having already undergone slight de- 
generation. No other anomaly was 
present in the child. (^Nouvelles 
Archives d Obstetrique et de GynScol- 
ogie^ Aug., 1894.) 



Digitized by 



Google 



REVIEW OF GYNECOLOGY. 



137 



multilocijlar dermoid ovarian 
Cyst. By Dr. Dranitzine. 

At the same meeting Dranitzine 
showed a dermoird, its cavity being 
divided into two pockets. One of 
these was filled with a creamy liquid ; 
the other contained grease, hair, etc. 
The walls of the cyst were infiltrated 
with calcarious deposit and were hard 
and friable. The pedicle was twisted 
and degenerated and nearly completely 
detached from the cyst. (^Nouvdle» 
Archives cC Obstetrique et de Gynecol- 
ogie^ Aug., 1894.) 



The Treatment ok Coma in Hy- 
steria. 

(1.) Give the following enema : — 



Tinct. valerian, 
Moschi, 
Vitel. ovi, 
Aqua, 



grammes. 

1 gramme. 
No. 1. 

250 grammes. 



(2) Digital compression of both 
auroteds. ('^) Perform r^^thmical 
tractions of the tongue (after La- 
bord's method?) and apply interrup- 
ted electric currents to different 
parts of the bodv. (La Trihune 
MSiUeale. Aug. 8o', 1894.) 



Uterine Fibroid Associated with 
Anuria, Hysterectomy, Kecov- 
ery. By Dr. Tuffier. 

The author reported the case at a 
meeting of the Soc'^SS de Chirunjie 
de Paris. In a patient from whom 
he had removed a uterine fibroid two 
years before there was absolute 
anuria which had lasted four days. 
Without any subjective symptoms a 
tumor the size of a gravid uterus had 
developed in the last ten months. 
Dysuria had been present for two 
weeks, resulting in anuria. Her 
general condition was extremely poor. 



pulse weak, frequent respirations and 
frequent vomiting." Tympanitis was 
marked, the intestines not having 
moved for a number of days. Hys- 
terectomy was performed. In the 
first twenty-four hours after opera- 
tion 1050 grammes of urine was 
voided. The uremic symptoms com- 
pletely disappeared in three days, and 
ten months after, the patient re- 
ported herself as entirely well. (Xe 
Mercredi MSdicale, No. 42, 1894.) 



The Effe(^ts of Quinine on Pjie(^ 

NANCY. 

A collective investigation of this 
subject has been recently under- 
taken, with the following conclu- 
sions: (1) The existency of preg- 
nancy is no bar to the administration 
of quinine. (2) For fevers and other 
affections during pregnancy, in which 
quinine is indicated, the effects of the 
drug are more marked tlian those of 
any other. (3) That abortion fol- 
lowing the administration of quinine 
is either the result of the original 
malady or the effect of idiosyncrasy. 
(4) That allowing for an idiosyn- 
crasy, in cases in which a tendency to 
abortion exists, and in others as a 
matter of precaution, quinine is best 
administered combined with a seda- 
tive (opium.) (5) Hence the old- 
standing view of the action of quinine 
on the duration of pregnancy is not 
borne out by the clinical experiences 
collected in the replies. (Indian 
MedicO'Vhirunjical Reinew ; reviewed 
in the Medical Records Sept. 8, 
1894.) 



The Treatment^ of Gonorrhceal 
Endometritis. By Dr. R. Arch. 

The author recommends as treat- 
ment in this affection the intrar 
uterine application of this formula : — 



Digitized by 



Google 



138 



BOOK REVIEWS. 



R. 



Aluranol, 
Laiidani, 
Glycerini, 
Aq. dest. aa, 



7 grammes 50 centigrammes. 
100 grammes. 

25 grammes. 



A small quantity of this mixture is 
injected into the cavity of the uterus, 
by means of a syringe, similar to that 
employed by Braun, but of larger 
calibre. These injections are prac- 
tised first every three days, later 
every four days. (^Semahie MS U- 
cale ; Gazette de GynScohufie^ Axuf, 
15, 1894.) 



FnisT Seules of 100 Operations 
OF Uko-genital Fistula ix the 
Feivfale. By Dr. O. Morisani. 

The author divides uro-genital fistu- 
Ise in the female into five sections, 
viz: (1) Urethro-vaginal fistuke ; (2) 
Vesicovaginal fistuhe ; (8) Vesico- 
uretero-vaginal fistulse ; (4) Vesico- 
cerv'ico utero-vaginal fistulae, sub -di- 
vided into deep and superficial; (5) 
Uretero-vesi CO uterovaginal, or uro- 
genital cloaca. Among the compli- 
cations of these various fistid?e, the 
author insists on stricture, even im- 
permeability, of the urethra ; on pro- 



lapsus of the vesical mucous mem- 
brane, stricture of the vagina, pro- 
duced by bands of adhesions project- 
ing into the vagina in form of rings, 
rendering small fistula? inaccessible 
or invisible, causing retention of 
urine and later calculus. The edges 
of the fistuke sometimes adliere to 
the bones of the pelvis, to the sym- 
physis pubis, or even to an ischio- 
pubic ramus. The peri-fistiilar celu- 
lar tissue may be in a state of 
sclerosis. Vaginal and vulvar ulcera- 
tions may be covered by false mem- 
branes and condylomata. As to 
treatment, the author especially in- 
sists on the necessity of complete 
antisepsis of the genital tract. In 
operating, Sim's position is usually 
employed and the patient is given as 
little anaesthetic as possible. The 
Avriter employs metallic sutures as 
much as possible, or metallic and silk 
sutures combined. Among accidents 
consecutive to the operation, spasms, 
vesical tenesmus and haemorrhage 
are to be noted. In some patients, in 
order to obtain complete cure, sev- 
eral operations are necessary. ( Grior- 
nale internaz, delle So. Mediche ; re- 
view in AnnaJes de Gj/nScoloffie et 
d ' Obstetrique. Aug., 1894. 



BOOK REVIEWS. 



TjiA>:s ACTIONS OF THE AmEKICAN 

Gynaecological Society, Vol. 
XIX. Wm. Doman, Printer, 
Philadelphia, 1894. 

This work, which ^contains twenty- 
six papers, is as usual of the highest 
order. As several of the memoirs 
have already been abstracted in the 
" Annals" the titles and names of the 



authors will simply be given. The 
president's address, by Wm. T. Lusk* 
was '* The Relative Value of the 
Various Surgical Methods of Treating 
Uterine Fibroids." Five papers on 
Extirpation of the Uterus in Diseases 
of the Adnexa came from the pens of 
Baldy, Krug, Hanks, BacKe Emmet 
and Wylie. Hysterectomy in BUat- 



Digitized by 



Google 



BOOK REVIEWS. 



139 



eral Pelvic Disease was ably pre- 
sented by Wm. R. Pryor. Three 
papers on the Management of Face 
Presentations by Reynolds, Jewett 
and Davis fonn. an interesting part of 
the volumt^ I'he Abuse of Trachelor- 
rhaphy, is by Wm. R. Prj or. A most 
inteiesting paper on Fatal Nausea 
and \'omiting of Pregnancy was read 
by E. P. Davis. One paper especially 
to be considered and read is Ilyter- 
ectomy in Septic Pelvic Diseases by 
Femand Ilenrotin. The other mem- 
oirs contained in this volume are as 
follows: — Myomectomy as a Sub- 
stitute for Hysterectomy by E. V. 
Dudley ; Intraligamentous and Retro- 
peritoneal Tumors of the Uterus and 
its A(hiexa, by Wm. 11. Wat hen ; 
Rupture of the Uterus is considered 
lus to tn»atment by U. M. (ueen and 
Malcolm McLean ; The Best Method 
of Operating Old Lacerations of the 
Perineum, by W. G. Wylie; 1he 
Ultimate Results of Treatment of 
Backward Displacements of the 
Uterus, etc., by F. H. Davenport; 
Inflammation of the Ureters in the 
Female, by'W. I). Mann; Symphsio- 
tomy versus Induction of Premature 
Labor, by ('. P. Noble; The Influ- 
ence of Minor Forms of Ovarian and 
Tubal Disease in the Causation of 
Sterility, by T. A. Ashly ; Vaginal 
Anus and Treatment, by A. H. 
Buckmaster ; Vaginal Hysterectomy, 
by E. E. Montgomery ; Shortening of 
the Round Ligaments for Uterine 
Displacements, by 11. P. Newman ; 
Ha?matocele Retro-uterina, by (i. T. 
Harrison. 



A Mantal of Nursin(} in Pelvic 
SriujEUY. BY Lewis S. McMiu- 
TRY, A. M.; M. I)., Professor of 
Gymecology in the Hospital Col- 
lege of Medicine, Louisville, etc. 
John P. Morton & Co., Publishers, 
1894. 

This neat little work of 92 pages 



has been prepared as a practical guide 
for nurses engaged in the surgical 
treatment of the diseases peculiar to 
women. The methods given are those 
practiced by the author and pains 
have been taken to make all subjects 
as clear as {)ossible. The work treats 
of the general anatomy of the pelvis, 
the preparation of instruments and of 
the patient, operations, complications 
and operations performed in private 
houses. 

The book is clear and concise and 
very well fills the place intended for 
it. " 



A Manual of Human PnYsiouKiv. 
By Joseph II. Raymond, A.M.; M. 
I)., Professor of Physiology and 
Hygiene in the Long Island College 
Hospital and Director of the Physi- 
ology in the Iloagland Laboratory. 
W. 'B. Saunders, 925 Walnut St., 
Philadelphia, 1894. 

The author's experience of twenty 
years as a teacher of physiology ha>i 
brought him to the conclusion that, 
in the shoi-t time allotted to the study 
of this science students, can only 
assimilate its principal fact^. The 
author has kept in mind this fact, and 
in his book he has endeavored to 
put into a concrete and available 
form the results of his experience. 
As in all books on the subject there is 
a little space devoted to embryology, 
which should not find its way into 
a work on physiology. The nervous 
system is the best feature of the 
work, and food and digestion are well 
treated. The Avork is good for what 
it is intended and probably best fitted 
for the author's students. The illus- 
trations, some of which are colored, 
are taken from the works of Ranvier, 
Heitzmann, KoUiker and others. The 
publishers have, as usual, printed and 
bound the work in the best of taste. 



Digitized by 



Google 



ANNALS 



—OF— 



GYNAECOLOGY AND P/EDIATRY. 



DEPARTMENT OF PEDIATRY. 



EDITORIAL. 



Dr. Viquerat's Treatment of Tuberculosis Before the Societe Medicale de 

la Suisse Romande. 



Of late, luaiiy papers have been 
talking much about the new treat- 
ment of tuberculosis by asses' blood- 
serum and we desire to relate the 
result of the meeting of the SociSt^- 
MSdicah de la Suisse Romande re- 
garding this treatment. The reader 
desirous of looking up the theory and 
teclmique of this new method is 
requested to consult Tho Lancet for 
Sept. 29, and Oct. i\. 1894. 

The Swiss Society met at \'evey 
on Oct. 11, and one of the papers 
figuring on the list was by Dr. Viq- 
uerat on his new treatment and this 
memoir was followed by a most 
animated discussion. Dr. Viquerat 
spoke for about an Iiour, chiefly on 
immunity, experiments Avith tetanus 
and diphtheria, quite forgettmg that 
he was dealing witli the profession 
which was perfectly au courant with 
these questions. The only essential 
point in which Dr. Viquerat diverges 
from the opinions of the French 
bacteriologists is his conception of 
the virulence of cultures. The 



French attribute this virulence to a 
poison secreted by the organisms 
which is dissolved in the culture 
bouillon, while Dr. Viquerat believes 
that the poison resides in the bodies 
of the organisms themselves, which 
only dissolve after their death in- the 
culture bouillon. Consequently it is 
the cadavers of the bacilli whicli con- 
fer toxicity to the media. The 
{)resence of glycerine in the media 
favors dissolution and this is the ex- 
planation of the toxicity of tuberculin, 
which is a culture of the bacillus of 
tuberculosis in a glycerine media, the 
culture being filtered and reduced to 
1-10 by heat at lOO^C. It is this 
property which explains the natural 
immunity in man against various in- 
fectious diseases. We eat and absorb 
each day the most virulent organisms, 
and while in such small quantity we 
digest them, and these organisms, dead 
and digested, produce in us- little by 
little a vaccination against disease. 
Thus, while children are very suscep- 
tible to tuberculosis and diphtheria. 



Digitized by 



Google. 



TREATMENT OF TUBERCULOSIS. 



141 



old people are much less so, liiaving 
little by little digested the specific 
germ during their existence. Ac- 
cording to Wassermann, 10 cubic 
centimetres of serum taken from an 
old man can neutralize one cubic cen- 
timetre of the toxine of diphtheria. 
Consequently, in a tuberculous 
patient, things take place as follows : 
If the subject has been placed in a 
position obliging him to absorb more 
bacilli than he can digest, these bacilli 
multiply and create their disease. 
As these organisms die, they are 
dissolved and send out tuberculin 
into the entire system; and this 
tuberculin, by the arterial congestion 
that it produces around the tubercular 
foci, favors their diffusion, thus ex- 
plaining the progi'ession of the 
affection. Now, the blood of an 
ass posseses the property of neutraliz- 
ing tuberculin, thus showing the re- 
fractory condition of this animal 
against tuberculosis. Since Dr. Viqu- 
rat's communication of last July, in 
which he announced that he simply 
injected pure serum of the ass, he has 
modified his method and believes that 
he increases the power of immunity 
by first injecting cultures of the 
bacillus of tuberculosis into the veins 
of the animal. Desirous of more facts 
than theory, the Society would have 
liked it better if Dr. Viquerat had 
brought some of his patients under- 
going the treatment as well as a few 
guinea pigs treated by the method. 
But the speaker was contented in 
announcing that he had cured twenty- 
five cases of tuberculosis and showed 
two of his cases, one of which was a 
little girl with lupus of the hand, and 



a young man, who, after a long sup- 
puration in the pleura necessitating 
the resection of three ribs, had a 
fistula which was cured by one 
month's treatment with injections of 
serum. Now, the little girl was not 
cured, which fact was affirmed in par- 
ticular by Dr. Dind, Professor of Dis- 
eases of the Skin, at the University of 
Lausanne, and the case of the young 
man was not reported, so that it is 
permissable to doubt the tubercular 
nature of his lesion, as the appearance 
recalled perfectly a simple cured em- 
pyema. In the discussion which fol- 
lowed. Prof. Bourget said that he had 
had in his hospital service a patient 
of Dr. Viquerat's, and, in spite of his 
long stay in the hospital, it was im- 
possible to find in him any sign of 
active or cured tuberculosis. The 
patient had a chronic bronchitis and 
emphysema, diseases considered by 
the majority of the profession as an- 
tagonistic to tuberculosis. Dr. Bour- 
nier related the case of a tuberculous 
guinea pig in the laboratory of Prof. 
Tavel, who died literally filled with tu- 
bercles in spite of an intensive treat- 
ment with serum sent by Dr. Viquerat. 
Prof. Revilliod then spoke. He ex- 
pressed his doubts as to the immunity 
of the serum of the ass, because every 
time that the cultures were in- 
jected, this animal reacts, very 
slightly it is true, but always with 
the same intensity. Still more, he 
expressed the fear that in the prep- 
aration of the animal by injection 
of the living bacillus, they might be 
found in the serum destined for 
the injection, the animal only ren- 
dering what had been given him. 



Digitized by 



Google 



142 



CHARLES (illEENE CUMSTON. 



But these theoretical considerations 
should give way to clinical observa- 
tion, and it is on this ground that Prof. 
Revilliod took his position. As Dr. 
Viquerat had given a bottle of serum 
to the Medical Clinic of the Faculty 
of Geneva, it had been injected into 
three cases. In two of these cases, 
after, seven and eight injections of 
serum, practised about everj' day, no 
increase or decrease in the disease 
was noted. The third case was that 
of a young Italian, very strong in 
appearance, and who had a tubercular 
lesion in the lungs just at its d(*but. 
The patient received in nine days, 
five injections of serum, and during 
this time his general condition 
became exceedingly grave. The 
appetite and strength, which were 
normal when the man entered the 
hospital, rapidly disappeared, and 
fever, which had not been present, 
was observed. When the patient 
left the hospital (for he wa« obliged 
to return to Italy) his condition was 
much worse than when he entered. 
Not wishing to draw any conclusion 



from so few cases, Prof. Revilliod 
made a rendezous for a near date, in 
order to conclude, after more expe- 
rience, the value of the treatment, 
as the professor desired to have some 
proofs, or at least some indications, as 
to the real efficacy of the method, 
and would also like to have either full 
details of the cases treated or labora- 
tory experiments, which are now 
completely wanting. The discussion 
was then closed for want of facte 
controlling the question, and by una- 
nimity the following resolution was 
proposed and adopted by the Society: 
** On account of the absence of proofs, 
the Medical Society of the Suisse 
Romande declares its inability to 
emit any appreciation on the subject 
of the treatment of tuberculosis ac- 
cording to Dr. Viquerat's method." 
Let us hopes however, that this 
question will continue in the road 
that it should have followed from the 
beginning: patient research, serious 
control and the publication of experi- 
mental and clinical work in medical 
journals. 



The Treatment of Whooping Cough, with Special Reference to Antipyrine. 



BY CHARLES GREENE CUMSTON, M. D. 



Chemical and PhyBiological Prop- 
erties. Antipyrine was discovered 
by Dr. Knorr, of Erlangen. He 
obtained it by combining acetacetic 
ether with phenylhydrazine ; ace- 
tactic phenylhydrazine-ether was 
thus formed, and when heated on 



a water bath changed to antipy- 
rine. This name was given the 
product for therapeutical use. Knorr 
announced it under the scientific 
name of d(5methyloxy-quinizine, 
which corresponds to its chemical 
constitution. A third name, anal- 



Digitized by 



Google 



WHOOPING COUGH. 



143 



gesine, has been given it. In fact 
this product last named, as prepared 
by Petit, a Paris chemist, is identical 
in every respect to that of Dr. Knorr. 
Antipyrine is a white substance com- 
posed of crystals in the form of fine 
needles. When perfectly pure it is 
without odor; when purification is 
not complete, it gives out a disagree- 
able smell of benzine. It has a 
slightly bitter taste, but this does not 
last. It is very soluble in water and 
alcohol; only slightly so in ether. Its 
melting point is not as yet absolutely 
fixed. Knorr thinks it to be a 113° 
C; other chemists put it at from 
110** to 1130 C. This difference of 
opinion is easily explained if it be 
remembered that antipyrine is ex- 
ceedingly hydrometric. When it is 
totally diy, fusion takes place at 
110'' C'., 60 that with this precaution, 
this physical character has a certain 
importance. Its chemical reactions 
are numerous, but are generally not 
characteristic. Antipyrine is precipi- 
tated by the general reagents of the 
alcaloids, such as those of Wry and 
Sonnensgien, Marm^, Meyer, Drag- 
gendorff, etc. Among these the 
iodated iodide of potassium should be 
mentioned, as it is quite characteristic. 
It gives a dark red precipitate, which 
is perceptible at 1-100,000 per cent. 
This reagent has been advised for the 
search of the drug in the urine. 
Picric acid and tannin also precipi- 
tate antipyrine. Hypobromide of soda 
produces a precipitate, which, if heated, 
is transformed into heavy oily drops, 
having an empyreumatic odor. The 
reagents which can be relied upon are 
perchloride of iron and nitric acid, 



the latter producing a green colora- 
tion, sensible at 1-100000 per cent. 
The perchloride of iron produces a 
blood red color, distinctly visible in a 
1-2000 per cent, solution, or even at 
1-5000 per cent. This color is pro- 
duced by a mixture of sulphuric and 
ozotic acid, but disappears rapidly. 
Antipyrine is decomposed by oxydiz- 
ing substances in presence of water; or 
by the action of heat a series of 
bodies are formed, among which 
phenol and acetone predominate. Let 
me add, before closing, that the re- 
search of antipyrine in the urine is easy, 
because is it preserved on account of 
its resistance against fei-mentation. 

In the administration of antipyrine 
in whooping cough, I shall pass in si- 
lence over its antithermal action and 
shall only occupy myself with its 
action on the nervous system. 

Pysiological action. Demme of 
Berne, in 1894, was the first who 
noticed that by large doses the animals 
were killed by paralysis of the heart, 
while smaller doses produced an exag- 
geration of the reflexes and an irrita- 
tion of the spinal cord. Cappola 
remarked an increase of reflex 
irritability in the frog at a dose 
of from 20 to 40 mg.; with 
doses of from 50 to 80 mg. he 
produced convulsions, which disap- 
peared when the cord was cut across. 
A large dose paralyzed the nervous 
centres, the sensitive nerves being only 
affected for a short time. Henocque 
and Arduin produced tonic convul- 
sions with paralysis and rigidity of 
the muscles in a dog by a hypodermic 
injection of antipyrine at the dose of 
6 grammes and a half per kg. of the 



Digitized by 



Google 



144 



CHARLES GREENE CUMSTON. 



weight of the animal. Bouchard 
showed in a note read at the Biologi- 
cal, Society of Paris in 1884 that the 
action of antipyrine on the convul- 
sions that it produced was through 
its action on nervous and not on the 
muscular system. Experiments show 
that if antipyrine be given to an ani- 
mal after you cut the sciatic and 
crural nerves on the same side, a 
general muscular rigidity takes place, 
excepting in the limb having its 
nerves sectioned. In 1885, Prof. G. 
Sde, in his first note read at the 
Academy of Medicine, of Paris, re- 
lates the following experiments made 
by Gley: Two grammes injected 
subcutaneously in a dog weighing 10 
kg., the drug produced three symp- 
toms, viz.: First, very marked de- 
crease of sensibility and even a real 
analgesia of the limb into which the 
drug was injected and sometimes on 
the other side as well ; second, in an 
animal under the influence of antipy- 
rine, excitation by electricity of the 
sciatic nerve only produced a very 
slight reflex contraction of the oppo- 
site side, consequently indicating .a 
weakening in the perceptivity of sen- 
sibility and reflex power of the cord ; 
third, if the animal is poisoned, ex- 
cepting one limb, which has had its 
artery tied, the muscles under the in- 
fluence of antipyrine are seen to con- 
tract slowly and with difliculty, while 
the muscles of the limb into which 
the drug had not entered, preserved 
their contractility, thus proving that 
antipyrine acts directly on the mus- 
cular nerves. Carasias, in his thesis 
written under the direction of Prof. 
S(3e, came to the same conclusions. 



After injections he found the sensi- 
bility lessened in the limb injected. 
If the dose was rather strong, anal- 
gesia extended into both, limbs but 
still predominated in the member 
which had received the ifijection. 
Antipyrine may consequently be con- 
sidered a ners^e medicine par excel- 
lence. It is an excellent sedative of 
the bulbo-medullaiy system, capable 
of diminishfng the neuro-reflex mus- 
cular contractions and of weakening the 
excito-motor action, whose expressions 
are so varied in paediatric pathology. 
It is a depressant and inhibitory drug 
of the highest order, and this is why 
I believe it indicated in certain nerv- 
ous diseases of childhood, and among 
them pertussis. 

Having given this short intro- 
duction on the chemistry and 
physiology of this important rem- 
edy, in order to demonstrate with 
some reason, based on experimen- 
tal therapeutics, its use in per- 
tussis, I shall proceed to give a des- 
cription of the treatment of this dis- 
ease by remedies other than antipyrine, 
and then antipyrine alone or in com- 
bination, that have appeared to me 
to be of some value. 

Pertussis is a complicated affec- 
tion, inflammatory, spasmodic and 
congestive in character, the pa- 
thology of which has not as 
yet been completely elucidated. Ac- 
cording to some writers, especially 
von Ilerff, whooping cough is con- 
sidered as a local catarrh of certain 
portions of the mucous membrane 
covering the arytenoid cartilages 
and the cartilages of Wrisberg and 
Santorini. Michael, Hack and Sch- 



Digitized by 



Google 



WHOOPING COUGH. 



146 



wadewald place it among the reflex 
neuroses of nasal origin, but the 
greater number of writers give it a 
parasitical origin, and in this theory I 
am inclined to believe. According to 
the writings and researches of Letzer- 
ich in 1870, of Tschamer in 1876, 
and the more recent ones of Dr. 
Afanassjew of St. Petersburg, the dis- 
ease is produced by a fimgus. which 
covers the mucous membrane of the 
respiratory passages. Afanassjew has 
named it Bacilltut ticssis convuhivce. 
This writer endeavored to put him- 
self out of range of the criticism which 
was made of his predecessors. His 
aim was to realize an asepsis of the 
mouth and throat of his patients by 
means of irrigations with a solution of 
permanganate of potassium and by a 
thorough cleaning of the teeth. After 
having -described the bacillus that he 
had discovered, he inoculated them in 
animals, killing them with all the 
symptoms of pertussis and broncho- 
pneumonia, from which results he 
concluded that the disease was of a 
parasitical nature and consequently 
contagious. Sremtschenkow after thor- 
ough experimentation with the bacillus 
of Afanassjew came to the conclusion 
that it was specific, it was to be found 
in the sputum about the fourth day of 
the disease ; it multiplies in the tissues 
of the human organism and as it 
increases the disease becomes more 
severe with complications, a^ for ex- 
ample catarrhal pneumonia, a great 
increase in their number is found in 
the sputum ; and lastly, the. baciUus 
disappears a little before the end of 
the affection. As to the treatment of 
this malady, it may be said that there 



are few diseases for which a greater 
number of remedies have been de- 
vised, and I wiU now pass in review 
the principal ones. In the first period 
of the disease the treatment is the 
same as for ordinary bronchitis and it 
may be continued in the second period. 
If there be abundant expectoration a 
vomative should be- prescribed as has 
been advised by Guersant, the syrup 
and powder of ipecacuanha should be 
chosen in preference to all others. 
CuUen prefered emetic ; he gave the 
antimoniated tartrate of potassium 
after the manner indicated by Fother- 
gill. The following is also good : 



R. Vint antimonii 
Syr, scillse aa 
Aluminii, 



10 grammes. 
5 grammes. 



M. D. S. — A teaspoonful every two 
or three hours. These means are often 
efficacious in lessening the attack. 
Antispasmodics, such as musk, assa- 
fcetida, oxide of zinc and above all 
the bromide of potassium and am- 
moniimi serve to calm the cough and 
diminish the number of attacks. 
Belladonna, datura, ergot, cochenil, 
chloroform, chloral, infusion of coffee 
have all been extoUed for the same 
end. An excellent formula for bella- 
donna as prescribed in Vienna is the 
following : — 

R. Palv. balladon. rad. 10 centigrammes. 
Sodae bicarb. 40 centigrammes. 

Pulv. sacchar. alb. 2 grammes. 

M. div. in dos. aq. No. X. 

D. S. — Take one powder every 
three hours. Liebemiester's treat- 
ment is as follows. In the catarrhal 
period the patient should remain in 
bed and take a teaspoonful of this 
mixture every two or three hours. 



Digitized by 



Google 



146 



CHARLES GREENE CUMSTON. 



R. Stibll Bolph. aurant. O. 50 grammes. 

Mucilag. gum arab, 20 grammes. 

Aq. dest. 50 grammes. 

When the cough is severe he pre- 
scribes, 



Ext. belladon. 
Aq. dest. 
Syr. ipecac. 
Vini antimon. 



50 centigrammes. 
100 grammes. 
25 grammes. 
10 grammes. 



M. D. S. — A teaspoonful twice to 
six times daily. To stop a paroxysm 
of coughing in the beginning he 
orders: — 



R. Ether, 

OU terpintin. 



4 grammes. 
l£ramme. 



able microbic nature of the affection. 
Some prescribed them internally, 
while others tried to act more directly 
on the respiratory passages by means 
of inhalations. Among the antisep- 
tics the most employed intemully and 
arranged in order of their value may 
be mentioned the salts of quinine, 
salicylate of soda, and lastly, carboUc 
acid, at the dose of 0.025 grammes. 
Carbolic acid may be formulated for^ 
internal use as follows : — 



M. D. S.— 10 to 20 drops to be m- 
haled on a handkerchief. I will only 
mention, en passant^ opium and its 
different preparations. It was much 
praised by Stall, Henke and Dewees, 
but it was not very long before the 
inconveniences in its use were dis- 
covered and to-day it is no longer 
employed. The treatment of pertussis 
by gas was recommended years ago 
and was brought back before the pro- 
fession in 1864 by Bertholle and 
Commenge. It is far from procuring 
all the advantages that its upholders 
claimed for it. However, in 1892, 
Hallett reported four cases of the dis- 
ease treated with good results by in- 
halations of ozone. Leurat Perraton, 
a former physician to the Antiquaille 
of Lyons, recommended the use of 
liquid ammonia as a specific, given 
at the dose of six drops in a potion 
of 150 grammes, to be taken by 
spoonfuls every hour. During the 
last few years a good number of phy- 
sicians have tried the effect of anti- 
septics, basing their use on the prob- 



R. Acid carbol. 
Splr. vini. sect. 
Aq. menth. pip. 
Aq. laurocerasi. 
Syr. sacchar. 



0.20 centigrammes. 
10 grammes. 
40 grammes. 
20 grammes. 
80 grammes. 



M. D. S. — A teaspoonful every two 
hours for a child over two years old. 
Other physicians prefer to act direct- 
ly on the mucous membrane of the 
air passages by inhalations of medi- 
cated vapours, instead of prescribing 
the drug internally. The salts of 
quinine have been employed by this 
means, but the most employed are 
carbolic acide thymol, resorcin, sali- 
cylate of soda or essence of turpentine. 
Inhalations incontestably diminish the 
number and intensity of the attacks. 
Michael tried different powders in 
order to test their efficiency. He ex- 
perimented with hydrochlorate of 
quinine, benzoic acide, bromide of 
potassium, benzoin, tannin, boracic- 
acid, iodoform, cocaine and pumice 
in powder. These different powders 
had for effect to diminish in number 
but not to suppress the attacks. Of 
various other drugs extolled in the last 
few years I will say but little and 
will only quickly mention a few. 
Benzol has been recommended by 



Digitized by 



Google 



WHOOPING COUGH. 



147 



Robertson at the dose of 12 mg. in a 
solution for children of six months, and 
3 eg. in capsules or solution for adults ; 
the success is attained when the air 
respired has the odor of the drug. In 
Germany and Austria, benzol was 
much given in this disease, and the 
writer would suggest the following 
formula, due to Macalister, as being 
the least irritating : 

R. Benzol, 1 gramme. 

Alcohol, q. 8. ad. sol. perfect. 

Tlnct. chloroform, comp. (B. P.) gtts. XV. 

Syr. cort aurant, 80 grammes. 

Aq. dest., 120 grammes. 

M. D. S. — A teaspoonful every 
three hours. Porteous mentions three 
cases of the disease in which he pre- 
scribed onabaine, an alcaloid found in 
the roots of onabaio. The dose is 
.001 of a gramme every three hours for 
a child under five years. The author 
claims that the drug is beneficial in 
all stages of the disease. Bromoform 
has been loudly praised by Krieger, 
Nauwelaers, Earl, and many others. 
Schippers gives the following doses 
as appropriate : — 

From 6 mos. to 1 yr. 10 ct. -gramme 3 times dy. 
** 1 to 2 ys. 20 ** *• 

" 2 to 3 •* 25 
*' 3 to 4 ** 30 
** 4 to 7 " 40to45 ** 

Bromoform should be kept in a 
dark place^ and I think that it is best 
administered in a potion, the quan- 
tity for one day only being prescribed 
and the bottle refiUexi for each day. 
I have treated a few cases with cer- 
tain benefit and have followed the 
doses given by Schippers without 
having met with any accidents. I 
prescribe it as follows : — 



R. Bromoform, q. s. for age of patient. 

Alcohol, q. t. ut f. sol. perfect. 
^ Syr. sacchar. 
Aq. dest. aa 30.0. 

M. D. 8. — To be taken by spoon- 
fuls in 24 hours. 

But of all the treatments devised 
for pertussis that are actually em- 
ployed, antipyrine appears tg be cer- 
tainly the most in favor. Quite a 
nimiber of papers have appeared on 
this subject, and I will take the liberty 
to rapidly recapitulate a few of the 
most important ones. Dubousquet- 
Laborderie was the first to try anti- 
pyrine in whooping cough, and in his 
paper which appeared in le Bulletin 
ginSral de ThSrapeutique of March 
15, 1888, he declared that he never 
met with a drug that gave him such 
good results in this affection, and in 
fact in eleven cases he produced a 
complete cure at the end of from 12 
to 15 days. In only two cases in 
which the attacks of coughing 
amounted to from 40 to 60 times in 
24 hours, did antipyrine appear to be 
useless. He gave it in doses of 30 
centigrammes to one gramme for 
children under 2 years and from 1 to 
4 grammes for older children. In 
every case the drug was well tolerated 
and never produced serious nervous 
symptoms or trouble in the heart or 
kidneys. His conclusions are as 
follows : 1. With rare exceptions 
children support the drug well ; it is 
not dangerous and is easy to adminis- 
ter and control. 2. The spasm is 
quickly calmed and the period of de- 
cline is announced in a few days. 3. 
By the rapidity of its action and its 

Digitized by VjOOQ IC 



148 



CHARLES GREENE CUMSTON. 



harmlessness, antipyrine seems to be a 
precious drug for arresting a disease, 
too often accompanied by compKca- 
tions. 4. The impurity of the anti- 
pyrine plays an important part in the 
production of gastro-intestinal trou- 
bles; consequently the source of manu- 
facture should be looked after. 

At the time this paper appeared, 
Genser, of Vienna, read at the med- 
ical society of that city a statistical 
report of 200 cases of pertussis, 76 of 
which were treated by insufflations 
of powders in the nasal cavity, after 
the method of Michaels, and 124 by 
antipyrine taken internally. The 
result was only fair in the 76 cases 
treated by insufflation, the mean 
duration of the disease was more 
than 42 days, and this fact is in 
accord with the greater number of 
those who have employed this treat- 
ment. The author concluded that 
insufflations only checked vomiting. 
Antipyrine on the contrary gave 
very superior results, the mean du- 
ration of the disease not being over 
24 days and the length and inten- 
sity of the coughing rapidly sub- 
sided, the dose employed .being 
one gramme in twenty-four hours, for 
children under five years of age. 
Some time later Sonnenberg gave 
the result of his pei-sonal experi- 
ence of over 80 cases. The 
method employed by this physi- 
cian consisted in giving thrice daily, 
preferably when the patient was quiet, 
as many centigrammes (each dose) 
as the child was months old and as 
many decigrammes as the patient was 
years old, continuing this treatment 
for eight days after cessation of the 



attacks. Sonnenberg, more enthusi- 
astic than his predecessors, declared 
that he had found the specific of 
pertussis. At the Italian Society of 
Medicine, held at Vienna, in Oct. 
1888, Prof. Guatia said that he had 
cured six cases of pertussis in the 
first stage out of ten which had 
been under his care ; the remaining 
four cases were only cured when in 
the second stage of the disease. He 
prescribed nasal insufflations at the 
same time and antipyrine was given 
internally. Leubuscher treated the 
disease which attacked Jena severely 
during 1888 by Sonnenbei^'s method, 
but did not obtain such brilliant re- 
sults as the latter. Having announced 
that Sonnenberg had exaggerated the 
therapeutic value of antipyrine in 
pertussis, Leubuscher came to the 
following conclusions : (1) Antipyrine, 
when employed in the commencement 
of the disease, exercises a favorable 
action on the duration and intensity of 
the affection. (2) In a great number 
of cases, the number of attacks remains 
limited to six or seven in 24 hours, 
and the length of the disease does not 
go' beyond three or four weeks. (3) 
In no case is the disease cut short by 
the use of this drug. When the 
affection is not at an advanced stage, 
antipyrine does not give more favor- 
able results than any other drug. 
Leubuscher did not observe any seri- 
ous accidents and the only one that 
was observed was a generalized ex- 
anthema in a boy aged seven. 

At a meeting of the SaciStS de 
ThSrepeutique, Feb. 27, 1889, Dr, 
Dubous(][uet-Laborderie brought up 
the question and completed the results 



Digitized by 



Google 



WHOOPING COUGH. 



149 



described in his paper of the previous 
year. The number of cases treated* 
by him up to the above date num- 
bered 94, of varying intensity, and 
inclu(^e both children and adults. The 
speaker this time was still more con- 
vinced and aflSrmative and gave to 
antipyrine a positive action on the 
fundamental elements of the disease, 
namely : specificity, cataiTh, neurosis. 
He had seen the catarrh rapidly 
diminish in several cases under the 
influence of the drug. As to the 
antiseptic and depressive action that 
antipyrine exercises on the nervous 
centres by diminishing the excito- 
motor power of the cord, they had 
been established by the experiments 
made by Brouardel and Loge. 

These are the proofs that the 
author gives. Out of the 94 cases, 
71 times the effect was most marked ; 
23 times only the effect was only fair 
or did not exist. Dr. Dubousquet 
adds that several times he was obliged 
to give up the drug on account of the 
gastro-intestinal troubles produced by 
it in some children. He says, how- 
ever, that generally speaking, children 
appear to support antipyrine better 
than adults, probably on account of 
their greater respiratory activity and 
the greater integrity, of the lungs. In 
one child aged 3, who was cured, how- 
ever, he observed a commencement of 
cyanosis with alarming nervous troub- 
les. He recommends, in spite of this, 
to begin with as large doses as pos- 
sible, watching attentively the effects 
of the drug, and to bear in mind that 
strong and apyretic children support 
antipyrine better than weak and fever- 
ish ones. Muttler and Hare consider 



antipyrine as the best remedy in this 
disease. The latter prescribes 2 
grains, (0.12 centigrammes) every 
three hours until effect has been 
accomplished, and then for every four 
or five hours. Hare also states that 
the drug should be carefully watched 
and should be stopped as soon as 
there is sub-ungual cyanosis. I pre- 
scribe antiyrine as follows : 

R 
Antipyrini pur. 1.0 gramme. 

Syr. cort. aurant. 30.0 grammes. 

Aq. dest. 70.0 grammes. 

M. D. S. A teaspoonful of this 
potion contains 5 centigrammes of 
antipyrine. Dose : a teaspoonful to a 
tablespoonful every three hours, ac- 
cording to the age of the child. 

When there are catarrhal synip- 
toms, add terpin. hydrat. as follows ; 



Antipyrini pur. 
Terpin. hydrat. 
Syr. cort. aurant. 
Aq. dest. aa. 



1.0 gramme. 
1 .50 gramme. 

60.0grammes% 



M. D. S. A teaspoonful contains 
4 centigrammes of antipyrine and 6 
centigrammes of terpine. Dose: a 
teaspoonful to a tablespoonful every 
three hours, according to the age of 
child. 

When the paroxysms are severe, 
I combine antipyrine with the bromide 
of potassium : 



R. 



Antipyrini pur. 
Potass, bromld. 
Syr. sacchar. 
Aq. dest. aa. 



2.60 grammes. 
8.0 grammes. 



60.0 grammes. 

M. D. S. A teaspoonful contains 
10 centigrammes of antipyrine and 30 

Digitized by VjOOQ IC 



160 



REVIEW OF PEDIATRY. 



centigrammes of bromide. Of this I 
give a teaspoonful every three hours 
until affect. 

The following table of doses of 
antipyrine, due to Prof. D'Espine, in 
excellent, and one that should be 
remembered when prescribing this 
drug. 

From 1 to 6 mos. 5 to 10 ct. -gramme per dose. 
" 6 mos. to 1 yr. 10 to 20 *' »* ** 

" 1 yr. to 4 ys 20 to 30 " ** " 

*• 4y8. to 6 " 30 to 50 " *' " 

'* 7 " and upwards 1 to 3 grammes pro die 

Never go above 3 grammes daOy 
in children. 

In closing, I would say that I do 
not believe that antipyrine is a specific 



for pertussis, as many writers think. 
• but I can say that the above formulae 
have been of great service to me in 
the conditions indicated. The par 
tients that I have treated with anti- 
pyrine have on the whole perhaps 
done better than when treated by 
other remedies, in lessening the num- 
ber and severity of the paroxysms; 
but I do not recollect any case that 
was shortened in its duration by anti- 
pyrine. Theoretically it is indicated 
and has proven itself useful in prac- 
tice, and I shall continue to prescribe 
it in this affection until something 
better has been found. 

826 Beacon street, Boston. 



REVIEW OF PiEDIATRY. 



Affections of the Testicles and 
Hereditary Syphilis. 

Taylor (New York Med. Jour,^ 
Nov. 18, 1893) reports six interesting 
cases of hereditary syphilitic envolve- 
raents of the testicles and their append- 
ages. The disease manifests itself most 
generally as an orchitis, with some- 
times an accompanying epididymitis. 
When this occurs it is generally ac- 
companied by an inflammation of the 
vas deferens. This form of syphilitic 
manifestation is not of frequent occur- 
ence, as shown by the presence of only 
about fifty cases reported or men- 
tioned in literature. It is generally 
foimd in children three to six and 
twelve months old, and in diminish- 
ing frequency in the second and third 
years, while there are exceptional 
cases, even as late as the twenty- 
fourth year. 



The orchitis begins slowly and in- 
sidiously without pain or subjective 
symptoms and is only noticed when 
its size attracts attention. It is then 
usually the size of a pidgeon's e^, or 
a small marble or walnut. As a rule 
it is smaU and there is no tendency 
towards the development of a large 
tumor. There is generally no ten- 
derness. Sometimes the ordinary" 
smoothness is not found, and the 
surface of the tunica albugiea is 
uneven and irregular. The epididy- 
mis may be slightly or considerably 
enlarged and also the vas deferens. 
These affections, uninfluenced by treat- 
ment, usually run an uneventful course 
and end in resolution or in atrophy, 
particularly of the gland substance. 
.The concomitants of these testicular 
affections vary according to the age of 
the child and the intensity of the in- 



Digitized by 



Google 



REVIEW OF PEDIATRY. 



161 



feotion. In very early months, roseola, 
popular syphilides, mucous patches, 
eye, ear, and bone lesions may be 
also present. In later months these 
accompanying lesions will be fewer. 
The diagnosis in most cases may be 
easily made, but in others it will not 
be as clear. The differential diag- 
nosis is most diffiqult between syphi- 
lis and tuberculosis, while it should be 
remembered that there may be a 
mixed infection or even malignant 
disease. 

This author would advise the use 
of mixed treatment, which he has 
found most efficient in these cases, as 
also in bone and joint lesions of 
hereditary syphilis. This treatment, 
with intermissions, should be kept up 
at least two or three years. Locally, 
much good can be derived from 
mercurial frictions to the scrotum, 
using, with great care as to the 
avoidence of dermatitis, white pre- 
cipitate or blue ointment. When 
the organ is much affected with 
d^nerative processes, ablation may 
be necessary. 



them to co-exist in the same individ- 
ual. 



Erysipelas and Gonorrh(ea in a 
Cheld. 

An interesting case is reported by 
Schmidt (^Centralfur. GyncekoL^lHo. 
39, '93), in which a child three years 
old was apparently cured .of gonorr- 
hceal vulvitis and urethritis by an 
attack of erysipelas, beginning on the 
left buttock and thigh and extending 
over the entire lower limbs. The 
second day after the appearance of 
the erysipelatous patch, the gonorr- 
hoeal inflammation had entirely dis- 
appeared and the patient at the end of 
one week made a good recovery from 
the erysipelas, with no recurrence of 
the gonorrhoea. It would thus seem 
that the poison or bacteriological 
cause of these two diseases are antag- 
onistic, and that it is impossible for 



A Case of Congenital Hydkocele 
OF THE Neck : Cured by Drain- 
age AND Compression. 

Dickinson (^Brit. Med. Jour.^ May 
12, '94),reports an interesting case of 
congenital hydrocele in a child three 
years old. The appearance of the 
cyst was white, translucent, and 
pearly; it was soft and fluctuated 
during crying and coughing, becom- 
ing alternately hard and soft. It ex- 
tended from the sternal end of the 
left clavicle in front to the middle 
line behind and quite filled up the 
sulcus between the shoulders and 
neck, overhanging the clavicle in front. 
Through and thorough drainage was 
established by a rubber tube, but had 
to be abandoned and was replaced by 
five or six strands of fishing-gut. The 
wound was dressed by a compressing 
antiseptic dressing, this was changed 
every other day ; the seton was re- 
moved thirteen days after operation 
and the wound healed completely five 
weeks after operation. 



The Starting Point of Tubercut- 
Loua Disease in Children. 

In an interesting article (LanceU 
May 12, 1894) J. Walter Carr calls 
attention to the striking contrast be- 
tween tuberculosis in adults and 
children. The three points of most 
marked contrast are the tendency in 
adults to pulmonary tuberculosis ; the 
localization in the lungs, rather than 
the marked generalization in children ; 
and the subordinate part taken by 
the lymphatic glands in tuberculosis 
in the adult. The conclusions he 
would draw from his investigation of 
the literature and reported cases are : 
(1) That tuberculous disease in chil- 
dren commences usually in the glands, 
the liability being at its maximum 



Digitized by 



Google 



162 



REVIEW OF PEDIATRY. 



during infancy and early child- 
hood. The caseous glands, especially 
internal ones, may (a) remain quies- 
cent for an indefinite period ; (6) start 
tuberculous mischief in adjacent parts, 
especially the lungs, by direct exten- 
sion ; and (c) set up general miliary 
tuberculosis. (2) That the internal 
glands, at any rate, are probably most 
often infected directly from the organ 
with which they are connected, al- 
though the possibility of infection 
through the blood-stream must not be 
forgotten. (3) That tuberculous dis- 
ease starts much more frequently in 
the thorax than in the abdomen, and 
certainly far more often in the thora- 
cic than in the mesenteric glands. 
(4) That glandular disease may 
often exist alone and unsuspected ; in 
very many cases, doubtless, it is quite 
impossible of diagnosis ; still, in deal- 
ing with obscure febrile conditions in 
children it is well to realize the 
very definite possibility of the symp- 
toms being due to caseation in glands, 
and to use appropriate medicinal treat- 
ment as well as climate. (5) But, 
after all, by far the most impor- 
tant treatment is prophylactic. This 
should be done by increasing the re- 
sistant power of the system and pre- 
venting the entrance of tubercular bac- 
illi. We have, therefore, to try and 
prevent gastro-intestinal and respira- 
toiy catarrhs, and especially to avoid 
their becoming chronic ; to deal prompt- 
ly with, and, if possible, prevent rickets, 
the great cause of such catarrhs in 
early childhood, and to take especial 
care of children during convalesence 
from measels, whooping-cough and 
other acute specific diseases that de- 
press the vitality of the system. 

'I'keatment of Hemoptysis in 
Children. By Dr. Cedet de 
Gassicoxjrt. 

Absolute rest in sitting posture, the 
patient not being allowed to speak op 



cough. Dry cups or mustard applied 
to the chest. Cold applications to the 
hands. Iced milk. A tablespoonful 
of one of the following formul» is 
ordered : 



R. Pulv. alum. 
X. Aq. Rabel. 
Ext. ratanlii89. 
Syr. simpl. 
Syr. cachou. 
Infus. rosar. 



5 centigrammes. 
(Codex), 15 gtt. 
2 grammes. 

i 30 grammes. 
160 grammes. 



M. D. S. A tablespoonful every half hour. 

R. Ferri perch lorid. 40 centigrammes to 
1 gramme. 
Syr. simpl. .30 grammes. 

Aq. dest. 100 grammes, 

M. D. S. A tablespoonful every half hour. 

R. Ergotin. 1 gramme. 

Ext. ratanhlse. 1 irramme. 

Syr. saccliar. 10 grammes. 

Aq. dest. 100 grammes. 

M. D. S. A tablespoonful every hour. 

In severe cases the author pre- 
scribes : 



R. 



3 grammes. 
«30 grammes. 



Pulv. ipecac. 
Syr. ipecac, 

M. 6. S. A tablespoonful every five min- 
utes until vomiting occurs. (La Presse Medi- 
cale. Sept, 1, 18»4.) 



X. KnU. The Eau de Rabel of the French Codex 
is composed as follows: acid. sui|tburlo at 66**, 100 

§ famines, alcohol at 85 per cent. 3U0 grammes. Mix 
y adding the alcohol little by liitle, allow the 
liquidi» to settle and then decant. G. 6. C. 



Two Cases of Hereditary Syphi- 
lis OF THE Middle Ear. By 
Dr. Chambellan. 

The author reported two cases of 
(jongenital syphilis of the ear. The 
disease showed itself in the form of a 
sclerous otitis of the middle ear, a 
lesion which up to the present time 
has not been written upon. The 
lesion in question does not get well 
spontaneously, but on the contrary is 
curable by specific treatment. (^Con- 
f/res de V association franfaise pour 
ravaiicement des Sciences ; in la Pro- 
ijres MSdicah Aug. 18, 1894.) 



Digitized by 



Google 



ANNALS 



—OF— 



GYNiECOLOGY AND PiEDIATRY. 



Vol. VIII. 



DE^CE^MBHR. 1894. 



No. 3. 



Suppression of Urine after Abdominal Section. 



BY EUGENE BOISE, M. D., 

OBAITD BAPIDS, MIOH. 



Total or partial suppression of 
uriQe after abdominal operations is 
by no means of rare occurrence, and 
the frequency with which it is fol- 
lowed by fatal results is well known. 

Notwithstanding the assertion in a 
recent number of the Times and Reg- 
isfer^ that suppression of urine is per 
^e rarely, if ever, a post-operative 
cause of death, the impression re- 
mains in the minds of many opera- 
tors that the fatal result is largely, 
if not entirely, dependent upon that 
condition. This condition too often 
exists, and in patients apparently in 
good condition before operation, and 
too often fatal results ensue. It is 
therefore imperative that, if possible, 
it should be relieved. 

That we may combat it success- 
fully it is necessary, first, to under- 
stand the physiology of the secretion 
of urine; second, to ascertain the 
i^uses that may give rise to its par- 
tial or total suppression ; and, third, 
to reason from the conditions existing 
after or arising from the operation 



to the conditions directly causative 
of the kidney disturbance. 

It will be necessary onl}*^ to briefly 
recall to your minds the salient points 
in the accepted physiology of urinary 
secretion, not to discuss the theories. 
Concisely speaking, the amount of 
urine secreted depends on the rela- 
tion of the blood pressure within the 
capillaries or the glomeruli and the 
pressure within the convoluted tu- 
bules and efferent vessels. . Other 
things being equal, increased blood 
pressure in the renal artery results in 
increased secretion of urine, and con- 
versely lowered blood pressure de- 
creases the amount of urine. In 
other words, the amount of urine 
secreted rises or falls according to 
the degree of fulness of the renal 
artery and the velocity of the cur- 
rent through tbe capillaries. 

The process is not merely one of 
pure filtration, as experiments have 
proved that the epithelial cells of the 
glomeruli have an influence on the 
secretion of the watery constituents 



Digitized by 



Google 



154 



EUGENE BOISE. 



of the urine, and, in health, prevent 
the filtration of the serum-albumen of 
the blood. When their vitality is 
partially or totally destroyed (as it 
may be by severe contraction of the 
renal artery, or acute renal anaemia) 
serum-albumen appears in the urine. 
The solids of the urine are separ- 
ated from the blood by the epithe- 
lium of the uriniferous tubules. 

Inasmuch as dilatation of the renal 
artery causes increased secretion of 
urine, and contraction of this vessel 
diminishes the secretion, it follows 
that severe or continued contraction 
of the renal vessels will necessarily 
cause such diminution in the amount 
of urine secreted as to amount to 
serious suppression. Overbeck has 
demonstrated that ligation of the 
renal artery for one and a half 
minutes caused suppression of the 
urine in the corresponding kidney 
lasting three-fourths of an hour. 

Ligation of the renal artery, or 
severe contraction of the smaller 
vessels of the kidney, so disturbs 
the vitality of the epithelium of the 
glomeruli as to allow of the trans- 
udation of the serum-albumen, 
causing* true albuminuria. Long 
continued, severe contraction of the 
arterioles, causes death of this epi- 
thelium, transudation of blood cor- 
puscles and albumen, and ultimately 
nephritis. 

Any factor, therefore, that causes 
severe contraction of the renal 
vessels may cause suppression of 
urine. 

Stimulation, either direct or reflex, 
of the vasomotor nerves of a part 
causes contraction of the arterioles of 
that part. 



Stimulation (or irritation) of the 
splanchnic nerve (which contains 
vasomotor nerves for the renal 
artery) causes contraction of that 
artery and lessened secretion of urine. 
Severe irritation of this nerve may 
cause total suppression of urine. 

Causes acting on the general vaso- 
motor system as irritants cause gen- 
eral arterial contraction and lessened 
secretion of urine, as has been shown 
in the history of certain spasmodic or 
convulsive attacks, such as epilepsy, 
lead colic, etc. In these there is pri- 
marily pallor, contraction of arteries 
and temporary suppression of urine, 
quickly followed by relaxation. 

But there is another factor that 
should be mentioned as having 
marked influence on the secretioQ of 
urine, and that is obstruction, in any 
form, to the free flow through the 
renal veins, which causes decreased 
velocity of the blood through the 
glomeruli, and thus decreased secre- 
tion. In general contraction of tjie 
arterioles, the veins are overloaded, 
and the current of blood through the 
kidneys proportionately retarded. 

Again, irritants that are excreted by 
the kidneys in some cases cause sup. 
pression of urine by causing an acute 
nephritis. Such are corrosive subli- 
mate, carbolic acid, cantharides, the 
poison of scarlatina, and, some say, 
ether. These cause nephritis by first de- 
stroying the life of the epithelial cells, 
and, secondarily, a dilatation of the 
capillaries, with effusion of leucocytes, 
etc., within the capsules of the glome- 
ruli, by which the capillaries are com- 
pressed, resulting in a virtual ansemia, 
with consequent scanty secretion of 
the watery elements of the blood, and 



Digitized by 



Google 



SUPPRESSION OF THE URINE. 



166 



often total suppression. If this con- 
dition be of short duration^ temporary 
suppression, with transient albumin- 
uria, is the only result; but, if it be 
long continued, organic changes take 
place and an actual nephritis is in- 
duced. When this condition becomes 
confined to a few glomeruli, compen- 
satory increased secretion occurs in 
others, and the urine regains its. nor 
mal color and consistence, but re- 
mains more or less impregnated with 
albumen. 

Ether has been classed with other 
irritants, such as cantharides, etc., in 
its supposed action on the kidneys, 
but whether it so acts or not has never 
been sufficiently proven. 

The difficulty in forming any posi- 
tive opinion which might be regarded 
as conclusive lies in the fact that 
when ether is used for operative pur- 
poses, other factors enter largely into 
the case, which render conclusions as 
to the influence of the ether in the 
•causation of any consequent urinary 
disturbances fallacious. 

Whether the ether is as injurious 
as we have generally considered it 
seems to me doubtful. In order to 
get an expression of opinion, from 
which I might deduce definite con- 
« elusions, I addressed a letter. of inquiry 
to several of the most prominent 
general surgeons in the country, bear- 
ing on the frequency with which, in 
their own experience, the use of ether 
had been followed by injurious effects 
on the kidney, and the nature of the 
operations most liable to be followed 
by such disturbances. The answers I 
received were so variable and even 
contradictory that the only conclu- 
sions I could form were that different 



operators drew different conclusions 
from similar obser^tions and experi- 
ences. In my own experience 1 have 
but once had serious kidney trouble 
following operation. But at my re- 
quest, Dr. J. B. Whinery, house sur- 
geon at St. Mark's Hospital, has kept 
an accurate record of urinary analysis 
in all my recent operations. He had 
made a careful examination of the 
urine previous to operation, and of the 
urine drawn immediately afterward, 
care being taken to draw directly into 
a bottle, which was securely corked 
at once. In all cases there was a 
strong odor of ether, and in nearly all 
cases there was a transient trace of 
albumen, often very slight. 

The color was somewhat darker 
than usual, and the amount greatly 
lessened during the first twenty -four 
or forty-eight hours, gradually there- 
after returning to the normal. la 
no case could I perceive any influence? 
on the secretion of urine which I 
could positively say was due to the 
action of ether. 

About six months ago I operated on 
Mrs. L. for chronic endometritis with 
retroversion of a large uterus. It 
seemed to be freely movable. I 
curetted thoroughly, and drew the 
uterus forward by shortening th& 
round ligaments. I then found that 
the right ovary (which I had thought 
movable) was adherent in Douglas* 
cul de sac, and by drawing the fundus 
of the uterus forward the ovarian 
ligament and nerves were made very 
tense. 

After the operation (at which no 
unusual amount of ether was used) 
there was almost complete suppression 
of urine for a few hours. About six 



Digitized by 



Google 



156 



EUGENE BOISE. 



ounces of dark urine were secreted in 
the twenty-four hours following the 
operation. When analyzed the next 
day it was found highly albuminous 
and continued so several days. Un- 
der vigorous treatment the amount 
was gradually increased to normal, 
the color became normal, and the 
amount of albumen was reduced to 
a trace, but the kidney has never re- 
gained an absolutely normal condi- 
tion. I believe that the kidney dis- 
turbance was entirely due to the 
severe irritation of the renal plexus, 
reflected from the irritated ovarian 
nerves, which may be said to be 
branches of the renal plexus of nerves. 

Many observers have recently ex- 
pressed the conviction that ether does 
not cause post-operative nephritis. 

Dr. Korte, at a meeting of the 
Berliner Medicinische Oesellschaft^ 
held January 81, 189:1, read a paper 
on the relative effects of chloroform 
and ether, and stated that he had 
made special investigation in more 
than two hundred cases of ether 
narcosis to determine the effects on 
the kidney, and found that two hun- 
dred and three cases had no albumi- 
nuria either before or after narcosis. 

In seven there was albuminuria be- 
fore etherization, but the preexisting 
nephritis was in no way modified. In 
six cases previously free from it 
albumen was observed in the urine 
after anaesthesia. He therefore con- 
cluded that ether had no injurious 
effect on the secretion of urine. 

Garre (^DetUsche Med. Wbchen- 
Mchrift, 1893, No. 40) denies that the 
nse of ether causes nephritis, and says 
that the only contraindication is pul- 
monary disease. 



Other experimenters are arriving at 
the same conclusions. 

We know that ether is absorbed 
unchanged, and that it is excreted, 
partly by the kidneys, unchanged. 
We have inferred that, because it is 
an irritant to the bronchial mucous 
membrane, it is also an irritant to the 
kidneys, but such inference does not 
seem to be warranted. In the north 
of Ireland it is customary to drink 
ether as an intoxicant instead of 
alcohol, but nephritis does not seem 
to be more prevalent there than else- 
where. Dr. H. M. Joy, of this city, 
instituted investigations bearing on 
that point, at my request, and he tells 
me that though in certain counties 
the use of ether as an intoxicant is 
alarmingly prevalent, and insanity 
seems to be a comparatively frequent 
result, he has not been able to learn 
that nephritis is more prevalent there 
than elsewhere. 

We must therefore hold, in the face 
of all this testimony, that the injuri- 
ous effect of ether on the kidneys is 
at least not proven. 

Why then do we have suppression 
of urine, either partial or total, after 
abdominal sections ? 

We have seen that the amount and 
character of the urine secreted de- 
pends on the amount of blood in the 
renal arterioles and its velocity. 
Also that all influences that lessen 
the amount of blood in the renal cap- 
illaries, or that retard its velocity, 
cause decreased secretion of urine. 
What then are the conditions arising, 
during or after an abdominal section, 
that can influence these two factors ? 
And how do they act ? 

We know that irritation of the 



Digitized by 



Google 



SUPPRESSION OF THE URINE. 



15T 



vaso-motor nerves of the renal artery 
will cause contraction of that artery 
and lessened amount of blood in 
the kidney, with consequent lessened 
amount of urine. Ligature of the 
renal artery, even for a short time, 
will cause suppression of urine for a 
considerable time. Severe contrac- 
tion of the renal artery will cause 
greatly decreased secretion of urine, 
or even temporary suppression. 

Severe irritation of the renal plexus 
will cause strong contraction of the 
artery, and, if long-continued, may 
cause destruction of the epithelium 
of the glomeruli, extravasation of 
blood corpuscles and leucocytes, sup- 
pression of urine, and even acute 
nephritis. This irritation may be 
direct to the renal nerves, or re- 
flex from some other sympathetic 
plexus. 

In every abdominal operation the 
simple exposure of the peritoneum 
to the air causes irritation to a cer- 
tain degree of the sympathetic nerves 
of the abdominal cavity. If, in ad- 
dition to this, the fibres of the 
ovarian plexus, or the broad liga- 
ment, are constricted by ligature, 
there is more marked reflex irrita- 
tion of the other sympathetic plexuses 
of the cavity. This may not be so 
severe as to disturb the vasomotor 
center, or to perceptibly effect the 
general circulation, but that it is 
severe enough to cause marked con- 
traction of all abdominal arteries 
which have well-marked muscular 
coats, I am convinced. 

In the condition known as surgi- 
cal shock, suppression of urine (par- 
tial or total) is a constant feature. 

Dr. R. H. Spencer, of Grand 



Rapids, related to me the particu- 
lars of a case of railroad injury so 
sudden and severe as to cause pro- 
found shock, but with no percepti- 
ble injury to abdomen or kidneys^ 
In the repair and dressing of the 
injuries no anaesthetic was used, and 
yet absolute suppression of urine 
occured at once and continued thii-ty- 
six hours, as demonstrated by the 
use of the catheter, after which 
time the secretion was gradually 
re-established. 

In all abdominal operations there is 
an element of shock; generally so 
slight as to be unnoticeable, but often 
so severe as to cause profound circu- 
latory depression. In all cases of shock 
there is contraction of the arterioles, 
with lowered blood pressure.* 

Contrary to the opinion held by 
many, the abdominal arteries and arte- 
rioles are in a state of spasm or contrac- 
tion equally with those of the other 
parts of the body. The general venous 
system is engorged. The renal artery is 
contracted, the rapidity of the current 
through the glomeruli is retarded, and, 
necessarily, the amount of urine 
secreted- is greatly lessened. A na- 
tural physiological result of severe 
surgical shock is total (if temporary) 
suppression of urine. The vitality of 
the epithelial cells of the glomeruli 
and tubules may be destroyed, allow- , 
ing the transudation of albumen, and 
sometimes resulting in plastic exuda- 
tion, nephritis, consequent continued 
suppression and death. 

But in the lessening of the blood 
pressure in the renal arteries other 
factors than the influence of the vaso- 



♦See "The Nature of Shook" (Bolae), In N. T. 
OyiuBcolog. Jour, for October, 1893. 



Digitized by 



Google 



EUGENE BOISE. 



motor nerves play an important part. 
The free catharsis before operation, 
and the free outpouring of serum into 
the peritoneal cavity after operation, 
tend markedly to remove the watery 
elements from blood and to cause 
general lowered blood pressure. In 
addition to this, the practice of with- 
holding liquids for twenty-four or 
thirty-six hours after section prevents 
the replenishing of the depleted blood 
vessels, and may be the very factor 
that converts a temporary functional 
suppression of urine into an acute 
nephritis and death. 

We have then, as factors in the 
causation of suppression of urine after 
abdominal operations : Fii-st, the 
direct irritation of the abdominal ves- 
sels by the mere opening of the ab- 
dominal cavity, aggravated to a 
greater or less extent by the more or 
less severe reflex irritation of the renal 
plexus by injury to other parts of the 
abdominal sympathetic. In this case 
we may have contraction of the renal 
arteries (with other abdominal 
arteries) without appreciable con. 
traction of the general arterial system. 
Or we may have, second, that condi- 
tion known as shock in which the 
contraction of the renal and other ab- 
dominal arteries exist conjointly with 
general arterial contraction, and conse- 
quent venous engorgeraent.In such case 
there is not only lowered blood pres- 
sure in the renal arteries, but retarded 
velocity through the renal capillaries 
because of venous obstruction. We 
have also, third, the direct depletion 
of the blood and consequent lowering 
of the' blood pressure by the removal 
and withholding of fluids. 

In addition to these we have, forth, 



the problematical irritant effect of the 
ansssthetic. 

Therefore, given these four factors 
as causative elements in the occur" 
rence of suppression of urine after ab- 
dominal operations, the indications for 
treatment would seem to be plain. 
First, to avoid the possible irritant 
action of ether by refraining from 
saturating the patient beyond the 
point of necessary anaesthesia. Too 
little attention is paid to this point. 

Second, to replenish the blood ves- 
sels by the free administration of hot 
water. This cannot, of course, be 
given by the mouth in quantities suf- 
ficient to do any appreciable good, and 
therefore other channels must be 
utilized. 

Of these, I prefer the rectum, for 
two reasons : First, the water is rap- 
idly absorbed, easily retained, and com- 
paratively painless; and, second, it 
brings the soothing effect of heat 
almost directly to the renal and 
solar plexuses, thus greatly aiding 
in allaying irritation and relaxing 
arterial spasm. To fulfil this indica- 
tion, it is necessary that the water 
should be hot rather than merely 
warm. For this reason also the 
rectal is to be preferred to the sub- 
cutaneous use of water. 

I regard this use of hot water as 
of very great benefit in the treat- 
ment of threatened or existing sup- 
pression, and now almost invariably 
direct its use immediately after every 
abdominal section, unless there is 
some special contra-indication. 

The treatment of the arterial 
contraction, by which the amount of 
blood can led to the kidneys is les- 
sened, should be treated by arterial 



Digitized by 



Google 



INJURIOUS EFFECTS OF PESSARIES. 



159 



relaxants (if I may so term them), 
chief among which are codeine and 
nitro-glycerine (aided, perhaps, later 
by pilocarpine). 

I say codeine rather than morphine 
because of its comparative freedom 
from nauseating and constipating 
effects. 

Morphine (and I think codeine) are 
classed among those remedies that de- 
crease the secretion of urine ; but 
that effect only occurs in normal 
physiological conditions of the cir- 
culatory apparatus, and occurs by 
reason of the very quality that ren- 
ders them valuable for increasing 
the amount of urine after abdominal 
section. They act as sedatives to 
the sympathetic system (in health) 



and dilate the entire arterial system, 
thus markedly lowering the blood 
pressure in the renal arteries and 
retarding the current. When these 
arteries are in a state of unnatural 
contraction by reason of irritation 
of their vaso-motor nerves, these 
remedies, by their sedative action, 
allay the irritation, relax the spasm 
and restore the blood current through 
the kidneys to its normal condition. 

The treatment of suppression oc- 
curring in connection with surgical 
shock, if treated in accordance with 
those general principles, will hold 
out the best promise of relief.* 

•See "After Treatment of Abdominal Sections 
with special reference to 8h KJk and Septic Peritoni- 
tis" (Bolae) — AnneUs of Qynaecology^ Oct, 1893. 



The Injurious Effects of Pessaries. 

BY DENSLOW LEWIS, PH. C, M. D., 

Gynoecologut and Obstetrician to the Cook County Eospitxily Chicago. 



I PRESENT a pessary recently re- 
moved from a woman seventy-four 
years of age. It is a hard rubber 
ring pessary, measuring twenty seven 
cm. in circumference, having a 
thickness of three cm. and weigh- 
ing thirty-three and six-tenths grams. 
The internal orifice designed to re- 
ceive the cervix is seven and one- 
half cm. in circumference. It had 
been placed in the vagina of this 
patient some two years ago for the 
purpose of relieving a prolapsus 
uteri. The first year it occasioned 
little, if any, disturbance. The be- 
gining of the second year an ex- 



tremely offensive leucorrhoea was 
noticed) which excoriated the vagina 
and vulva. Pelvic and abdominal 
pains supervened, but the principal 
subjective symptom was the leucor- 
rhoea, which had- become so objec- 
tionable in character on account of 
the very offensive odor that the 
patient was cJbliped to practically 
isolate herself. Upon examination 
the vajrina was found contracted 
and inflamed. The pessary could 
be felt in the upper part of the 
vagina imbedded in the tissues, 
which had almost surrounded it 
completely. With considerable dif- 

Digitized by VjOOQ IC 



160 



DENSJ.OW LEWIS. 



ficulty it was removed by means 
of the examining finger, assisted by a 
large vulsella forceps. Its removal 
caused considerable laceration of the 
vaginal mucous membranes and peri- 
neum. Hot bichloride douches were 
advised, and three weeks later, when 
the patient was again seen, the 
lacerations had cicatrized and the 
leucorrhoea, now no longer oflEensive, 
had materially diminished in quan- 
tity. There was no prolapsus uteri 
observed. 

This case recalls to my mind the 
advice of Josh Billings, who says: 
" If I were a doctor, I would treat 
the patient and let the disease take 
care of itself." In this case the 
disease was treated, and the patient, 
perhaps from her own fault, was 
without care. 

I have had occasion during the 
past sixteen years to remove twenty- 
eight other pessaries which had been 
retained a variable period — none 
of them more than one year — and 
had become the starting-point of 
inflammatory conditions, fortunately 
none of them of sufficient severity 
to tht eaten life. 

Many cases are, however, to be 
found in medical literature illustra- 
ting the danger of allowing pessa- 
ries to remain in the vagina with- 
out care. In American, English, 
French, German, Russian, Polish and 
Italian journals there are reported 
more than 800 cases, many of them 
collected and classified by Neuge- 
bauer. (1). 

The vagina was certainly never 
intended as a receptacle for foreign 
bodies. Tie degree of tolerance 
varies in different cases according 



to the form, size and material of 
the pessary, depending also upon its 
proper application and care. In 
one case it became imbedded in 
the tissues after two months. In 
other cases it was freely movable 
after twenty years. Hamilton (2) 
saw a case of perforation in eight 
months, whereas in other cases wo- 
men have worn pessaries many 
years without serious consequences. 
In general, however, prolonged use 
of a pessary occasions unnatural dila- 
tation of the vagina, which in 
time becomes irritated, inflamed 
and often excoriated. (3). 

The irritation produced by the 
presence of a foriegn body causes 
an increase, and, at the same time, 
a rapid change in the vaginal secre- 
tion, which soon becomes thickened 
and then muco-purulent. 

Little by little the external genital 
organs become swollen and the finger^ 
when introduced into the vagina, 
enables us to recognize a ridge of 
mucous membrane, the origin of which 
is difficult to explain, if we do not 
know the nature of the accident. The 
ridge is formed by the swelling of the 
vaginal mucous membranes in front of 
the anterior border of the pessary. 
The bladder, which is full of urine, 
may project above the pubes, where it 
may be clearly defined by percussion. 
The great pressure caused by the pes- 
sary is added to that which results 
from the swelling of the mucous 
membranes and of the sub-mucous 
cellular tissue, so that the obstruction 
of the urethra may gradually become 
complete. The retention of fseces 
occurring in the same manner is very 
rarely complete, although one case of 



Digitized by 



Google 



INJURIOUS EFFECTS OF PESSARIES. 



161 



its occurrence has been reported by 
Bayaid (4), and many cases of ob- 
struction of the anus are reported 
where the pessary has been pressed 
into the rectum. 

Often a forgotten pessary, which 
has been misplaced, causes inflamma- 
tion of the tissues surrounding the 
vagina, resulting in parametritis, 
pelvic abscess, pelvic peritonitis, 
general peritonitis with ileus, etc., 
terminating sometimes in sepsis, 
which may result in cachexia an^ 
death. 

In other cases the normal secretion 
is increased, profuse and o£fensive; 
leucorrhoea supervenes; ulcers or even 
fistulae may form in the bladder and 
rectum. It is especially worthy of 
remark that a part of the increased 
secretion may gather on the surface of 
the pessary near the fundus and 
gradually encrust it with hard calca- 
reous matter, so that in time the open- 
ing of the pessary is closed. Ulti- 
mately adhesions may be formed with 
the uterus, resulting in the most seri- 
ous consequences. These effects are 
unfortunately seldom made known 
until too late. 

The injuries produced by the pres- 
ence of pessaries in the vagina act in 
two ways: They occasion in the 
entire vagina and especially around it 
an inflammation which terminates in 
the formation of fungosities, or which 
gives rise at one or more points to 
perforations, which are merely the 
results of gangrene from compression. 
(5). 

Berard reports the case of a pessary 
which had remained in the vagina for 
twenty-five years, finally producing 
almost complete obliteration. (6). 



Instead of the normal vagina there 
remained only a cul-de-sac, which 
communicated with the remainder of 
the cavity and the foreign body, by 
means of a small opening situated in 
the upper part. 

Considering the injurous effects of 
pessaries more in detail, I instance : 

Thirty-six cases of vesico-vaginal 
fistula. 

Twenty-one cases of perforation of 
the bladder. 

One case of uretero-vaginal fistula. 

One case of perforation of the 
urethra. 

Twenty-four cases of perforation of 
the rectum. 

Eleven cases of perforation of the 
rectum and bladder. 

Two cases of perforation of Douglas* 
cul-de-sac. 

Five cases of forcing of a pessary 
by pressure into the tissues surround- 
ing the vagina. • 

In a case reported by Deneux, the 
perforation of the recto-vaginal sep- 
tum had been occasioned by the stem 
of a ball pessary. The crown was 
found to be retained by vegetations. 
They formed a mass which was very 
similar to a cauliflower excrescence 
and scarcely permitted the body and 
branches of the pessary to be felt in 
two places (7). The mechanism of 
these perforations from gangrene is 
simple. The process often lasts many 
years. The vaginal, urethro-vesical 
and rectal mucous membrance are 
continuously compressed for a long 
time between the foreign body on the 
one hand and the bony wall of the 
pelvis on the other. This results in 
swelling and redness, infiltraiion and 
hardening of the tissues where pres- 



Digitized by 



Google 



162 



DENSLOW LEWIS. 



sure is exerted, terminating in a slow 
atrophy, necrosis and fistula. 

Other accidents occur. I note: — 

Six cases of pessary forced into 
the uterus. (In one of these cases 
a ring was introduced by a midwife 
into the cervix, immediately after 
labor. Again a glass stem four and 
three-fourths inches long was re- 
tained in the vagina twenty-five 
years and gradually forced its way 
into the uterus. In another of these 
cases a cup pessary was forced into 
the uterus and remained there several 
weeks.) 

One case of proliferating new 
growth in the rectum in conse- 
quence of protracted use of pessary. 

One case of atresia of os and 
pyometra, resulting in death. 

One case of new growths in both 
walls of vagina. 

Three eases of abortion. 

Two cases of especially difficult 
removal during the fourth month of 
pregnancy. 

Eight cases of carcinoma, most 
probably occasioned by pessary. 

Six cases erroneously diagnosed as 
carcinoma owing to the clinical pic- 
ture presented on account of imbed- 
ded pessary, attended with ulcem- 
tion, haemorrhage, offensive odor 
and pain. 

Seven cases of strangulation of 
portio vaginalis in pessary — in one 
case during pregnancy. 

One case where the entire uterus 
slipped through the lumen of a 
pessary during a violent fit of 
coughing and was so strangulated 
that^the pessary had to be cut into 
pieces in order to extricate the 
uterus. » 



One case where the infection from 
an ulceration due to a pessary occa- 
sioned a kind of typhus. Patient 
recovered on removal of the pessary. 

One case where the patient suf- 
fered terrible pains during nine 
months in a partly reclining and 
partly sitting position. 

One case of chronic peritonitis 
attended with constant abdominal 
pains and vomiting. 

Many cases of imbedded pessary 
have been observed. The pessary 
remains movable in the vagina but 
will not allow withdrawal. This 
has been especially observed in the 
case of egg and ball pessaries, but 
also in the case of round rings and 
Hodge pessaries. The cause is un- 
doubtedly partly due to senile 
shrinkage of the vaginal walls and 
partly to the contra-ction of cicatri- 
ces. The cicatrices left by ulcers, 
etc., often cause stenosis of the rec- 
tum and finally of the vagina. In 
addition to the injurious effects al- 
ready enumerated there are others: 
pressure on a sunken or inflamed 
ovary, tumor or tube, cystitis with 
strangury, tenesmus, etc., caused by 
large irritating pessaries, exacerba- 
tions of old parametritic and peri- 
metritic processes, etc* 

Nine cases of death due to pessa- 
ries are recorded as follows: 

Death from peritonitis following 
incision of the recto-vaginal wall 
for the extraction of an imbedded 
pessary (8). 

Death from exhaustion after the 
extraction of an incarcerated pes- 
sary (9). 

Death from sepsis caused by ulcer- 
ation and perforation of rectum after 

Digitized by LjOOQIC 



INJURIOUS EFFECTS OF PESSARIES. 



168 



an operation for the removal of the 
pessary had been refused (10). 

Death from exacerbation of an old 
pelvic peritonitis (11). 

Death in two cases from uraemia 
following the extraction of a pessary 
in cases of purulent septic parametri- 
tis (12 and 13). 

• Death frpm pyometra in conse- 
quence of atresia of os uteri caused 
by a pessary (14). 

Death from ulcerative parametritis 
and exhaustion (15). 

Death from supposed cancer, but 
at the autopsy was found to be due 
to a rude pessary made from a spool, 
which had eaten its way into the 
bladder and into the cul de-sac of 
Douglas, where it lay in a foul cavity 
surrounded by a mass of inflammatory 
material.* 

The social position of the victims 
of retained pessaries varied from the 
highest to the lowest. Their ages at 
the time of extraction of the pessary, 
were from nineteen to ninety years. 
The ages in many of the recorded 
cases are not given. One woman 
was eighty ; eighteen were between 
seventy and eighty, nineteen were 
between sixty and seventy, twenty- 
one between fifty and sixty years old. 

The length of time the pessary was 
retained varies considerably. In the 
case of the woman ninety years of 
age, the pessary had been retained 
forty -five years. (25). In two in- 
stances it remained forty years (26) ; 
four times it was retained thirty-five 
years, once thirty-three years, three 
times thirty yeai-s, twelve times from 
twenty to twenty-seven years, and so 
on ; the shortest time it caused seri- 

*E. W. Gushing, personal communication. 



OU8 inconvenience was only a few 
weeks. 

The form of pessary differed 
greatly. In many cases it is not 
mentioned. The fashion in pessaries 
has changed more frequently than the 
seasons. Forty-one times some form 
of stem pessary is reported as the 
cause of serious injury. Almost 
every variety of pessary has been re- 
sponsible for some traumatism. The 
injury has, however, been caused 
more often from want of care, forget- 
fulness, disproportionate size and im- 
proper adjustment than from any 
special form or variety. 

The material of which the pessary 
is made has apparently had no etio- 
logical relation to the •Mature or ex- 
tent of the injury. As a matter of 
interest it may be stated that the 
materials reported are cotton, lint, 
linen, porcelain, oakum, wax, gum, 
elastic, whalebone, wire of iron, gold, 
or silver, nickel, tin, aluminium, cop- 
per, lead, hard rubber, glass, wood, 
cork and celluloid. 

The injurious eflEects of pessaries 
are ^ not alone occasioned by their 
presence. Various accidents have 
occurred in the attempts that have 
been made at their removal. The 
pessaries themselves have sometimes 
become corroded by the altered vagi- 
nal secretion so that now mechanical 
dangers have been added to those 
due to the prolonged presence of a 
foreign body. 

In a case reported by Morand, the 
pessary was found perforated in sev- 
eral places apparently from the 
effects of the acid matters which 
were secreted by the vagina. These 
irregular openings were filled with 

Digitized by VjOOQ IC 



164 



DENSLOW LEWIS. 



portions of the vaginal mucous mem- 
brane, which had become elongated 
and swollen in the thickness of the 
pessary and had formed hooded ex- 
crescences retaining putrid matter in 
the cavity of the pessary. (16). 

Occasionally more than ordinary 
difficulty is experienced in the re- 
moval of pessaries from the vagina 
and numberless accidents occur. 
Mayer in extracting a bullet-shaped 
pessary adhering closely to the vagina 
bored into it with a wooden screw 
and tore away large pieces of the 
vagina (17). 

In cases of imbedded pessaries 
there is often exceptional difficulty. 
In one case systematic dilatation of 
the vagina by means of sponge tents 
was necessary for several days in 
order to ascertain the presence of the 
pessary. Great difficulty was experi- 
enced in its extraction. (18). In 
five cases there was laceration and 
tearing of the vaginal wall. In re- 
moving a lindenwood pessary a por- 
tion of the anterior vaginal wall was 
lacerated so that a piece of mucous 
membrane two inches in length was 
partly torn oflE, and fell away on^ the 
sixth day from gangrene. (19). On 
. another occasion the posterior vaginal 
wall was perforated into the periton- 
eal cavity (20). 

Janin found in one case the upper 
part of a pessary bent backwards and 
more than half the staff penetrating 
the rectum, in which it could be 
distinctly felt. The faeces escaped 
by the vagina. Incisio s were made 
with a bistoury in order to disengage 
the pessary from the fragments which 
held it. The faeces gradually re- 
sumed their ordinary course, and at 



the end of a month only a small 
fistula remained. The half of the 
staff which was in the rectum was 
covered with irregularities of a black 
color, very fetid and covered with 
shining crystals. The portion lodged 
in a fold of the vagina was covered ' 
with a stony incrustation, which had 
at its lower part a slightly convex 
facet an inch in length (21). 

The treatment of neglected pessar 
ries consists in their removal from the 
vagina or the neighboring viscera or 
tissues in which they may have be- 
come imbedded or displaced. Fortu- 
nately in most cases this is a compara- 
tively easy matter. The finger often 
suffices to dislodge and remove the 
pessary, which may conveniently be 
steadied, if necessary, by a bullet or 
vulsella forceps. Care must be 
taken to avoid undue laceration of 
the vaginal tissues. In some in- 
stances it will be advisable to sepa- 
rate the adhesions that have formed 
about the pessary,thoroughly disinfect 
the parts by antiseptic douches and^ 
after an interval of several days when 
the pessary has become detached and 
freely movable, proceed to its re- 
moval. Occasionally a pessary will 
have to be extracted by fragmenta- 
tion. Holmes speaks of a case where 
a metallic pessary was so firmly im- 
bedded that it became necessary to 
incise the perineum in order to facili- 
tate its extraction. (22). In a simi- 
lar case Lisfranc made a posterior 
vulvar incision. 

The adhesions present will often 
necessitate the division of the pessary 
by means of bone forceps before its 
removal becomes possible. Occasion- 
ally a metacarpal saw may be used 



Digitized by 



Google 



INJURIOUS EFFECTS OF PESSARIES. 



165 



with advantage. The pessary will 
perhaps have to be held by a forceps 
and the vagina widely dilated by 
some form of Sims' specula. Chrobak 
and V. Ott in extracting ring pessa- 
ries made use of the galvano-caustic 
platinum wire snare, which Neuge- 
bauer regards as an excellent way, 
safer than any other (23). In other 
cases incisions of the soft parts of the 
patient will be* necessary. The in- 
juries inflicted will, of course, be as 
limited as possible and will be anti- 
septically repaired as far as prac- 
ticable, but it must be remembered 
that the history of all cases shows the 
necessity of removing the pessary, 
if the life of the patient is to be 
saved. 

A pessary lying in the vagina has 
been observed to be held firmly by a 
cystocele. In two cases where the 
extremely inverted anterior vaginal 
wall presented itself in the rima 
vulvsB a rubber ball pessary was 
noticed jn the upper portion of the 
vagina (24). 

In cases of this chamcter and in 
cases of perforation of the rectum 
and especially the sub vaginal cellu- 
lar tissue and peritoneal cavity, the 
greatest care must be exercised. By 
carefully reducing by means of re- 
tractors the cystocele or rectocele 
present, the pessary can usually be 
reached, and systematic measures 
instituted for its removal. 

In case abscesses have formed in 
the tissues surrounding the vagina, 
the treatment of the impacted pes- 
sary will consist not only in its re- 
moval, but in the treatment of the 
•dangerous concomitants. 

I cannot in this connection discuss 



the subject of pelvic suppuration. I 
must, however, be allowed to insist 
upon the importance of free and abso- 
lute drainage, secured at any cost, by 
any means — even by the removal of 
the uterus and adnexa, in case other 
means are inefficient. 

The consideration of my abstract of 
more than three hundred cases of the 
injurious effects of pessaries, suggests 
naturally the inquiry as to the advis- 
ability of the use of pessaries ip gen- 
eral. Personally I can make answer 
very readily. My experience with 
pessaries during the past ten years 
has consisted solely in their removal. 
Some form of the Alexander opera- 
tion, the operation of colporrhaphy, 
perineorrhaphy, trachelorrhaphy hys- 
terorrhaphy and in a few cases hyster- 
ectomy — singly or combined, accord- 
ing to the requirements of each indi- 
vidual case — have sufficed in my 
experience and that of my assistants 
to control all displacements of the 
uterus, as well as all inconveniences 
occasioned by them. 

I do not, however, presume dog- 
matically to assert that pessaries 
should be banished as a relic of bar- 
barism. I cannot agree with Fritsch 
that the sale of pessaries should be 
restricted like that of poisons. I 
consider it unwise to discard the use 
of pessaries altogether. There are 
many cases where the judicious use 
of a pessary makes the woman feel 
" like newborn," as Neugebauer graph- 
ically expresses it. Moreover, every 
physician is not accustomed to do 
plastic gynaecological operations, nor 
can the patient in every case submit 
to operative procedures. The physi- 
cian who inserts a pessary should. 



Digitized by 



Google 



] 



166 



DENSLOW LEWIS. 



however, realize its powers for evil 
as well as for good. He should insist 
on frequent examination ; he should 
be ou the alert for the .possibilities ; 
he should remember that deviations 
of the uterus have not the importance 
that was attached to them twenty 
years ago ; he should remember that 
the inflammatory conditions of the 
tubes and ovaries frequently cause 
a prolapse of these organs into Doug- 
las' cul-de-sac, and, that eminent gyn- 
aecologists to-day do not hesitate to 
assert that cases of so-called retro- 
flexions of the uterus are all of them 
really tubes or ovaries often bound 
down by adhesions behind the uterus. 
These facts should be remembered 
by every practitioner, and he should 
further understand that a pessary, if 
suitably applied, causes relief and not 
distress. In case the patient com- 
plains of sensations of pressure or of 
other inconveniences, the possibility 
of incorrect adjustment or improper 
application should not be forgotten. 
Above all things the patient should 
be instructed in the care of the pes- 
sary. It should be remembered that 
she carries in her vagina a foreign 
body which requires attention. At 
suitable intervals it should be re- 
moved, cleansed and disinfected, and 
the opportunity should be utilized to 
ascertain the benefits or injuries 
occasioned by its use. The vagina 
should be regularly and systematically 
douched, not alone to disinfect the 
parts, but also to remove the excess 
of secretion resulting from the pres- 
ence of the pessary. These measures 
are easily carried out in private prac- 
tice. In hospital, and especially in 
dispensary practice, they are imprac- 



ticable, as a rule, and for this reason, 
if for no other, the pessary should, in 
my opinion, be rarely advised in such 
cases. 

618 Tacoma Building. 



BIBLTOO'RAPHT. 

(1) Franz Ludwig Neugebauer: 
Archiv fUr Oyncekologie^ Hft. 
III., Bd. XLIIL, p. 373. 

(2) Hamilton: ** Practical Obser- 
vations on Various Subjects of 
Midwifery." Part I. Edin- 
burgh, 1886. 

(8) Carl Meyer: Beitrag zwr 
Kenntniss und Behandlung dei 
Prolapsus uteri et vaginm. 
Verhandlungen der Geselischaft 
fiir Geburtshuelfe in Berlin, 
1846, III. Jahrgang, S. 128, 
137. Berlin, 1848. 

(4) Bayard: v. Poulet; loc. cit. 
p. 190. 

(5) Poulet : " A Treatise on For- 
eign Bodies in Surgical Prac- 
tice," p. 194. 

(6) B^rard: v, Poulet: loc. cit., 
p. 197. 

(7) Deneux : Jbum. Oen. de 
MSd., 1822, T. LXXVIII, p. 
197. 

(8) Lisf ranee : Maladies de Tut^ 
rus. Lemons de Lisfranc par 
Pauly, p. 528. Paris, 1836. 

(9) Henkel: "Neue medicinische 
und chirargische Anmerkun- 
gen." Berlin. 1772. 

(10) Maercker: Huf eland's Jour- 
nal der Praktischen Heilkunde^ 
band, XVI ; Heft 4. Berlin, 
1808. 

(11) Bernutz and Goupil : ** Clin- 
ique mSd. sur les maladies des 



Digitized by 



Google 



EXTRA-UTERINE PREGNAJ^Cl. 



167 



femmes,'' T. II, p. 721. Paris, 

1862. 
(12) Kelly: Med. News, p. 480; 

Philadelphia, 1884. 
(18) Gillette: **Bull de la Soc. 

anatom. de Paris, 1884. 

(14) Robin: Gaz, mSd. de Paris, 
1885, p. 174. 

(15) Jawdynski: v. Neugebauer ; 
loc. cit., p. 410. 

(16) Morand: Arte. Acad, de Chi- 
rurgie 1877, p. 421, obs. XL 

(17) August Mayer : Monatssehrift 
filr Geburtsh. und Frauen- 
krankheiten 1858, Bd. XII, S. 
1 — 42. 

(18) Clay: Med. Times 1844, No. 
281. Cf. Neue Zeitschrift fUr 
Gehurtskunde, Bd. XXII, S. 
301 ; Berlin, 1847. 



(19) Rainer : Gemeinsame deutsche 
Zeitschrift fuer Geb., 1828, Bd. 
II, S. 127. 

(20) Zweifel: Vorlesungen iiher 
klinische Gynoekohgie^ Berlin, 
1892. 14. Vorlesung, S. 390. 

(21) Janin : Joum. gen. de mSd. 
1822. T. LXXVIII. p. 200. 

(22) Holmes: London Med. Ga- 
zette, 1854. 

(23) Chrobak and v. Ott: **Die 
Untersuchung der weibliehen 
Genitalien." S. 213; Stutt- 
gart, 1870. 

(24) Neugebauer : loc. cit., p. 432. 

(25) Bjoorlomann : ^ Inaugural Dis- 
sertations, S. '11 of Josef 
Diefenbach." 

(26) Rousset : ^ De Tenfantement 
Cesarien," p. 176. 1581. 



Report of Two Cases of Extra-Uterine Pregnancy. Operation— Recovery.* 

HERMAN B. HA YD, M. D, OF BUFFALO, 

M. B. O. 8., EKOLAKD, 

Fellow of the American Association of Gyncecologists and Obstetricians, 
Gyncecologist to the Erie County Hospital. 



Although extra-uterine pregnancy 
may be looked upon as one of the 
rarer manifestations of nature's aber- 
rant function, yet its occurrence is so 
frequent that one must always think 
of Its possibility in any pelvic tumor. 
In most cases it is of tubal origin, 
and may be either extra-peritoneal or 
intra-peritoneal, the latter situation 
being due to rupture of the sac and 
expulsion of the ovum into the peri 

1 Read before the Medical Society of Western New 
Yorfc. 



toneal cavity. Rupture usually takes 
place between the tenth and four- 
teenth week, and most frequently 
through the upper and free surface of 
the tube; but occasionally into the 
folds of ^ the broad ligament. 
Hsernorrhage and shock are usually so 
great when rupture takes place into 
the peritoneal cavity that death of 
the mother speedily results. If this 
does not occur, the ovum and ex- 
tra vasated blood may become digested 
and absorbed by the peritoneum ; or 



Digitized by 



Google 



168 



HERMAlf E. HAYD. 



suppuration may occur and death re- 
sult from the absorption of septic 
matter ; or, the ovum may, by trans- 
plantation, grow to full time and then 
die or be removed by operation. If 
the rupture takes place between the 
folds of the broad ligament, the ex- 
travasated mass may, and often 
does, entirely disappear; or, it may 
continue to grow and be removed by 
operation ; or undergo suppuration 
and be discharged in pieces through 
the bladder, rectum or vagina. 

The diflSculties in connection with 
the early diagnosis of extra-uterine 
pregnancy are" often very great, and 
as the vast majority of cases come 
under observation only after rupture 
has taken place, conservative meas- 
ures are not often applicable. More- 
over, the diagnosis is often only made 
by delivering a suspicious mass in oper- 
ation, when what was thought to have 
been a pyosalpinx or ovarian abscess, 
or dermoid cyst, ia found to be an un- 
recognized ectopic gestation. The 
converse is equally true. Still, we 
often meet with cases so clear in their 
clinical features that a diagnosis can 
be made with reasonable certainty; 
and then an operation, if undertaken, 
is simple and uncomplicated and with 
the smallest possible mortality. 

The two cases which I have oper- 
ated upon present the following his- 
tories : — 

On October 23rd, 1893, I was 
called to see in consultation with Dr. 
GUray, Mrs. L., aged twenty-eight; 
married twice; no children. Menses 
first appeared when fourteen. No 
pain and always regular. Second 
marriage occurred fifteen months ago, 
and four years after the death of the 



first husband, whom she lived with 
two years without bearing him any 
children. Three months after this 
second marriage, she had an attack 
of inflammation which lasted two 
months. She was in bed three 
weeks. After this illness, she was 
quite well until three weeks ago, 
when Dr. Gilray was called to see 
her. While combing her hair one 
morning before a looking glass, she 
felt something give way, and so great 
was the pain and the shock, she fell 
upon the floor. For some weeks pre- 
vious to this attack, she had irregular 
discharges of blood from the vagina, 
jand was also nauseated; yet there 
was no suspicion on her part of preg- 
nancy, since she had been so many 
years sterile. 

I found, upon examination, a ten- 
der mass filling the left side of the pel- 
vis and cul-de-sac. The right tube 
was thickened, but evidently from old 
trouble. The uterus was somewhat 
movable antero-posteriorly. The his- 
tory pointed so strongly to a ruptured 
tubal pregnancy — together with the 
fact that there now existed in the 
pelvis a large mass which could not 
be disposed of by any means short of 
surgery — an operation was recom- 
mended ^t once. The patient ac- 
quiesced, and I took her to the 
Women's Hospital, and, after suita- 
ble preparation, opened the abdo- 
men. A mass the size of one's closed 
fist was removed ; and, upon dissec- 
tion, was found to be the tube and 
ovary. The tube had ruptured on 
its under surface, and it was sur- 
rounded by a mass of firm coagulated 
blood, stratified, and in the centre of 
this mass was the amniotic sac, un- 



Digitized by 



Google 



INTRA-UTERINE PREGNANCY. 



169 



broken, and containing a seven week's 
embryo with placents and cord attach- 
ment. The right tube and ovary 
were loosened from their adhesions 
and removed. The tube was very 
much thickened; its fimbriae closed; 
and the ovary was dense, firm and 
enlarged. The peritoneal cavity was 
thoroughly irrigated and a drainage 
tube was inserted. There was free 
drainage for the first six hours, and 
at the end of sixteen hours the tube 
was removed. The patient made an 
uneventful recovery and left the 
hospital on the sixteenth day, and 
is, at present, a perfectly well woman. 
Mrs. J., married, aged thirty- 
five. Six children. Youngest three 
years old. No miscarriages and no 
history of any pelvic inflammation. 
Always a well and h<»althy woman, 
and never had to consult a doctor ex- 
cept when her babies came. Regu- 
lar, no pain, and flow lasted three 
or four days. On August 11th, 
1894, her period was due, but it did 
not make its appearance until the 
16th, when she flowed about as much 
as usual. Instead of stopping in four 
days, she continued to lose some 
blood and used from one to three 
napkins a day until she consulted 
me on October second. She had no 
nausea or vomiting. She complained 
of some pain in the lower abdomen 
on the right side, and she was weak 
and fenemic from loss of blood. 
She saw no shreds or pieces of mem- 
brane. The breast symptoms were 
negative, but there was slight dis- 
coloration about the meatus and 
labia minors. Upon examination, a 
tense, elastic and somewhat movable 
tumor could be felt in the right side. 



which could be clearly defined by 
combined manipulation. It was not 
tender, and the uttTUS was freely 
movable and enlarged. The os was 
slightly patulous, and dark blood 
was discharging from the uterus. A 
diagnosis of extra-uterine pregnancy 
was made: first from the continued 
hsemorrage, which had not abated 
by rest and medicines which she 
had taken ; second, an enlarged 
uterus, and to the right side a clearly 
defined, p^nless tumor ; third, slight 
discoloration of the meatus. 

After having stated the case fairly 
to the husband and the necessities 
of an operation, even if the tumor 
were but a simple ovarian cyst, the 
patient was removed to the Wo- 
men's Hospital and ' an operation 
performed on the following morn- 
ing, Dr. Frederick assisting. The 
OS was dilated and the interior of 
the uterus thoroughly curretted and 
packed with iodoform gauze. The 
abdomen was then opened and the 
tumor, which was of a dark bluish 
appearance and the size of one's 
closed fist, was separated and re- 
moved. During the delivery it rup- 
tured and some dark fluid, mixed 
with clots, escaped. The left tube 
and ovary were found healthy. The 
abdominal cavity was thoroughly 
irrigated and a glass drainage tube 
was placed in position. The wound 
was closed and the patient was put 
to bed. 

I then examined the specimen 
more carefully, and found it to be 
a dilated tube. Its fimbriated ex- 
tremity was closed and the fimbriae 
and outer end of the tube were 
greatly distended with hard, more 



Digitized by 



Google 



170 



HERMAN E. HAYD. 



or less organized blood. Upon care- 
ful dissection, a placenta was found 
attached to the roof of the tube, 
from which the cord was traced into 
a hard mass, which, upon further 
examination, proved to be about a 
ten weeks' embryo. 

The patient made an excellent 
recovery. No nausea or vomiting 
followed the operatien, and the 
drainage tube was removed in 
eighteen hours. 

* The history of the first case is 
clear and classical, and tells us of 
the terrible dangers of extra-uterine 
pregnancy. 

First. There was no suspicion 
of pregnancy. 

Second. TUere was a long 
period of sterility. 

Third. A sudden rupture of the 
sac ; but, fortunately, a small rent 
on the inner and under side of the 
tube, and therefore no great 
haemorrhage occurred, as the open- 
ing became occluded by a firm 
coagulum about it. 

Fourth. Operation before an- 
other fatal haemorrhage took place 
and the removal of the dangerous 
mass, as well as the other tube and 
ovary which, sooner or later, would 
have caused much suffering and 
future trouble. 



Fifth. There was no free blood 
in the peritoneal cavity. . The first 
haemorrhage was, no doubt, slight; 
yet sufficient to have caused sud 
den and great shock and even col- 
lapse. 

The second case would have rup- 
tured at any moment, as the tube 
was exceedingly thin. Moreover, 
the manipulations of frequent ex- 
aminations, or even the application 
of electricity, would, I am sure, 
have caused the thin tube wall to 
have given way. and, no doubt, 
fatal shock and collapse would have 
resulted. The operation was a very 
simple one, as such early operations 
usually are, and the patient made 
a quick recovery. There was no 
history of previous pelvic trouble, 
or attacks of inflammation ; but, no 
doubt, a tube can be slightly dis- 
eased and offer a favorable seat for 
the development of an extra-uterine 
pregnancy, and cause no apprecia- 
ble symptoms. Ths woman had no 
suspicion that she was pregnant, 
nor did she suffer from nausea and 
vomiting, — constant and early 
symptoms in her previous pregnan- 
cies. 

78 Niagara St.,. Buffalo, N. Y. 



Digitized by 



Google 



DANGERS AND RESULTS OF SYMPHYSEOTOMY. 



171 



EDITORIAL. 



The Dangers and Results of Symphyseotomy. 



Symphyseotomy has for the last 
two years been a much talked about 
procedure among the practitioners of 
the obstetrical art. Much has been 
said in favor of this operation, and it 
certainly has its indications. Sym- 
physeotomy is by no means a new 
operation, bat it has benefited by 
antisepsis as other procedures have, 
and it is now becoming an operation 
d la mode; the indications for its 
performance are so well-defined that, 
if our information received is good, 
there is a certain Paris school which 
is on the point of putting it into prac- 
tice in every case where formerly 
other methods were employed. This 
is without doubt an exaggeration, 
and this teaching is far from being 
accepted by accoucheurs who have 
practised the operation in certain cases 
with excellent results ; but this is not 
the point that we wish to discuss. 

Dr. Fraipont, in a paper read 
before the SodStS M^dico-chirurgicale 
de lAige^ affirms that symphyseotomy 
is an operation not unattended by 
some danger, and in this is be right ? 
Or should Dr. Carusio's opinion put 
forth in his thesis entitled '* Gontri^ 
butioi alia practica della sinfisotomia^*^ 
be accepted, when he says that if 
death occurs after such an operation, 
it is the fault of the operator and not 
the operation. 

Let us show Dr. Fraipont's arguments. 
This writer invokes, in the first place, 



what he says are the most recent sta- 
tistics and gives the following figures : 
In France, of thirty-three symphyseot- 
omies performed in 1892 there were 
six deaths, consequently a mortality 
of eighteen and one-tenth per cent. 
In Germany, according to the sta- 
tistics furnished by Frommel, of a 
total of seventy-eight symphyseoto- 
omies, the mortality for the mothers 
is eleven and five-tenths per cent., 
and twenty-eight atid two-tenths per 
cent, for the children. As is seen, 
this is something to be taken into con- 
sideration if statistics are to be relied 
on. Death in these cases was due 
to haemorrhage, shock (an indefi- 
nite term), and even to septicaemia, 
according to Dr. Fraipont. 

If now we compare symphyseotomy 
andthe Caesarian operation, Dr. Frai- 
pont finds for the latter operation a 
mortality of two and eight-tenths per 
cent., out of a total of thirty-five 
cases, and the mortality of the child 
is also much lower. The complica- 
tions arising in -symphyseotomy are 
haemorrhages taking place from the 
retropubian venous plexus, or from 
the clitoris ; tears of the bladder and 
vagina have been reported, leaving 
sometimes urethral or vaginal fistulae. 

As to the ulterior condition of the 
patient, much has been written. It 
is certain that in many cases the 
symphysis does not unite, and the 
motility of the iliac bones one on 



Digitized by 



Google 



172 



EDITORIAL. 



the other has produced functional 
troubles either in the legs or in the 
urinary organs. Consequently, the 
suture of the pubis is indicated, 
which, according to some obstetri- 
cians, should be done immediately. 
The suturing of the pubis succeeds 
very well, and may be resorted to 
when reunion does not take place. 

These are the arguments of Dr. Frai- 
pont which we give and will not dis- 
cuss them here. According to this 
accoucheur, symphyseotomy should 
not be abandoned, but the surgeon 
should know how to limit its indica- 
tions. It is certain, if understood in 
this light, that momentary widening 
of the pelvis is a most recommend- 
able procedure, and this is the opinion 
upheld V»y a friend of Dr. Fraipont, 
Dr. Lambinon, who is also a partisan 
for symphyseotomy under certain cir- 
cumstances, without, however, taking 
too much credit away from induced 
labor and the Csesarian operation. 

As to the after results of symphys- 
eotomy, an fnteresting article by Dr. 
H. V. Woerz has appeared in the 
Centralblatt fUr Qyncekologie for Sep- 
tember 28, 1894, in which the author 
relates ten cases of symphyseotomy 
performed in Professor Shauta's clinic, 
which are studied principally as to 
the advantages of suturing the pubis 
with silver wire. In five cases in 
which the suture was successful. 



union was effected in a rapid, com- 
plete and definite manner. The 
patients were able to walk as soon 
as they left their beds, and the sym- 
physis pubis was immovable and 
remained so. In four cases in which 
the suture for some reason or other 
did not hold, a difference was noted 
between immediate and tardy results. 
At the time the patients left the hos- 
pital, there existed a diastasis of the 
bones of the pubes, which were united 
by a bridge of connective tissue. This 
diastasis produced considerable diflS- 
culty in walking in one of the four pa- 
tients. Two of them were followed over 
a year, and in these two the progressive 
disappearance of the diastasis and 
gradual solid reunion of the pubes 
could be noted. 

Contrary to Dr. Fraipont's remarks, 
Woerz states that in his cases the 
lesions of the soft parts produced dur- 
ing the operation were not followed 
by any disagreeable accidents, and 
although this happy result has been 
recorded by the German writer, we 
think that from what has been said, 
the accoucheur should bear in mind 
the possible complications arising 
from operative lesions of the vessels, 
and, before closing the wound too 
hastily, to make sure by means of 
tampons whether there exist a hsen"- 
orrhage, in which case the proper 
lieemostasis may be accomplished. 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



178 



SOCIETY PROCEEDINGS. 



Proceedings of the American Association of Obstetricians and GynaBcolo- 

gists. 



(CONTINUED FROM NOVEMBER NUMBER.) 



FIRST DAT — AFTERNOON SESSION. 

Dr. George S. Peck, of YouDgs- 
town, O., read a paper entitled 

APPENDICITIS: REPORT OF SEVEN 
CASES, FOUR OF WHICH WERE 
SURGICALLY TREATED DURING 
THIRTY-SEVEN CONSECUTIVE 

HOURS. (See ^^Annals," p.p. 81-96.) 

Out of the great amount of liter- 
ature, controversial and otherwise, 
three important landmarks are estab- 
lished : 

1. That for all practical purposes 
all inflammatory processes in the 
right iliac fossa arise from the vermi- 
form appendix. 

2. That practically the vermiform 
appendix is always intraperitoneal, 
and that any operation undertaken 
for appendicitis that does not involve 
the entering of the peritoneum is 
false in its surgical conception. 

8. That idiopathic peritonitis 
does not occur ; that many cases diag- 
nosticated as such are really cases of 
perforating appendicitis. 

From a careful consideration of 
pathological conditions and clinical 
histories, appendicitis may be classi- 
fied in the following varieties : 

1. Acute perforating, fulminating 
appendicitis with general peritonitis. 

2. Acute suppurating appendicitis 
with local plastic peritonitis and 
abscess. 

3. Subacute appendicitis, variously 
termed catarrhal, chronic, relapsing. 



or obliterating appendicitis or appen- 
dicular colic (Talman). 

It is not claimed that pathologically 
these conditions are absolutely dis- 
tinct — quite the contrary is true — 
but that the type is determined by 
the amount of bacteriological invasion 
and the degree of immunity possessed 
by the patient. That perforation 
occurs very much earlier than is com- 
monly believed can be demonstrated 
by many clinical histories and early 
operations. It may mark the osent 
of the disease. That the prognosis 
in acute perforating appendicits, with 
or without operation, is always 
grave ; that operations undertaken 
while perforation is impending but 
has not occurred are followed by fatal 
results 'by extension of inflammation 
in many cases ; that acute suppura- 
tive appendicitis with local peritoni- 
tis presents the most favorable field 
for operation during the attack ; that 
removal of the appendix is to be un- 
dertaken with great circumspection 
when it lies in the wall of an abscess 
cavity, are claimed. 

The third group of cases do not 
require operation during the first at- 
tack, but if repeated attacks occur 
operative interference is demanded. 
Operative results in these cases are 
most favorable. 

Errors in diagnosis are yet common 
and arise from two causes, namely, 
carelessness in treating abdominal 
diseases without physical examination, 
and mistaken pathological notions. 



Digitized by 



Google 



174 



SOCIETY PROCEEDINGS. 



The profession has awakened and 
neglected cases are much less common 
than formerly. That in the future 
cases will be seen and operated upon 
earlier, and the results will be corre- 
spondingly improved, is believed. 

Dr. Joseph Hoffman, of Phil- 
adelphia, followed with a paper en- 
titled 



PUS IN THE PELVIS, WITH SPEC- 
IAL REFERENCE TO APPENDICITIS 
AND ITS TREATMENT. 

Others disease and disorders have 
manifestations peculiar to themselves, 
but pus may be the product or result- 
ant of every disease, broadly speak- 
ing. It was long before this was a 
recognized fact in reference to the ab- 
dominal cavity. Women died with 
pints of pus bathing their viscera 
without its presence ever having been 
suspected, and idiopathic peritonitis 
held sovereign sway in death certifi- 
cates and pathology. Once it was 
discovered that pus might get into 
the abdominal and pelvic cavities, 
then the wise men in physics began 
to discover reasons why it ought to 
get out of itself just as it got in, and 
the let-alone doctrine held sway, with 
opium and poultices for its viceroys. 

If there is pus in the liver we are 
often left to surmise it, though the 
exploring needle is a safe means of 
diagnosis. But the general manifest- 
ations of pus are not to be considered 
except incidentally in this contribu- 
tion, and we will consider briefly the 
various organs in which pus makes its 
appearance. In the order of its prob- 
able frequency may be mentioned the 
kidneys, appendix vermiformis, tubes 
and ovaries, liver, pancreas and 
spleen. 

In the kidneys its symptomatology 
is different according to the cause. 
If from a stone in the pelvis of the 



organ, the usual manifestations of 
pain and renal colic are present pre- 
vious to suppuration ; while if the 
origin is from the urinary tract by the 
transmission of purulent matter up 
through the bladder along the uterers, 
at last reaching the kidney, there is a 
previous history either of general 
disease, cystitis from some cause, en- 
larged prostrate with retention, or 
chronic cystitis from stone and sup- 
puration. Either one of these causes 
has a perfectly distinct history, and 
the treatment, with the exception of 
the removal of the stone from the kid- 
ney, is identical. 

If an abscess goes on to rupture 
into the peritoneal cavity, operation 
can only give the slightest chance of 
success when done at once. So also 
into the other cavities, the pleura and 
pericardium. It must also be remem- 
bered that abscess of the liver may 
simulate the same disease of the kid- 
ney, and that the disease of the lat- 
ter organ has been mistaken for that 
of the former. The presence of ab- 
scess of the spleen, as well as of the 
pancreas, is so rare that diagnostic 
features are wanting except in a gen- 
eral way. The nature of the organs 
is such that when abscess is present 
it must soon make its way into the 
peritoneal cavity, and then, from the 
symptoms of peritonitis as they exist 
under other circumstances, operation 
will be indicated, and begun most 
probably as exploi-atory and end with 
the removal of the offending organ. 
Pus as a foreign element is most 
common in the pelvic organs. Ap- 
pendicitis is a most frequent cause of 
the trouble, and, alongside of tubal 
and ovarian diseases, it is the most 
prolific of causes. The diagnosis of 
pus as a concomitant of appendictis 
is not always an easy matter. 

The history of cases is that where 
one case escapes without suppuration, 
in which no effort is made to save 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



176 



the patient, a vast number do not. 
So it is in recurrent attacks of appendi- 
citis. Those who have most studied 
the condition, who have watched 
patients said to have recovered, know 
that in a great majority of instances 
they finally go into other hands and 
either die in an attack or escape by 
operation. Operation in these for- 
lorn cases has its justification only in 
the hope that a saving chance is 
offered an otherwise necessarily hope- 
less case. 

Considering that the uterus is the 
starting point of the pus infection, 
physicians anticipate the clearing out 
of the tubes and ovaries, when 
infected, by the curretting of the 
uterus. This idea is worthy of as 
little sound consideration, no matter 
by whom advanced, as the vagaries of 
a madhouse brain. It has no com- 
mon sense to originate it, and it has 
not a surgical argument to support it. 

The rules to be laid down for the 
relief of pus in the abdomen are to 
get at the point of suppuration, the 
cause, and remove it. If this is 
impossible, as it is in some cases of 
appendicitis, and the peritoneal cavity 
is shut off by adhesions, the evacuar 
tion of the pus by incision over the 
abscess is the best procedure to save 
the life of the patient, and that is all 
we are after. If the patient is in a 
condition to find and remove the 
appendix, so much the better, but the 
best thing is to work so that life can 
be saved. In appendicitis we have 
one of the most trying operations in 
surgery, for the simple reason that 
the relation of the parts is not con- 
stant, and he who operates expecting 
to find the appendix by McBumey's 
or any other point will be wofully 
disappointed. In the presence of pus 
in the pelvis, apart from the appen- 
dix, when the ovaries and tubes are 
involved, the best operation is by all 
odds the complete one. Remove the 



offending organs, and these in the 
great majority of cases can be re- 
moved by the experienced hand. If 
the hand is not experienced it had 
better be out of the case. In the 
presence of haemorrhage, gauze or 
sponge packing is a valuable aid in 
controlling the blood. In the pres- 
ence of pus, gauze packing is to be 
deprecated unless to shut off the peri- 
toneal cavity from infection. In 
these cases it is only to be used if we 
are satisfied that there is more risk 
without it than with it. Gauze will 
not drain pus ; it will only hold it in. 
Treat each case according to the 
demands it makes and the complica- 
tions. 



FIRST DAT^EVENING SESSION. 

The discussion of the papers on 
appendicitis was proceeded with, the 
opening remarks being made by 

Dr. Robert T. Morris, of New 
York. — I am not inclined to say 
much this evening on the subject of 
appendicitis. I would say, however, 
that I am opposed to and dislike the 
classification of cases as men classify 
them today. Most men who have 
been trying to classify cases of appen- 
dicitis have classified them from their 
ultimate symptoms. I believe appen- 
dicitis is an infective, exudative 
inflammation of the appendix vermi- 
forn^iis. 

Mistakes in DiagnosiB, — I think 
men w^o are engaged in making 
diagnosis of appendicitis very seldom 
make a mistake. I have had occasion 
to see a great many cases of this 
disease and have removed a good 
many appendices ; and though I do 
not profess to have more diagnostic 
acumen than my confreres, I yet have 
been misled in one case of tuberculosis 
of the appendix, and in another of 
carcinoma of the appendix, in which. 



Digitized by 



Google 



176 



SOCIETY PROCEEDINGS. 



A year or two after an attack of 
typhoid fevej-, I removed a normal 
appendix from among adhesions which 
I bfilieved had beau c^uned by chronic 
appendieitm, Iheae are the only 
C4ises in which I have }>een deceived. 

As to the analysis of foreign bodies, 
it IS qult^ true we do not find cherry 
seedi^, grajje seedi^, and various other 
iH^edB ill the huiieii of the appendix. 
I have liad a pretty large collection of 
specimens carefully examined and 
analyzed, and I find more frequently 
than anything else calculi consisting 
of ealcinm phosphate and a little 
inspifeksatcil ftcal matter and fat. 
The projiortion of fat was very great 
in sevcnil of thf^ w}H*ciniens examined. 
It h rnther difiirntt to account for 
thii! projMirtion of fat. especially as 
srotne of the eonort?tions were large, 
and, as the lumen of the appendix 
was cut off from the lumen of the 
eeeum, it occurred to m*' that possibly 
it may be due to retrograde meta- 
morphonis of the lymphoid cells of 
the ajipcudiK, 

With reference to tlit- question as to 
whetlier we had l>etter separate adhe- 
sions, it had better be determined by 
the operator himsolf, who knows his 
residts folio wiug^ his particular tech- 
nique. Evciy man in surgery is a 
htw unto liimself. If I were to prac- 
tice drainjige tis Or, Price practices it 
I could not obtain the results that he 
doe8. Hut, |H:i'sonaily. 1 separate the 
Jidhesious in almost cveiy case of 
apjH^ndicitis ujnm Avhicli I operate. I 
do this hi seart*hiii^ for other collec- 
tions of puis, 1 do it to si^parate loops 
of bo%\ el hekl in bad i>osition by ad- 
hesions wlni'h would stningidate the 
boweU and to prevent rendhesion in a 
bad jmpsiition. I bi*H**ve that can be 
done, l>Ht it would be unsafe to teach 
this. 

Ihi. JoHKPH Fiui IC, iti Philadelphia. 
— The remarks of Dr. Morris on ap- 
liendicitts Ut which we have just lis- 



tened are the best I have ever heard, 
and his closing remarks are quite 
suflicient. We may all go home withr 
out any further discussion of the sub- 
ject. I agree with him excepting in 
one point — namely, that he would 
not dare teach what he would do him- 
self in these cases. And to verify 
and emphasize that point I will simply 
allude to the statistics of one of the 
papers. For instance, in speaking of 
the separation of adhesions and deUv- 
ering the appendix, or in alluding to 
the recurrence of cases, the author 
gives two fatal cases in twenty. That 
of itself should be a suflBcient argu- 
ment for surgeons to follow the prac- 
tice advocated by Dr. Morris of 
completing all operations, removing 
the cheesy, disorganized appendix, and 
breakuig up all adhesions. I am sorry 
Dr. Morris does not stand out and in- 
sist upon others doing just what he 
can and does do successfully. 

Dr. Morris has alluded to foreign 
bodies, and I am rather inclined to 
think that the variety of foreign 
bodies found in the appendix is much 
greater than is ordinarily supposed. 
A short time ago a Philadelphia 
surgeon found a fish fin in the appen- 
dix, and another gentleman found two 
sugar-coated pills. We know that 
cases of appendicitis increase about 
the strawbeny and grape season. A 
few years ago an intelligent gentle- 
man, a man of considerable wealth 
and leisure, travelled around the 
world and had twenty-four attacks of 
the disease in different parts of the 
world. He was treated by twenty- 
four or more physicians and by some 
declared cured, when, in the twenty- 
fifth attack. Dr. Agnew removed the 
appendix and the man recovered. 

Dk. a. H. Cokdier, of Kansas 
City, Mo. — I have seen a great deal of 
the work of Dr. Price and 1 have done 
a little of this class of woik myself, 
and must beg leave to differ from them 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



177 



in regard to breaking up adhesions in 
this locality. I wish to call attention 
to the fact that there is a great deal 
of difference between pus found in the 
appendix and that in the pelvis. If we 
accept the theory advanced by Dr. 
Price, that the majority of cases of 

Eelvic suppurative diseases are caused 
y gonnorihoea, we must accept the 
fact that this a form of poisoning 
brought about by the gonococcus of 
Neisser. It does not invade the peri- 
toneum to the same extent, and it is 
not as dangerous a micro-organism as 
the bacillus coli communis. We have 
a different septic germ in this locality. 
If we go to work and break up the 
adhesions in a case of appendicitis 
that are walled off, we are sure to 
have a larger mortality than if we 
simply make an incision, evacuate the 
pus, clean out the cavity, and intro- 
duce rubber drainage in addition to 
gauze packing. My results in operat- 
ing for cases of appendicitis have 
been extremely satisfactory to me. 
Where I find them with walled-off 
abscesses I simply make an incision, 
evacuate the pus, and di-ain as in other 
localities. 

I wish to speak now of the symp- 
tom — colic. We pay too little at- 
tention to colic occurring in the abdo- 
men. A patient presents himself with 
colic occuring from year to year, and 
it is more significant than we are dis- 
posed to think. Two weeks ago I 
operated upon a gentleman for appen- 
dicitis who lost a son three months 
before from this disease without an 
operation. He presented a history of 
having had repeated attacks of colic 
for eighteen years. He baid he had 
never had an attack of appendicitis 
to his own knowledge. On the morn- 
ing of the operation I saw him in con- 
sultation with a normal temperature 
and pulse, but pain in the region of the 
appendix, this attack differing from 
previous ones. Appendicitis was di- 
agnosticatd and I operated on him 
the next day. I evacuated fully a 



teacupful of pus and found a gan- 
grenous appendix. 

With regard to foreign bodies, in 
one case I found apiece of chewine 
gum, in another a piece of wax, and 
in a case I found a cherry-stone, 
which the patient had swallowed a 
week or ten days before, that had 
gotten into the appendix. From 
moisture and heat it had swollen 
and torn a hole into the peritoneum. 

Dr. J. B. MuBPHY, of Chicago. — 
This battle of appendicitis has been 
contested all along the line. The 
first thing we had to defend was 
the presence of pus in these cases. 
Almost every general practitioner 
that you discussed the subject of 
appendicitis with would say, *" There 
was no pus in my case. The patient 
got well." Finally, after careful ex- 
amination at the post-mortem table, 
it is practically agreed that in every 
case of appendicitis there has been 
or there is present pus. What will 
be the outcome of that pus? You 
know the way in which Nature per- 
forms so-called cures or takes care 
of this disease. Every general prac- 
titioner will tell you how many cases 
he has had with recovery. At a 
meeting in one of our Western cities 
this summer, a practitioner who lived 
in a hamlet of two or three hundred in- 
habitants had sixty-two recoveries 
from appendicitis I They were not 
of the variety that came under my 
observation. 

A word with regard to the pathol- 
<>gy« W^6 agree that some cases get 
well without operative interference. 
What cases will you, and what cases 
will you not, operate on ? These are 
two things we want to settle. What 
shall we do with a man in his first 
attack of appendicitis? Shall we 
wait? That is the question. In his 
first attack what happens? He has 
his first symptom either from a per- 
foration, from an invasion with infec- 
tion of the mucous membrane, which 
is the most common, or from an ob- 



Digitized by 



Google 



178 



SOCIETY PROCEEDINGS. 



literation. The outcome of these 
three things will be all the pathologi- 
cal conditions that you can possibly 
imagine, almost, in the peritoneal 
cavity. In the early stage what have 
you to contend with? By the early 
stage I mean at the time when the 

Eatient has his first symptom. You 
ave a disease at this time that is 
limited to the cavity of the appendix, 
while a few days later— many times 
a few hours — it has no limitations 
except the peritoneal cavity. What 
would you do with pus of that danger- 
ous variety anywhere else ? Of coui-se 
you would cut down, evacuate it, and 
try to save the life of your patient. 
When a patient has unmistakable 
symptoms of appendicitis, not to- 
morrow, not to-day, but now is the 
accepted time to operate. The sym- 
toms of the disease are more definite 
and less liable to mislead the surgeon 
in the early stage than the symptoms 
of any one affection I know of, except- 
ing pneumonia. We must not delay 
operative interference until tomor- 
row, but resort to it at once. When- 
ever you have a patient with a sudden 
attack of pain in the abdomen, with 
nausea and vomiting, increased local 
tenderness over the seat of the appen- 
dix, with perhaps a rise of tempera- 
ture, you may conclude that you have 
a case of appendicitis to deal with. 
There are very few conditions in the 
abdomen resembling that. ImJeed, 
the exceptions are so few that we can 
lay down a rule, except in diseases of 
women where there has been a previ- 
ous history of trouble. Even if you 
have symptoms on that side of the 
abdomen in a woman, I think the 
indications are just as great to oper- 
ate as in the appendix. As soon as 
you have the symptoms I have men- 
tioned you should at once proceed 
to prepare your patient for an 
operation. 

Dk. J. Henry Oarstens, of De- 
troit. — Dr. Murphy has said nearly 
everything I wanted to say. I per- 



fectly agree with what he has said, 
but I must differ from Drs. Morris 
and Price with reference to one point. 
There are cases where there is no 
earthly need of going down and 
breaking up adhesions, removing the 
appendix, and so on. I am fully in 
accord with Dr. Oordier's remarks, 
that there is a vast difference between 
pus from the gonococcus and that 
which we get from the bacillus coli 
communis. That is not the only 
thing : we have sometimes a strepto- 
coccus in there. 

I desire to emphasize the pomt 
brought out by Dr. Murphy and for 
which I have been criticised in my 
own city — namely, that in the pres- 
ent state of our knowledge we can- 
not always tell whether we have a 
severe or mild case of appendicitis 
to deal with. 

Dr. E. W. Gushing, of Boston. — 
I agree fully with what Drs. Mui^ 
phy and Oarstens have said. I sim- 
ply wish to call attention to one 
point in Dr. Peck's paper, about a 
secondary operation for freeing the 
bowel. I would be glad to have 
this point referi'ed to in the further 
discussion of the papers, because I 
think one of the most important 
things in the whole subject of lap- 
aratomy is whether we can do any- 
thing for the patient after the oper- 
ation in relieving bowel obstruction 
— whether we shall open the abdo- 
men again. 

Dr. W. E. B. Davis, of Birming- 
ham, Ala. — Reference has been made 
to purulent peritonitis as being dan- 
gerous in connection with appendici- 
tis. We are told that the question 
in regard to the appendix and tubal 
disease is settled, and now we are to 
decide what to do with this affection. 
I think if there is anything to do it 
would be to prevent it. When we 
get general suppurative peritonitis it 
is my opinion that we can do nothing 
for our patient. We have a local 
condition of sepsis that will kill the 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



179 



patient, even though we might relieve 
the general condition ; therefore I 
think the treatment of purulent peri- 
tonitis is preventive. It is the only 
treatment that we can succeed with. 
Cases have been reported of suppura- 
tive peritonitis; they are not cases 
of purulent peritonitis, but cases of 
large abscesses which have ruptured 
into the cavity, which have been 
cleaned out before there was peritoni- 
tis which could have produced these 
abscesses in the general cavity. 

In regard to breaking up adhe- 
sions, I will speak briefly of the 
treatment of appendicitis. It must 
be borne in mind that the most dan- 
gerous kind of appendicitis, that pro- 
duces peritonitis in twelve hours, 
also produces the same condition that 
we get in stab wounds of the intes- 
tines. You all recognize the fact 
that you cannot save these cases 
unless you operate within the first 
day. Many of the cases that need 
our help are cases of fulminating 
appendicitis, in which death comes 
from obstruction of the bowels. I 
am sure it has been the experience 
of all of you that in the majority of 
cases in which you are called upon to 
operate upon the bowels they do not 
have invagination, but obstruction 
due to dynamic eauses. Paralysis 
and inflammation of the bowel not 
due to obstruction of the bowel from 
mechanical sources is not an uncom- 
mon thing to meet with. The patients 
that most need an operation do not 
call us in time to operate. The cases 
of appendicitis that we see on the sec- 
ond or third day we can usually save, 
because the pus is circumscribed. 

With regard to removing the ap- 
pendix and breaking up adhesions, I 
think Drs. Morris and Price have ad- 
vocated a dangerous practice. They 
have recommended a system of treat- 
ment which will, if adopted, cause 
many deaths. I can conceive of 
nothing so dangerous as allowing the 
smallest quantity of this offensive 



septic pus to escape into the abdo- 
men. In the last year, by gentle 
manipulation of the abscesses, I have 
had two secondary abscesses pro- 
duced by the escape of pus, and the 
patients came very near dying. If 
you do not find the appendix by very 
careful and gentle manipulation you 
had better let it alone. 

Reference has been made to foreign 
bod.es being very frequent causes of 
appendicitis at certain times of the 
year. I think the cause is due to a 
catarrhal condition brought about by 
eating too much fruit, not from the 
seeds themselves. 

Dr. a. Van Deb Veeb, of Albany, 
N. Y. — Dr. Peck has placed on rec- 
ord cases that, if we study them 
carefully, will be of value to us and 
to him. As has been remarked by 
Dr. Davis, I do not believe it is pos- 
sible to cure septic peritonitis in 
which we have the bacillus coli com- 
munis. We have the perforative and 
fulminant forms of appendicitis, that 
go on and are precisely like gunshot 
or stab wounds. If we could reach 
these cases early enough, lives might 
be saved; but how many surgeons 
reach the patient in time to perform 
a life-saving operation ? 

As to foreign bodies, I do not think 
this is a matter of so much impor- 
tance, but fecal concretions are found 
in a great many cases. I have a num- 
ber of specimens that I have pre- 
served, but I believe with Dr. Price 
that at certain periods of the year, 
during the blackberry and grape 
season, more cases of the disease are 
liable to occur. The cecum is filled 
with seeds. It does not hold impac- 
ted faeces particularly, but it holds 
foreign substances in such quantity 
as to produce irritation of the mucous 
surface of the appendix, and by ex- 
tension of the irritative or inflamma- 
tory process we meet with a greater 
number of cases at the time of the 
year when fruit and certain forms of 
vegetables are eaten with greater free- 



Digitized by 



Google 



180 



SOCIETY PROCEEDINGS. 



dom. A word about the cases in- 
which we do not find foreign sub- 
stances — they are cases of the ca- 
tarrhal form of the disease. 

As to the time of operating, I am 
an advocate of early surgical interfer- 
ence, although I have operated on six 
cases of relapsing appendicitis with- 
out a death. 

DA. C. A. L. Rebd, of Cincin- 
nati. — I was called by an intelligent 
physician to examine a case that pre- 
sented a classical history of appen- 
dicitis. The doctor had been hesita- 
ting about the necessity of an opera- 
tion, although he recognized there 
was inflammation about the head of 
the colon. He concluded it was one 
of those cases the tendency of which 
was to recover, and the point upon 
which he deferred operation was the 
fact that he was unable to discover 
McBurney's point. There are a 
great many members of the profes- 
sion who believe in McBurney's 
point ; they look for it, and they do 
not call in a surgeon until they think 
they can find it. I wish to emphasize 
the fact that this point must not be 
looked for. 

I recently operated upon a man 
who came to me with a relapsing ap- 
pendicitis. I operated upon him in 
the midst of the twenty-first attack. 
He was a stout, well-built man. I 
could make out no physical symptoms 
whatever, but the history was classi- 
cal, and I operated in the midst of 
the acute symptoms. I found the 
head of the colon adherent to all the 

froximal surfaces. Bringing it up, 
found where there had been seem- 
ingly spontaneous amputation of the 
appendix and closure of the orifice. 
I could find no pus about the head 
of the colon, yet the symptoms in 
the midst of which i was operating 
pointed unmistakably to pus. I en- 
larged the incision, liberated the ad- 
hesions, and three inches above the 
head of the colon I found a pocket 
containing not more than an ounce 



of Dus which had already perforated 
the parietal peritoneum and was 
burrowing into the abdominal wall, 
and withm two inches of this, and 
two inches further remote, I found 
the appendix alive and well, being 
nourished by its adhesion to the 
colon. When we wait for positive 
symptoms, when we wait for a posi- 
tive diagnosis, we simply welcome 
our patient into an untimely grave. 

Dk. James F. W. Ross, of Tor- 
onto. — I take issue with Dr. Davis 
with regard to large intraperitoneal 
abscesses. I have opened the peri- 
toneum of a little girl, from which 
pus and gas spurted out like soda 
water out of a siphon, and after the 
operation the patient lived for two 
or three weeks and died from starva- 
tion. The original cause of the 
trouble was an abscess in the mes- 
enteric glands, which perforated into 
the abdomen. I made a post-mortem 
examination and removed a pailful 
of pus from the child's abdomen. 
The omentum and intestines were 
firmly glued together, with the ex- 
ception of the peritoneal cavity, which 
was almost obliterated, and there was 
nothing but a hole in the drainage 
tube for anything to escape. Some 
of these cases of purulent peritoni- 
tis will have a tendency to cure 
themselves. 

With reference to cases of fulmina- 
ting gangrenous appendicitis, they all 
die. My own cases have all died, 
and, for that reason, when they come 
to me in what I call the second stage 
I do not opei-ate. I do not think anj 
of us can disagree with Dr. Carstens 
that when a patient reaches the third 
stage, in which there is pus walled 
off, the right thing to do is to let the 
appendix alone. An operation done 
in the relapsing stage is not danger 
ous. I have never lost a case on 
which I have operated in the relaps 
ing condition. As to immediate 
operation, advocated by Dr. Murphy 
I consider it to be sound doctrine, but 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



181 



here in Toronto, at any rate, we do 
not see these eases early enough. Dr. 
Murphy says when we see a man with 
classical symptoms of appendicitis we 
should operate at once, but here we 
do not see them when these symptoms 
present themselves. 

Dr. J. D. Gkiffith, of Kanas 
City. — I would ask the gentlemen 
who have spoken, particularly Drs. 
Morris, Price, and Murphy, whether 
they have noticed that a catarrhal con- 
dition of the appendix produces a 
stricture. I have operated within the 
last six months on three cases for ap- 
pendicular colic, not for suppurative 
appendicitis, and I have been able to 
demonstrate satisfactorily to myself 
that in at least two of the cases there 
was nothing beyonda stricture, except 
an enlargement of the canal. I could 
only pass a whalebone guide through 
the strictured portion. There was a 
marked thickening of the circular and 
longitudinal fibres of the appendix, 
showing that the circulation had been 
interfered with to such an extent that 
there was the commencement in one 
of the cases of an active ulcerative 
process. A collection of mucus be- 
yond the stricture and its escape back 
toward the colon was the cause of the 
appendicular colic. It seems to me 
we have an easy way to account for 
some of these cases, as in the one cited 
by Dr. Reed, where there was no fecal 
matter but the orifice of the appendix 
was closed. We speak of closure of 
a stricture in the urethral canal, and 
why cannot the same thing occur in 
the Fallopian tubes? Why can we 
not account for the cutting off of the 
circulation in this way ? 

Db. M. Hart wig, of Buffalo 
(by invitation), took a conservative 
stand with reference to appendicitis. 
While the preceding speakers had 
shown proof of the great danger at- 
tending this disease, still, if we take 
the average cases as they come to the 
general practitioner, appendicitis was 
not very fatal. German statistics 



give about ninety per cent, of recov- 
eries in cases not operated on. He 
admitted that we may have the relaps- 
ing form of the disease, and he has 
had five or six cases of this form occur 
in his practice. Dr. McDonald has 
done a good service by pointing out 
the difference between the operable 
and non-operable cases, as the speaker 
fully believes that such a distinction 
can be made. 

Db. Donald Maclean, of De- 
troit. — First of all I endorse heartily 
the doctrine that has been presented 
by Dr. Carstens — namely, that when 
you have appendicitis with adhesions 
feYicing off the abdominal cavity and 
pus outside, you should open it as you 
would an ordinary abscess and wash 
it out. But not even the eloquence 
of Dr. Murphy, the logic of Dr. Price, 
or the experience of the members of 
this Association would induce me to 
break up the adhesions and enter the 
peritoneal cavity. 

As to the question of early opera- 
tion. If I had my patients entirely 
under my control in the hospital I 
certainly would advise and advocate 
early operative interference. Let us 
take, for example, a hundred cases in 
which an early operation is done for 
appendicitis, and I believe a great 
many of them would have recovered 
without an operation and perma- 
nently. I have had quite a number 
of cases under my observation and 
the opportunity of watching them. 
One was a coachman who had a severe 
acute attack of appendicitis, but was 
unwilling to have an operation per- 
formed. He got well without it. I 
have watched him ever since and he 
is well today. I could cite many 
other cases, if necessary. 

Dk. L. S. McMuRTRY, of Louisville, 
Ky. — One cannot but recognize in 
the remarks of the several speakers 
the marked advance of knowledge in 
relation to appendicitis. Four or five 
years ago many eminent surgeons ad- 
vocated expectant treatment in all 



Digitized by 



Google 



182 



• SOCIETY PROCEEDINGS. 



cases until general peritonitis was es- 
tablished, and inveighed against oper- 
ative interference until the last 
moment. Now the course so forcibly 
advocated by Dr. Murphy and others 
in this discussion is generally con- 
ceded to be the only safe method of 
dealing with this disease. 

Of the many important practical 
points discussed, I beg to direct atten- 
tion to one in particnlar. It is to the 
importance of doing, in every case 
that will permit, a complete opera- 
tion. We have learned the disast- 
rous results of leaving behind diseased 
tissues £^nd multiple pockets of pus in 
suppurative salpingitis, and the same 
principles should be applied in opera- 
ting for appendicitis as in salpingitis. 
But in all cases where the patient's 
strength will permit, a thorough oper- 
ation should be done. Adhesions 
should be separated, multiple pos- 
terior pockets of pus should be 
emptied, and the appendix removed 
with free flushing and drainage. 

Db. W. G. MacDonald, of Albany 
(in closing). — From what I have seen, 
the operative treatment of appendici- 
tis has been largely confined, am6ng a 
great many operators, to two classifi 
cations — cases of localized abscess 
with plastic peritonitis and cases of 
relapsing appendicitis. Of all cases 
of relapsing appendicitis upon which 
I have operated, every one of them 
has got on well, and of the other 
class of cases there is a morality of 
twenty-eight per cent. Five of these 
cases can be attributed to the break- 
ing up of adhesions and establishing 
a communication between the gener^ 
peritoneum and this area of the abdo- 
men which has been suffering. I do 
not believe there is any system by 
means of which you can make it safe 
to turn this portion of infected perito- 
neum into the general peritoneum 
again, drainage or no drainage. 

Db. Joseph Hoffman, of Phila- 
delphia (in closing). — Why gonor- 
rhoea! pus is less irritating than that 



from the coccus which is supposed to 
inhabit the colon is beyond my under- 
standing. It is only an effort on the 
part of some to explain what we can- 
not understand ; and the explanation 
does not go far, for the reason that 
we can constantly open up these 
colonic abscesses and they get well. 
There is no reason why, if the coccus 
of the colon is more poisonous than 
any other, one patient should get well 
and another should not, if there has 
been an abscess opening into the peri- 
toneum. A case was cited in point. 



SECOND DAT^MORNING SESSION, 

President RoHB in the chair. 
Db. Hknry HowiTT, of Guelph, 
Ontario, read a paper entitled 

KBMABK8 ON THE SURGICAL TBBAT- 
MENT OF INTUSSUSCEPTION IK 
INFANTS, BASED ON TWO SUCCES- 
FUL CASES. 

(See Annals, October, pp. 75.) 
Dk. Robert T. Morris, of New 
York, in connection with the above 
paper, demonstrated 

A METHOD OF INTUSSUSCEPTION IN 
RABBITS. 

The demonstration which I shall 
make will take but a few moments. 
It will show you the mechanism of one 
form of intussusception — viz., ileo in- 
tussusception. I do not know of 
what practical value it is, but we 
may suppose I shall produce this in- 
tussusception by touching the ileum 
with a bit of carbonate of sodium. 
We will suppose the ptomaines from 
decomposition of the intestinal con- 
tents may cause some spasm of the 
muscle in the infant. We know in- 
testinal feruientation will cause con- 
vulsions in the child, and it is fair to 
assume sometimes that it may produce 
this form of intussusception which I 
now show you. When I touch the 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



183 



bowel with carbonate of sodium, in 
twenty to forty seconds you will 
notice a sudden spasm of the circular 
fibres of the bowel. It will occur 
quickly, usually in twenty seconds, 
but in older rabbits it takes about 
forty seconds. Please notice now 
that the circular muscle is in a state 
of spasm and the calibre of the bowel 
is reduced very decidedly. [Here Dr. 
Morris conducted the experiment, and 
in about thirty seconds there was an 
intussusception of probably about two 
inches, it being limited only by the 
crowding of the mesentry in the in- 
tussusception.] ITie intussusception 
occurs steadily and quite regularly 
until the mesentery crowds. 

Dr. W. E. B. Davis, of Birming- 
bam, Ala. — Referring to the paper 
read by Dr. Howitt, I think there is 
a good deal of diflBculty frequently in 
diagnosticating these cases in children. 
Appendicitis will often simulate in- 
vagination. If we can feel the tumor 
it will assist us very materially. It 
is difficult to examine the abdomen 
of a child unless we administer an 
anaesthetic. We must not be guided 
by the symptoms of bloody discharge 
and pain alone; they are not very 
reliable. We must feel the tumor. 
I believe invagination is a much rarer 
condition in young children than the 
older text-books taught. 

As for Dr. Morris' experiment, it 
<5ertaiuly opens up a field of much 
interest to us all. He has suggested 
that there may be some germs in the 
intestine that will bring about, under 
certain conditions, invagination in the 
naanner described. 

Dr. M. Rosbnwassbr, of Cleve- 
land, Ohio. — Dr. Davis has just said 
that bloody discharge is not essential, 
but that a tumor is. About two 
weeks ago I saw a case in consulta- 
tion in which a diagnosis of intussus- 
ception was made. The patient was 
a little older than the cases reported 
by Dr. Howitt ; the child was about 
five years of age. The little girl had 



had for two weeks colicky symptoms 
and straining at stool, with inabilitv 
to pass stool. An evacuation took 
place from time to time. Sometimes 
the stools were a little solid and at 
other times fluid. I did not see the 
case at this time. Then, on Wednes- 
day, the child began to vomit inces- 
santly. On Thursday the bowels be- 
came obstructed. There was no dis- 
tention of the abdomen, no fecal 
vomiting. The vomited material was 
purely a mixed fluid, and no passage 
of gas or stool. A surgeon was called 
to see the case on Thursday evening, 
and the child was brought to Cleve- 
land on Friday. . I saw the case on 
Saturday morning. The obstruction 
had lasted for three days. A tumor 
was felt in the region of the trans- 
verse colon, and there were only two 
symptoms lacking to make the pic- 
ture complete — there was no bloody 
stool and no fecal vomiting, no abdo- 
minal distention, but otherwise the 
history of the case looked like a grad- 
ually increasing intussusception with 
finally complete obstruction. As the 
obstruction had existed for three 
days and the child was in collapse, 
almost pulseless, with extremities 
cold, 1 did not advise an operation 
but urged to get the child in better 
condition to withstand surgical inter- 
ference by first giving hypodermic 
injections of strychnia and brandy per 
rectum. This was done, and on the 
following morning the pulse was 
better, with the tumor rapidly in- 
creasing, when a diagnosis of intussus- 
ception was made. Gangrene had 
already set in, and I therefore advised 
an operation, at which I ftssisted the 
surgeon. We found a gall bladder 
as big as my fist, full of gall, perfectly 
round. The intestines were collapsed 
and there was no sign ff invagina- 
tion. The gall bladder >must have 
pressed upon the duodenum. There 
was no fecal vomiting, because pres- 
sure was two high up. » The child 
died in a few hours. There was no 



Digitized by 



Google 



184 



SOCIETY PROCEEDINGS. 



stone found in the gall bladder. This 
ease simulated to a high degree one 
of intussusception where tumor was 
present but no bloody stool. The 
question arises whether or not bloody 
stool is essential to make a diagnosis, 
or whether fecal vomiting is one of 
the essential symptoms in these cases. 

Dk. How ITT. — It appears to me 
Dr. Davis has misunderstood me. 
My paper was confined entirely to 
infants under one year of age. I be- 
lieve, in the infant under this, that 
obstruction from any other cause 
than intussusception is extremely 
rare, and the exceptions are gener- 
ally easily made out. The most im- 
portant part of the diagnosis is the 
suddenness of the attack. It may 
come on during sleep ; it generally 
comes on dining perfect health, and 
there are symptoms of collapse. 

In the case cited by Dr. Rosen- 
wasser, I will say that bloody dis- 
charges are not essential to make the 
diagnosis; but they are frequent. 

Dr. Frank A. Glasgow, of St. 
Louis, Mo., read a paper entitled 

TREATMENT OP DISTENTION OF THE 
FALLOPIAN TUBES WITHOUT LA- 
PABATOMY AND REMOVAL. 

A discussion then followed on 

INFLAMMATORY DISEASE OF THE 
UTEBUS AND APPENDAGES AND OF 
THE PELVIC PEBITONEUM. 

Dr. George H. Rohb, of Catons- 
ville, Md. — Conservative surgeons 
were very much shocked at first by 
the proposition to remove the uterus, 
together with the aduexa, in cases of 
inflammatory disease in the pelvis. 
However, the operation has won its 
way against opposition and must now 
be considered as an elective procedure 
in cases of extensive suppuration with 
adhesion, and especially in those 
cases, so numerous, in which the 
endometrium is likewise the seat of 
purulent inflammation. Gonorrhoeal, 



puerperal, or tubercular inflamma- 
tions, and dense adhesions with dis- 
placement of the uterus, demand re- 
moval of this organ as well as of the 
appendages, if permanent good results 
are expected. 

Total extirpation of the uterus and 
appendages by the vaginal method for 
pelvic suppuration was first done by 
r^an in 1886. P4an, S^gond, Doyen, 
Jacobs, and Landau have performed 
the operation upward of five hundred 
times, with an average mortality of 
less than five per cent. 

The operation by the vagina is 
easier than abdominal extirpation, 
and, in the hands of most surgeons 
who have performed it, is attended by 
less shock. It leaves the parts in 
condition for perfect drainage. The 
after-treatment is simple. Patients 
may sit up in a week or ten days. 
Forceps are preferred to the ligature 
for hemostasis. 

Db. a. H. Cordieb, of Kansas 
City, Mo., read a paper on 

HYDROSALPINX. 

Articles by the so-called conserva- 
tive writers have, in the last few 
months, appeared in journals all over 
the country, in which the aspiration 
or catherization of Fallopian tubes 
filled with liquid of any character has 
been advocated as a procedure of re- 
lief and cure. Such articles have 
engendered a retrograde tendency on 
the part of many, and it is sure to 
be at the expense of an increased 
mortality from subsequent operative 
procedures to cure these cases after 
abandoning the unsurgical and uncer- 
tain tinkering. 

A desire to assist in correcting these 
false theories and aid in establishing 
the truth has prompted the author to 
write this short article, giving his 
personal experience and observation 
in that class of cases. 

Hydrosalpinx has been looked upon 
as the least hazardous of all inflamma- 
tory results to the Fallopian tubes. 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



185 



The writer claimed that hydrosalpinx 
was, in the majority of instances, a 
sequel, to some old inflammatory dis- 
ease of the tubes (pyosalpinx), an off- 
spring of a virulent process that had 
wrought permanent and irreparable 
injury to the delicate structures of the 
tubes. There exists no microscopical 
appearances of the affected tubes or 
their contents to indicate whether or 
not the transition from a virulent to 
an innocent (so-called) condition has 
been completed. A true dropsical 
condition of the tubes is found occa- 
sionally. 

The writer said he did not consider 
hydrosalpinx as a retention cyst. 
Cases of hydrosalpinx that have a 
mild history, and a few inflammatory 
bands discovered at the time of opera- 
tion, were probably due to a catarrhal 
salpingitis, tubular salpingitis, or a 
subinvoluted tube following a septic 
" getting up " after a full-term labor 
or a miscarriage. 

Cases of hydrosalpinx are rarely di- 
agnosticated prior to operation. A 
digital examination of one of these 
cases causes less pain than is produced 
in examining a pyosalpinx. Adhe- 
sions, as a rule, are less firm and the 
uterus is more movable than in a pyo- 
salpinx, but he said that we never see 
an acute case of hydrosalpinx. Many 
cases had their origin in a bad "get- 
ting up" from childbirth. All the 
writer's cases had been in married 
women, and all had given birth to 
one or more children, and in each 
case a period of sterility extending 
over from two to eighteen years. 
Gushes of water from the vagina are 
not of necessity diagnostic of hydro- 
salpinx, yet such do undoubtedly take 
place. A hydrosalpinx* may, by a 
rupture, be symptomatically cured, 
but no surgeon will recommend such 
a procedure. The knowledge of the 
possibility of a tupture should make 
an operative procedure for their safe 
removal imperative. The microscope 
and culture tubes are the only means 



of classifying the character of the 
fluid in these cases. The ovaries are 
not so often injured in these cases as 
in the more acutely virulent purulent 
cases. 

Where hydro succeeds a pyosal- 
pinx, the latter very likely had a 
mild beginning and a slow course. 

Hydrosalpinx had been a complica- 
tion of uterine fibroids in two or three 
of the writer's abdominal hysterecto- 
mies for the removal of these neo- 
plasms. He had seen a pyosalpinx on 
one side and a hydrosalpinx on the 
other. 

A twisted pedicle of a hydrosal- 
pinx had caused death in more than 
one case reported. 

These watery filled tubes may rup- 
ture as a result of a rapid menstrual 
distention, admitting that the tubes 
are menstruating organs, as is claimed 
by some. 

A hemorrhage had in one case been 
caused by the rupture of a hydrosal- 
pinx, nearly proved fatal, and was di- 
agnosticated as an extrauterine preg- 
nancy prior to operation. 

In one case occurring in the essay- 
ist's practice the uterine extremity of 
the tube was largely dilated and 
filled with a clear fluid, while in the 
ampulla there existed a collection of 
pus, separated from the clear fluid by 
a closed stricture. 

Dr. Robert T. Morris, of New 
York, then read a paper entitled 

THE REASON WHY PATIENTS RECOVER 
FROM TUBERCULOSIS OF THE PERI- 
TONEUM AFTER OPERATION. 

He stated that he had been experi- 
menting with a view to determine the 
reason for the cure of tuberculosis of 
the peritoneum after operation, it be- 
ing well known that more than eighty 
per cent, of these cases recover as a 
result of simply exposing the perito- 
neal cavity to the air. Dr. Morris 
collected fluid from the abdominal 
cavity of patients with tuberculosis of 



Digitized by 



Google 



186 



SOCIETY PROCEEDINGS. 



the peritoneum, placed it in an incu- 
bator for forty-eight hours, and devel- 
oped the bacteria of putrefaction 
which would ordinarily enter in such 
fluid exposed to the air. From this 
fluid Dr. Eiloart then isolated a tox- 
albumin, the product of the growth 
of putrefactive bacteria in this peri- 
toneal fluid. The toxalbumin em- 
ployed to destroy tubercular bacilli in 
culture tubes destroyed them very 
promptly. A control experiment, 
which was not yet completed, was in 
progress for determining if these bac- 
teria were absolutely dead. How- 
ever, enough had been proven to show 
that tuberculosis of the peritoneum 
recovers after operation because pu- 
trefactive bacteria produce a toxalbu- 
min in the fluid which is fatal to 
tubercle bacilli in the peritoneum. 
The reason why it is more effective 
in curing cases of tuberculosis of the 
peritoneum than tuberculosis of the 
knee joint, is because the lym- 
phatic anatomy of the peritoneum is 
such that any toxic agent absorbed 
by the lymphatics of the peritoneum 
is brought into close contact with the 
entire structure, whereas in the knee 
joint the lymphatics are fewer and 
with more definite channels. 

Dr. Morris was asked the ques- 
tion as to whether we should leave 



some of this fluid in tuberculosis 
of the peritoneum, and whether we 
should drain it completely under 
aseptic methods. He answered the 
question in this way : that cases in 
which he did the most perfect asep- 
tic operation were cases which did 
not recover from tuberculosis of the 
peritoneum after operation. The 
cases in which he had used drainage 
and had allowed the saprophytes or 
putrefactive bacteria to enter through 
the drainage opening were cases which 
recovered promptly. 

Dr. I. S. Stone, of Washington, 
D. C, asked how he could explain 
the disappearance of certain tumors. 

Dr. Moruis replied that certain 
tumors are microbic in origin, or by 
analogy we believe them to be, ana 
it is probable that the tumors whose 
microbes are killed by the toxalbu- 
mins are the ones which disappear 
after opening the abdominal cavity. 

Dr. Hayd, of Buffalo, asked why 
these bacteria developing in the peri 
toneal fluid would not be injuripus to 
the patient. And Dr. Morris replied 
that the peritoneum was capable of 
disposing of toxic products in most 
instances. 

The Association then adjourned 
until 8 P. M. 

(T6 be continued.) 



Philadelphia Obstetrical Society, December 6, 1894. 



JLB8TBA0T. 



Dr. R. H. Hamill in the chair. 

AUTO-INFECTION IN THE PUERPERA. 
BY DR. THOMAS D. DUNN. 

The cause of puerperal disease is 
the organisms which cause suppura- 
tion elsewhere. The streptococcus 
is usually present in the severe forms. 
The staphylococcus may also cause 



infection. The organisms of putre- 
faction may, by the absorption of 
ptomaines, cause the affection called 
sapreemia. It has also been held 
that these affections are due to the 
gonococci. In four cases coming 
under the author's observation where 
there had been pain, fever and muco- 
purulent discharge, he had suspected 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



187 



that the cause of the aflfection was 
the gonococcus; and this suspicion 
was strengthened by the presence of 
gonorrhoea in the husband, although 
no search was made for the gono- 
coccus. A review of the literature 
shows that a variety of organisms 
may produce puerperal infection, and 
that in the majority of cases they are 
carried into the genital tract on the 
hands of the accoucheur. 

One of the most important ques- 
tions is, « Is this the only cause of 
infection, or may infection come from 
organisms present in the genital canal 
previously ? " It is believed that in 
a small percentage of cases, patho- 
genic germs may have been intro- 
duced into the birth canal during 
pregnancy and have remained in a 
latent state until labor, when they 
are absorbed into wounds that may 
have been produced, causing a septic 
process, this being simply a variety 
of external infection. 

Careful investigations have shown 
the presence of pathogenic organisms 
in the birth canal in a positive per- 
centage of cases not previously exam- 
ined. The frequency with which 
this is the case is, however, so out of 
proportion with the cases of child-bed 
fever, that other conditions favoring 
the development of the afifection 
must be looked for. These facts 
would seem to indicate that patho- 
genic organisms do not play as im- 
portant a part as we should expect 
from the bacteriological examination. 
But this is the same as is seen by 
the surgeon, — the mere presence of 
gern^s does not necessarily mean a 
septic wound.. It is probable that 
certain conditions with which we are 
not familiar are necessary for the pro- 
duction of infection. The mechan- 
ism of labor with the gush of water, 
the passage of the child's head and 
the delivery of the placenta are ad- 
mirably adapted to clean the genital 
tract. A study of the statistics shows 
that the use of one ante and one post- 



partum douche is not harmful, but 
the use of external antiseptics is of 
much greater importance. 

THE MORBID CHANGES IN THE PUER- 
PERAL ENDOMETRIUM DUE TO SEP- 
TIC INFECTION, AND THEIR RELA- 
TION TO THE GENERAL SYMPTOMS. 
BY DR. W. REYNOLDS WILSON. 

The modern treatment of early 
infection in the puerperal state illus- 
trates the theory of its causation. 

The point of attack is proven to 
be the endometrium by the eflBcacy 
of local treatment in removing the 
general symptoms. There are two 
primaiy forms of septic puerperal 
infection, the putrid and the septic. 
The putrid form of endometritis occurs 
in two forms. First, the localized, in 
which a granulation zone is formed, 
preventing the passage of germs; 
and, second, the form in which the 
granulation zone is absent, and we 
have septic endometritis with general 
infection. The infection may occur 
through the lymphatic system or 
through the veins. 

While putrefactive germs may be 
present in septic endometritis, they 
do not predominate and foetid local 
discharge usually does not accompany 
the more active septic processes. The 
active causes in septic endometritis 
are usually the streptococcus pyo- 
genes aureus, the staphyloccocus 
aureus and albus and the strepto- 
coccus of erysipelas. These attack 
the placental site and points of denu- 
dation about the cervical canal. In- 
fections of wounds about the vulva 
and vagina are less likely to communi- 
cate the disease to the general system 
on account of the less active devel- 
opment of the lymphatics in these 
regions. 

The causes which predispose to 
local infection are early local changes 
due to forming endometritis, and 
secondly the constitutional condition 
of the patient. 



Digitized by 



Google 



188 



SOCIETY PROCEEDINGS. 



The symptoms of local infection 
are abdominal tenderness and sub- 
involution. The general symptoms 
are those of a mild irritative fever. 
There is often a roseolous eruption 
over the face and neck, and foetid 
lochia. In acute infection with active 
lymphatic absorption there are pres- 
-ent symptoms of peritonitis and the 
symptoms produced by the absorp- 
tion of germs and their products. 

In necrotic endometritis the symp- 
toms are those classed under the 
head of saprcemia. In the broadest 
sense, the cause is the retention of 
putrid materials vrithin the uterus. 
There is a general necrotic condition 
•of the endometrium or a necrosis 
localized to the placental site. 

Infection into the lymph channels 
may occur through the placental 
site, or the micro-organisms may 
enter through lacerations in the cer- 
vix and lower segment of the uterus. 

In saprsemia the irorbid manifes- 
tations are those of a toxsemia, and 
they may be of a mild or grave form. 
Tt is important to note that putrid 
changes at the seat of infection may 
'have an important bearing on the 
spread of infection, rendering the 
septic germs more active. The sapro- 
phytes may render the individual 
more susceptible to infection by other 
bacteria. 



^PUERPERAL SAPBJSMIA. 
E. P. DAVIS. 



BY DR. 



The parturient patient is exposed 
not only to poisoning by infective 
germs but also by certain toxines 
which accompany the process of pu- 
trefaction. Injuries occurring during 
labor place the tissues in a favorable 
position for infection, while foetal 
death places in the body of the pa- 
tient a mass of tissue ready to putrefy, 
and offering favorable conditions for 
the growth of germs. The causes of 
saprsemia are those which produce 
necrosis of tissue and introduce into 



this infecting germs. The fate of 
the germs will depend in part on the 
blood serum. In some cases, the 
bacteria grow rapidly and abscesses 
promptly follows. In other cases, 
the germs fail to increase rapidly. 
The products secreted by these bac- 
teria constitute toxines. Sapnemia 
is most often observed after tedious 
labor, where injury to the soft parts 
has taken place. Observation has 
shown that absorption begins about 
ten hours after labor. In some cases, 
haemorrhage by impoverishing the 
blood, renders the patient peculiarly 
susceptible to septic absorption. 

The clinical signs of saprsemia are 
foul discharge, fever, rapid pulse, and, 
usually, tenderness over the uterus. 
In severe cases there may be rigors 
and delirium. A comparatively sud- 
den onset with rapid pulse give evi- 
dence of a toxaemic poison rather than 
a gradual development of bacteria. 
Pathogenic germs present in the 
tract after labor find favorable food 
in the putrefactive material present. 

Differential diagnosis of saprcemia^ 
septicaemia and pycemia : In sa- 
prsemia, the symptoms are those of 
an absorption toxaemia. In a septi- 
caemia the absorption is more gradual 
and the course of the case is more 
gradual, the fever showing remis- 
sions. In pyaemia the symptoms of 
septicaemia are increased by the 
symptoms of abscess formation. 

Treatment of Saprcemia. As the 
retained decomposing tissue, from 
which are absorbed the toxines, is in 
the birth canal, the first step is to 
empty and cleanse this region. For 
this purpose the intra-uterine douche 
curette is of service. The curette 
should be large and its edge not 
sharper than that of a paper cutter. 
No attempt should be made to remove 
the granulation tissue beneath. An- 
tiseptic solutions, preferable one of 
the phenols, are of service. There is 
no necessity for the uterine catheter 
in these cases. After using the 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



189 



currette we should pack with iodo- 
form gauze, or use a suppository con- 
taining iodoform or boric acid. If 
the disinfection is thoroughly done it 
is rarely necessary to repeat it. If 
there is evidence of further ab- 
sorption, the treatment should be re- 
newed. Saline purgation may also 
be employed to relieve the pelvic 
lymphatics. 

Saprsemia may seriously complicate 
labor where parturition is prolonged, 
and may offer an indication for speedy 
delivery, this being called for both in 
the interests of the mother and child, 
as the foetal mortality is increased by 
the occurrence of saprsemia during 
labor. In these cases it is well to de- 
liver with the least possible risk of 
injury. There is increased risk from 
symphyseotomy under these circum- 
stances. In highly contracted pelvis 
where sapraemia is present, the child 
should be delivered by abdominal sec- 
tion rather than through the vagina. 

When proper treatment is insti- 
tuted, the chances of the patient are 
but little imperiled by the complica- 
tion. When a patient is allowed to 
remain in impossible labor, the mor- 
tality rate is high. 

PUERPERAL CELLULITIS ANt) PUER- 
PERAL PERITONITIS. BY DR. 
CHARLES P. NOBLE. 

The author has made these affec- 
tions the subject of a collective in- 
vestigation through correspondence 
withover thirty eminentgynajcologists. 

On April 6, 1894, the author had 
reported five cases of puerperal cel- 
lulitis and true pelvic abscess, verified 
by abdominal section. To these he 
was able now to add eleven others in 
the hands of competent men. In 
these cases the uterine appendages 
were entirely normal or only slightly 
diseased. His correspondents also 
referred to numerous other cases in 
which the affection was supposed to 
be of thb character, but the diagnosis 



was not confirmed by abdominal sec- 
. tion as the patients recovered without 
operation, or the abscess was opened 
directly. These studies bear out the 
opinion that pelvic cellulitis and true 
pelvic abscess are met with in the 
puerperal state and are surgical curi- 
osities in the non-pvierperal woman. 
His treatment in cases of this kind 
has been to open the abdomen to 
determine whether or not the uterine 
appendages were involved, and if pus 
were present to evacuate it by a 
second incision. 

The author then considered puer- 
peral peritonitis : firsts as a complica- 
tion of lymphangitis and cellulitis; 
second, as due to the injury of pelvic 
tumors in labor; and, third, as due to 
the bruising or rupture of pus sacs 
and other accumulations in the ap- 
pendages existing prior to labor. 

The first class of cases is more 
fatal than any others. In these cases 
the septic element predominates over 
the peritonitis and local pelvic inflam- 
mation. The case usually terminates 
fatally in a week or ten days. If 
surgery is to be of service in these 
cases, it must be prompt while the 
trouble is limited to the uterus and 
vagina. By the curette and douche^ 
the infective process may be cut 
short. If the disease is advanced and 
the uterus is thoroughly infected and 
the infection is spreading, perhaps 
the radical operation ot hysterectomy 
may save a certain number. Pre- 
vention of infection and vigorous 
treatment of puerperal sepsis offers 
the only rational means of preventing 
death from this variety of peritonitis. 

In cases of peritonitis due to the 
bruisinjr of tumors during labor, opei-a- 
tions offer more for the cure of the 
case than in any other variety of 
peritonitis. 

Peritonitis from the rupture or 
bruising of pus tubes or other ac- 
cumulation in the appendages is not 
common because women with these* 
conditions are usually sterile. Th& 



Digitized by 



Google 



190 



SOCIETY PROCEEDINGS. 



proper treatment in these cases is 
prompt operation, irrigation and 
drainage. 

KBMOVAL OF THE UTERUS AND AD- 
NEXA FOB PUERPERAL SEPSIS. BY 
DR. J. M. BALDY. 

In 1887 the author had done abdom- 
inal section removing the adherent 
ovaries and distended pus tubes in a 
puerperal woman suffering from sep- 
sis. The patient made a prompt 
recovery. This is the first case of 
this kind of which he had knowledge. 
He advocated that, where the ovary 
or tube is found distended with pus in 
the puerperal woman, the distended 
organ should at once be removed. 

In the large class of cases where 
infection of the Fallopian tube and 
ovary has occurred and possibly of 
the peritoneum without the forma- 
tion of pus, the treatment is to be 
determined by two conditions, 1, the 

feneral condition of the patient and 
, the ability of the physician to de- 
termine, whether or not, suppuration 
has occurred. In general it is safe to 
say that in any attack of puerperal 
salpingitis and puerperal peritonitis^ 
no pus being present, immediate oper- 
ation is not demanded. In those 
cases in which it is doubtful whether 
or not pus is present, and the general 
condition permitting, he would prefer 
to delay, watching the patient and 
operating later on if necessary. 

There is another class of cases in 
which the patient suffers from puer- 
peral fever without local signs of 
pelvic trouble. A certain number of 
these patients will inevitably die, un- 
less the source of absorption is cut 
off. The only proper procedure in 
these cases is the removal of the 
uterus, thus stopping the absorption 
of sepsis, and unless sufficient has 
already been absorbed to disorganize 
the blood the patient stands a chance 
of recovery. The success will depend 
directly on the period of the disease 



at which the operation is performed. 
The earlier the operation the greater 
the likehood of a successful result. 
The author, however, believed that in 
the vast majority of septic cases seen 
in time, dangerous complications can 
be avoided by thorough curetting, 
irrigation and antiseptic packing. 

Conclusions : Patients suffering 
with puerperal septicaemia with pus 
in the appendages should be submit- 
ted to abdominal section. If the dis- 
ease is limited to one organ, only the 
affected organ should be removed. 
If it becomes necessary to remove 
both appendages, the general condi- 
tion permitting, the uterus should be 
removed at the same time. 

In cases of septicaemia where sup- 
puration has not taken place, the 
general condition not contra-indicat- 
ing, we should wait for the subse- 
quent occurrence of symptoms. 

Patients suffering from puerperal 
septicaemia from the absorption of sep- 
tic matters through the uterus whose 
lives are seriously threatened, will in 
carefully selected cases demand early 
abdominal section. 

1 NFECTION OF THE URINARY TRACT 
AND BLADDER AFTER LABOR. BY 
DR. R. O. NORRIS. 

Infection of the urinary tract is not 
uncommon, and it may be of the 
ascending variety, beginning in the 
bladder or adjacent structures and 
extending to the ureter and kidneys ; 
or of the descending variety, begin- 
ning primarily in the kidneys and 
passing to the ureter and bladder 
secondarily. The infecting poison 
may gain access in different ways, but 
usually by the catheter not being 
clean or by a clean catheter becoming 
contaminated by coming in contact 
with the lochial discharge. The 
healthy bladder can resist the action 
of bacteria, but in the puerperium this 
normal condition is not present on 
account of the contusions received by ■ 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



191 



the bladder during labor. It has also 
been found that micro-organisms, in 
other of the pelvic viscera, may find 
their way into and infect the bladder. 
It is easy to understand how the kid- 
neys may become infected by continu- 
ity of structure. The time required 
for the spread of infection from the 
bladder to the kidneys is usually ten 
days to two weeks. 

The symptoms of septic puerperal 
cystitis are those of cystitis under 
other circumstances. The fever of 
cystitis generally passes over in a 
few days. Where the gradual de- 
pression of the temperature curve is 
followed by secondary rise accom- 
panied by tenderness over the kid- 
ney, the diagnosis of secondary in- 
fection of the kidney is made out. 
In all cases of puerperal sepsis it is 
desirable that frequent examinations 
of the urine be made in order to 
detect the occurrence of ascending 
or descending nephritis which may 
insidiously develop. 

The prognosis of septic cystitis is 
favorable if proper treatment is be- 
gun early. The most important ele- 
ment in the treatment is the pre- 
vention. The use of the catheter 
should be delayed as long as possible. 
The danger of over-distension must 
also be borne in mind, for the trau- 
matism resulting therefrom renders 
the bladder more susceptible to the 
influence of septic organisms. If the 
bladder is not evacuated within 
twelve hours, a clean catheter should 
be passed visually, with antiseptic 
cleansing. When cystitis develops, 
irrigation of the bladder should be 
employed at intervals of four hours, 
some mild antiseptic being employed, 
as creolin one-half per cent., or boric 
acid, fifteen grains to the ounce. 
Warm applications over the bladder 
and diluent drinks in connection with 
irrigation will usually check the cys- 
titis in a few days. 

With regard to infection of the 
rectum, the speaker said that the 



complication was a very rare one, 
but few cases being on record. 

SEPTIC PHLEBITIS IN THE PUEEPBEA. 
BY DR. BARTON COOKE HIRST. 

Of all the forms that sepsis can 
present, phlebitis is the least under- 
stood, the most often mistaken and 
most frequently maltreated. The 
most misleading features of the affec- 
tion are the late appearance of the 
symptoms and the entire absence of 
local and physical signs of inflamma- 
tion. It may develop as late as 
five weeks after labor. There is an 
absence of local signs, while the 
general symptoms may be most 
marked. The disease usually begins 
ten days or more after confinement. 
The temperature may show a de- 
cided rise in twenty-four or forty- 
eight hours. The pulse is rapid, out 
of proportion to the temperature. 
There is distinct flushing of the 
face and patches of red may appear 
on other parts of the body, particu- 
larly the chest. The patient may 
not complain of feeling ill. The dis- 
ease runs a tedious course. It may 
continue for from three weeks to 
four months. Another distinctive 
feature is the tendency to complete 
remissions of the fever and other 
symptoms for more than a week at 
a time. Then there is a recurrence 
of the symptoms with the former 
intensity. 

The commonest complication of 
phlebitis is phlegmasia, but many 
cases run their course without swell- 
ing of the legs. Thrombosis is 
another complication, and it is not 
necessarily confined to the veins of 
the lower extremity. The longitud- 
inal sinus and other large veins far 
distant may be involved. Another 
complication is metastatic septic in- 
flammation anywhere in the body. 
Again, there may be repeated haem- 
orrhages from the veins of the placen- 
tal site. 



Digitized by 



Google 



192 



SOCIETY PROCEEDINGS. 



The treatment consists iu absti- 
nence from local interference and 
the freest possible use of stimulants 
and food. Any attempt at local 
disinfection will make the patient 
worse. The use of injections may 
cause a rapid rise of temperature. 
This is often a valuable differential, 
diagnostic sign. In view of the pos- 
sible presence of saprsemia, one 
thorough local disinfection should be 
practised. 

Prognosis : The disease should end 
n recovery in the great majority of 
cases. 

Dr. Egbert Grandin, of New York, 
was expected to be present, but was 
unavoidably detained. He sent a 
piaper giving his views, of which the 
following is an abstract: — 

Thesubjectof puerperal septicaemia 
may be simplified by the statement, 
that the disease is due to lack of 
cleanliness on the part of some one 
of the attendants of the parturient 
female. An aseptic technique on the 
^part of all coming in contract with 
the puerpera means an afebrile and 
uncomplicated convalesence. Auto- 
infection is a myth unless we are 
pleased to so denominate pueiperal 
saprceraia. The truth of this view 
is shown by the practical obliter- 
ation of septicaemia from the practice 
of all who pay strict attention to the 
laws of surgical cleanliness. 

The vast majority of cases of puer- 
peral sepsis originate in that portion 
of the genital tract which is accessi- 
ble to local thenipeusis ; hence the 
necessity for careful repair of all 
lesions immediately after the com- 
pletion of labor in order to close the 
avenues of entrance of septic material. 

Puerperal cellulitis is a possibility, 
although its occurrence is a rarity. 
Puerperal peritonitis is usually an 
epiphenomenon of septic endometritis. 
The treatment of puerperal periton- 
itis may be said to consist in its 
prevention. On the first signs of 
local sepsis, the genital tract should 



be thoroughly cleansed. Many a 
septic tube and ovary may be saved 
by early radical treatment of the 
lower genital tract. If, however, the 
tubes, ovaries and peritoneum become 
involved, there is great danger of the 
development of general septicaemia 
and death. If there is any treatment 
for these complications, it is the extir- 
pation of the tubes, ovaries and 
uterus, but this must be resorted to 
early. Septic salpingo-oophoritis in 
the puerperal state necessarily means 
septic metritis. If operation is re- 
sorted to early, the patient has a 
chance of recovery, but if the periton- 
eal cavity has become infected and 
filled with multiple abscesses, the 
best that we can do is to extirpate 
tubes, ovaries and uterus, open every 
pus sac and drain, but no matter how 
radical we may aim at being, the 
great majority of these cases will 
terminate fatally. 

DUPLICATE OF DISCUSSION. 

Dr. H. H. Hamill in the chair. 

Paper of Dr. Dun. 

Paper of Dr. Wilson. 

Paper of Dr. Davis. 

Paper of Dr. Noble. 

Paper of Dr. Baldy. 

Paper of Dr. Norris. 

Paper of Dr. Hirst. 

Paper of Dr. Grandin, of New 
York. 

Dk. J. Whitbridge Williams, 
OP Baltimore. — As some of yoa 
know, I have taken more or less in- 
terest in the question of puerperal in- 
fection, particularly from an etiologi- 
cal standpoint. During the past 
eighteen months my work has been 
unavoidably, interrupted but I expect 
to continue it and hope soon to bring 
forth some material which may go 
toward solving the interesting prob- 
lem as to the etiology of puerperal 
sepsis. 

As was said by the first speaker, 
puerperal sepsis is undoubtedly due 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



19a 



to a number of micro-organisms. 
The most frequent cause is the 
streptococcus pyogenes, that is the 
organism which causes puerperal in- 
fection in the vast majority of cases. 
Then there are cases caused by the 
staphylococcus aureus and possibly 
other forms. These cases are compara- 
tively rare and are usually of moderate 
severity. Then we also have cases of 
gonococcus infection, nearly all of 
moderate severity. As far as I know 
none of these cases have died. We 
have other cases due to the colon 
bacillus. One Berlin observer found 
in seven cases a pure culture of the 
colon bacillus. Eisennart and Kronig 
have also had to do with the colon 
bacillus. Several French observers 
have also met with it. There is no 
doubt that other organisms take part 
in the puerperal infection. 

My own work has been conducted 
in rather a different line. I was in- 
terested in the work of Derelin on 
the vaginal secretions and undertook 
some work to see if my results would 
correspond with his. It is only nec- 
essaiy to say that my results did cor- 
respond very closely with his, and in 
my article I had no hesitation in say- 
ing that his conclusions were abso- 
lutely justified. When in Leipsic, 
last winter, I found that Derelin's 
place had been taken by Kronig and 
Maman. These two men have taken 
up the same line of work and have ar- 
rived at diametrically opposite con- 
clusions. 

Derelin divided his cases into those 
with a normal discharge, which con- 
stituted the majority, and those with 
pathological discharge. In a certain 
number of the latter he found patho- 
genic streptococci, and from this he 
stated that it was possible to Lave 
infection of the woman without the 
introduction of new organisms. My 
results confirmed those of Derelin. 
The two men who have followed him 
in Leipsic say that they can find no 
pathogenic organisms except the gon- 



occus. It is diflBcult to account for 
this difference in results. Derelin*8 
work was conducted with care and I 
have watched the work of the other 
men and can detect no flaw. It may 
be that the material which they use 
is not suitable for the growth of 
streptococci. I hope, however, to 
have the opportunity of going over 
the subject again and seeing what 
the result will be. I believe, however, 
that my results show that in a cer- 
tain number of women we can find 
in the vagina a certain number of 
pathogenic organisms as the strep- 
tococcous, staphylococcus and gono- 
coccus. The question then is, do 
these things give rise to puerperal 
infection. This must be answered 
in the negative. The great majority 
of women will, not have puerperal 
infection, although many will have 
the organism present. Something 
else is required beyond the presence 
of the organism. We have the pos* 
sibility of infection, but for practical 
purposes it does not occur. When 
we do any operation we necessarily 
introduce many organisms, but we 
do not infect the wound. I think 
that while infection is theoratically 
possible and occassionally may occur 
in this way, yet that in the vast major- 
tiy of cases when infection does occur 
it has been brought from without 
by the physician or attendents. This 
view appears to be borne out by 
the results obtained in the best lying- 
in hospitals. Maman who does not 
believe in auto-infection but in sub- 
jective antisepsis, reports thirteen 
hundred cases. Only three per cent, 
of these had a temperature above 
100° ; he has lost no case from sepsis 
contracted in the hospital. Only 
one woman died and she had sepsis 
when admitted. I think that such, 
results show that practically we 
have very little anto-infection. 

When we come to the practical 
management of labor cases, I believe 
absolutely in subjective antisepsis. 



Digitized by 



Google 



194 



SOCIETY PROCEEDINGS. 



I do not believe in vaginal douche. 
The general practitioner is liable to do 
far more harm than good with it. 
In hospital practice, however, I do not 
think that we do our duty unless we 
differentiate the cases from a bacte- 
riological standpoint and douche those 
cases with abnormal secretion. Where 
the secretion is pathological there may 
be a chance of auto-infection, and 
those cases we should douche, but in 
private practice I condemn douch- 
ing. 

I should like to say a word in re- 
gard to the treatment of puerperal 
fever. I do not know that there is 
as much sapraemia as is generally be- 
lieved, but I think that a consider- 
able number of these cases are in- 
stances of mild septic infection. In 



such cases all that is necessary is to 
clean out the uterus and wash it out 
I think that it makes no difference 
whether we use bichloride or carbolic 
acid solution or simply boiled water, 
as the fluid acts mechanically and we 
cannot use enough of the antiseptic 
to do any good unless we resort to 
continuous irrigation. 

To sum up my view on the subject, 
I would say that I believe that auto- 
infection is possible, but that we do 
not have to reckon with it. I believe 
in the most rigid subjective antisep- 
sis, but I do not believe in vaginal 
douches in general practice. In 
hospital practice, where we differenti- 
ate our cases, douching has its 
uses. 

Adjourned. 



Transactions of the Detroit Gynaecological Society, November 7, 1894. 



DI8 CU88ION — PELVIC INFL AJtf M ATION8. 



The President, 
M. D., in the chair. 



E. T. Tappey, 



^ETIOLOGY. 

• 

Dr. Tappey. — The most frequent 
cause of pelvic inflamnaation is what 
has been spoken of so much in this 
society and others, namely, gon- 
orrhoea. The inflammation caused 
by the virus starting, usually, in 
the vagina, and extending through 
the uterus and Fallopian tubes to the 
ovaries. The next factor of impor- 
tance in the causation is the various 
infections that take place at child- 
birth. A third factor is tuberculosis, 
which affects the pelvic organs as it 
4oes almost all the organs of the 
abdomen, by setting up a low grade 
chronic inflammatory condition, and 
sometimes the formation of abscesses. 



Besides these, one may have inflam 
matious caused by the extension 
of inflammations from abdominal 
organs, as, for example, appendicitis. 
Briefly, these factors, to which I 
should probably add traumatism, 
seem to me to be the chief causes 
of pelvic inflammations. 

DIAGNOSIS AND SYMPTOMS. 

Dr. Longyeah. — I feel a little 
embarrassed at telling these learned 
gynaecologists and surgeons the symp- 
toms and methods of diagnosing 
pelvic inflammations; but, as our 
president has assigned this part of 
the discussion to me, I will endeavor 
to do so, noting the salient points of 
my subject only, however, as the time 
at my disposal is insufficient for me 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



196 



to do complete justice to it in all 
its details. 

I shall first consider the symptoms. 
The title of the discussion is rather 
broad, and may cover any structures 
in the pelvic cavity; but to simplify 
matters I shall speak mostly on 
the inflammation of the uterus and 
appendages, and peritoneum of the 
pelvic cavity. The symptoms of 
acute inflammation of these organs, 
which we shall consider first, gener- 
ally begin with pain in the uterus. 
When it is infectious — and nine- 
tenths of these cases are — the pain 
begins in the uterine endometrium, 
and passes upwards. This pain is 
generally located by the patient in 
the back of the pelvis and across the 
middle and lower part of the abdo- 
men, sometimes running down the 
inside of the thighs, and is increased 
by motion. There is often some dis- 
turbance of micturition, but that 
usually comes later, anJ, as a rule, 
there is no febrile action at first. 
The pain gradually ascends and 
reaches out into the pelvic cavity on 
each side, and tenderness on pressure 
begins to be manifest. It may ad- 
vance into one side only, and that 
side is usually the left, observing the 
same rule as in diseases of the tes- 
ticles of the male. This tenderness 
increases as the disease advances, and 
comes to be at last very acute. The 
patient will not have chills or fever 
at first, but as the disease advances 
and invades the Fallopian tubes, and 
especially if pus forms, chills and rise 
of temperature occur. On examin- 
ing by the vagina the cervix is found 
to be very hard and sensitive, and if 
the disease has just commenced, there 
will not be much tumefaction around 
it, but later you will find that the 
uterus becomes somewhat fixed, and 
the broad lig^ament on the side on 
which the inflammation is most severe 
will be found to be thick and oede- 
n)atous. The tissues have become 
filled with serum, which causes this 



stiff condition of the vaginal vault, 
feeling as though made of pack 
board. The whole vault of the vagina 
will sometimes be found to be solid. 
This condition dissolves to a certain 
extent after a few days, so that you 
can map out the organs with more 
ease. The uterus is still rather im- 
movable, and by bimanual palpation 
you can find the enlarged tube and 
distinguish the separation between 
the tube and the uterus. 

In the beginning of these attacks 
you are often in doubt as to the seat 
of the trouble, and when it is neces- 
sary to settle the diagnosis at once, 
give an anaesthetic, as the extreme 
sensitiveness often makes an exam- 
ination otherwise impossible. 

As the disease progresses resolution 
may take place without pus forming 
for you do have fever without pus; 
there may be only an exudation of 
serum. Where no pus is contained 
in the Fallopian tube after such an 
attack, it feels like a large cord, and 
the distinct elongated tumor can be 
made out lying next the uterus and 
running off to the ovary. This acute 
inflammation may run on a week or 
ten days, and where pus does not 
form, the less active symptoms will 
last from three to six weeks more. 
Where pus forms there are always 
chills and fever and more or less local 
peritonitis, which produces adhesions 
of the parts, and sometimes this 
pus ruptures through the fimbriated 
extremity, and you have a pelvic 
abscess, which is separate from the 
Lube, the pus lying on the perito- 
neum, and walled off from the abdo- 
men by adhesions. The symptoms of 
this would be a sudden exacerbation 
of pain, chills, and rise of tempera- 
ture. General peritonitis would be 
caused by escape of pus through the 
adhesions into the abdominal cavity, 
and can be excluded by the symp- 
toms. This pus may be evacuated 
by the surgeon's knife, or it may 
evacuate itself through the vagina 



Digitized by 



Google 



196 



SOCIETY PROCEEDINGS. 



or rectnm, in which latter case we 
should have preceding symptoms of 
tenesmus and diarrhoea. If through 
the vagina the only symptoms would 
be the pus comfng through, although 
the pointing of the abscess can be 
located before. There is another 
symptom in the bpginning, and that 
is the colicky pain which is quite 
characteristic. This pain is called a 
tubal pain, although it is undoubt- 
edly uterine. The pain is more 
marked where there is a discharge 
from the tube through the uterus. 
These pains I think are due to this 
discharge passing into the inflamed 
uterus, and its presence, with the 
stenosis of the inner os, causing the 
contraction, as in one case I made the 
experiment of putting a drain of 
silver wire into the flexed uterus, and 
this relieved the pain. 

This description would fit a pelvic 
inflammation coming from gonorrlioeal 
poison, as it would one also caused by 
the streptococcus or staphylococcus. 
You may also have abscess of the 
tubes produced by tubercular deposit. 
In these cases the symptoms will not 
begin in the uterus, but in the ovary 
and tube, which are first attjicked, 
and abscess will form. This condi- 
tion is sometimes found in young 
girls, and the diagnosis is often ex- 
tremely difficult. It is said that in 
these cases you will usually find de- 
posits in the lungs, but I have rarely 
found this so. The inflammation 
resulting from infection at the time 
of childbirth may be somewhat differ- 
ent, and you mjiy have a nearer ap- 
proach to the pelvic cellulitis and 
abscess, which used to be supposed 
to exist where pyosalpinx was pres- 
ent. After childbirth, when infection 
occurs, the uterus often takes on an 
acute inflammation with resulting 
abscesses in its walls, and. the pus 
which forms often passes to the bioad 
ligaments. 1 hese cases generally go 
rapidly, and tlie patients either suc- 
cumb to the activity of the inflam- 



mation, or the pus is evacuated, either 
by the surgeon's knife or spontane- 
ously, through the rectum or vagina, 
or the abscess may point in the 
groin. 

There are a few diseases only 
which you need to differentiate. One 
of these is neuralgia of the ovary, 
which is very often confounded with 
a true pelvic inflammation. I do- 
not think there is any excuse for 
this mistake, for examination will 
always show the difference. In neu- 
ralgia of the ovary you have those 
peculiar hysterical symptoms coming 
from reflex action, and there is no 
tumefaction or any of the physi- 
cal signs of inflammation. Those I 
have enumerated. I think it is very 
essential to make a differential diag- 
nosis, because the neuralgia can often 
be successfully treated medically in- 
stead of surgically, while it would be 
a crime to remove a healthy ovary* 
Another trouble that may be mis- 
taken for pelvic inflammation is ab- 
domino-lumbar neuralgia of the sur- 
face. In that case the pain is located 
apparently in the region of the ovary. 
Examination again will show the 
difference, the tenderness being ex- 
ternal, and the ovary and tube free 
from the signs of inflammation. I 
would recommend that, in making 
the physical diagnosis of inflamma- 
tion of the pelvic organs, the exam- 
ination be made with the patient 
in the dorsal position. The thighs 
should be flexed and rotated out- 
ward, so as to put the psoas mus- 
cles on the stretch, thus marking the 
boundaries of the pelvic cavity more 
plainly. With the patient in this 
position, and the use of bimanual 
palpation, the diagnosis should be 
made. 

TREATMENT. 

Dr. Carstens. — The question of 
treatment is, of course, a very plain 
and simple one. It resolves itself in- 
to two kinds, — the preventive and the 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



197 



<5urative. The preventive, it seems 
to me, is the principal one. Having 
had our attention called to gonorrhoea 
as a cause, the great thing is to pre- 
vent the gonococci from getting into 
the Fallopian tubes. Tbese cases 
generally come into the hands of the 
general practitioner and the treat- 
ment should be most thoroiij^h and 
systematic. This cannot be done by 
merely giving a little wash arid injec- 
tion. You must use the speculum 
And thoroughly clean the vagina with 
some germicide, and be sure to clean 
out tbe cervical canal. By this thor- 
ough treatment you prevent the form- 
ation of gonorrhoeal pus tubes. The 
•other factor is puerperal infection, 
sometimes after labor, but generally 
after miscarriage, and due to the 
streptococcus and staphylococcus ; the 
fault dirty fingers and instruments, 
and trusting too much to the vis 
medicatrix naturce. The germs find 
a most fruitful soil for development 
And get up into the tubes, simply 
because, following a simple case of 
miscarriage, the woman has not been 
properly treated. The uterus should 
be thorpughly cleaned as soon as you 
are called to the case. Give an 
■anaesthetic and dilate the uterus and 
thoroughly clean and disinfect it. 
Sivab it out with strong carbolic acid, 
which does not hurt a particle, and 
the uterus will contract and there 
'will be no trouble. You must, if pos- 
sible, dilate the uterus and get your 
finger in, especially if the case is of 
some time standing. If the general 
practitioner would take care, the occu- 
pation of the abdominal surgeon 
would be practically gone. We have 
another class of cases, in young girls 
who ride bicycles atod are run into 
and knocked over, servant girls who 
fall down stairs, — these dislocate their 
ovaries and uterus. The uterus be- 
comes congested, which is the first 
stage of inflammation; then comes 
oedema of the submucous tissues and 
iiypersecretion, and a good soil is 



formed for the developement of germs. 
If we can take these cases early and 
if we can put false modesty aside, 
give an ansesthic and make a thor- 
ough examination and introduce a 
properly fitting pessary, these cases 
could be cured, but they are neglected. 
The treatment is on general principles, 
hot douches, etc., and finally tbey 
come to me. The treatment has 
been correct as far as it goes, but it 
has had no effect. Sball I repeat all 
this treatment ? No I all I can do is 
to remove the diseased pus sack. In 
other cases, as Dr. Longyear says, 
they are sick four, six or eight weeks 
when I am called to see them. What 
shall I do, — build them up? The 
physician in attendance has been try- 
ing to build them up with tonics and 
proper food, but they are gradually 
getting worse, there is absorption of 
pus and every day they become more 
splensenic. Shall I wait? No I I 
must operate right away and I know 
these cases are desperate cases; some 
will virtually die, on the table, but it 
is the only chance. Probably one 
out of four or five die, but if I waited 
another week or two they would die 
of general debility. As we have to- 
day a much better knowledge of the 
causation of this trouble it makes the 
treatment much more simple than it 
used to be. Sometimes the tube be- 
comes obliterated by itself and the 
patient gets well with a little simple 
treatment, but these cases are very 
rare. After all reasonable treatment 
has been tried there is only one thing 
to do and that is to remove the organs. 
The point I particularly wish to make 
is that in the great majority of cases 
the general practitioner can prevent 
the trouble, but when it does exist 
the sooner the operation is done the 
better and the results we get are 
sometimes simply wonderful ; but 
sometimes they are so far run down 
when they come for operation that all 
hope of recovery is doomed to disap- 
pointment. When a woman is hyster^ 



Digitized by 



Google 



198 



SOCIETY PROCEEDINGS. 



ical and undergoes such an operation 
she will be neurotic just the same. I 
think we get better results in elderly 
than in young women, but in any case 
we must not promise too much. 

Dr. Helen Warner.— I would 
like to ask Dr. Longyear and Dr. 
Carstens if they think all cases of 
pelvic inflammation are either septic, 
gonorrhoeal or tubercular. 

Dr. Cakstens — Nearly all, but 
there are exceptional cases, as the 
traumatic, which I menlioned. 

Dr. Warner. — I have seen many 
cases where there was no traumatism 
and gonorrhoea was out of the ques- 
tion, yet where there was severe in- 
flammation with suppuration. All 
recovered, some perfectly. It seems 
out of the question that they were 
tubercular as they showed no symp- 
toms 

Dr. Cakstens. — We have tuber- 
cular salpingitis in only a small pro- 
portion of cases, but we have some 
cases where the infection is simply 
from the staphylococcus, which is the 
most benign of germs, and in these 
cases we may get a discharge of pus 
into the vagina or rectum, and as soon 
as drainage is established the cavity 
heals up. It is simply due to cervical 
endometritis. 

Dr. Longyear. — There is one 
fact I want to put on record. I have 
never operated for the removal of a 
pus tube where I could positively ex- 
clude gonorrhoea or tubercular disease 
as the origin. 

Dr. Warner. — I had a case once 
where there was undoubtedly a pus 
tube in a young girl where the hymen 
was intact and where there was a con- 
dition of vaginismus from bsemor- 
rhoids in the rectum. The first at- 
tack did not result in an abscess. In 
the second an abscess formed which 
opened through the rectum and pus 
was seen several times. She is mar- 
ried and the case ought to be operated 
on, as there have been several sub- 
sequent attacks. 



Dr. Longyear. — I cannot always 
tell that a woman has a pus tube be- 
fore I operate; no one can. I think 
in these cases we may think there is 
a pus tube, while in reality the pus 
comes from somewhere else. 

Dk. Carstens. — You may have 
a tubercular lymphatic gland, as you 
do in the neck, which may suppurate 
anddischarge. 

Dr. Huson. — I would like to ask 
Dr. Carstens if in all cases of abor- 
tion he would clear out the uterus if 
the patient appeared normal and he 
had to take the patient's word for what 
had come away. 

Dr. Carstens. — Virtually in all 
cases, though occasionally you may 
leave one alone. 

Dr. Metcalf. — I would like to 
add to the symptoms of chronic in- 
flammation. We have a great many 
reflex disturbances in other organs as 
the result of pelvic inflammation. 
The heart is influenced through its 
ganglia, which are very large, and are 
reached by impulses from the pelvic 
viscera passing to the solar plexus 
and thence either up the lateral chains 
of the sympathetic or by means of the 
splanchnics to the vaso-motor centre 
in the medulla and thence by means 
of the pneumogastrics. In many cases 
we have constipation, the rhythm and 
sometimes, the secretions of the intes- 
tines being interfered with. The 
mind is greatly involved, especially 
when the junction of the nervous sys- 
tems at the internal os is inflamed. In 
these cases I have found a number of 
cases of insanity which were quite 
easily relieved. As to the elevation of 
temperature,whetherpus forms or not, 
might not the vasomotor centres in 
the medulla and ^long the cord from^ 
reflex irritation produce a rise of tem- 
perature. The peritoneum is sup- 
plied by large terminal ganglia of the 
sympathetic and the elevation may be 
due to disturbance of the vaso-motor 
system. Then as to the colicky pains 
in the tubes, perhaps the tubes have a^ 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



199^ 



rhythm and when they are stopped by 
pus the rhythm may be interfered 
with, until the pus is evacuated, and 
cause the colic. In those cases which 
remain neurotic after operation, per- 
haps we have not removed the whole 
cause. I know of one case which got 
worse after operation. She had con- 
stipation, cystitis and painful micturi- 
tion and was so fearfully nervous that 
she feared insanity. All these symp- 
toms were cured by carefully remov- 
ing the uterus. 

Dr. Sprague: — As to the etiol- 
ogy I would be inclined to agree with 
Dr. Warner that we do have cases of 
pelvic peritonitis where there is no 
gonorrhoeal infection, and none of the 
causes mentioned are at work. We 
have endometritis where there is no 
tubercular trouble. It sometimes 
seems to be due to imperfect develop- 
ment, and may extend into the tube. 
I have in mind one case of a seam- 
stress who came with a retroverted 
womb immensely large, and a very 
bad endometritis and it developed 
into a hsemato-salpinx. None of the 
causes mentioned were possible in 
that case. She recovered, is married, 
has a child of eight months, and is 
again pregnant. Then, as regards the 
treatment, it seems to me that it was 
thoroughly exhausted as to prophy- 
laxis and the desperate cases, but it 
seems to me that the intermediate 
treatment has not been dwelt upon 
enough. We have many cases of 
pelvic inflammation that recover al- 
most wholly, but bands of adhesions 
remain that draw the organs out of 
position, and, from the strain on the 
ligaments, pain results and the 
patients are invalids liable to a fresh 
attack with any indiscretion, and 
ought to have treatment. There is a 
treatment for these cases, that which 
has been given to the world by a non- 
professional man, Brandt. His claims 
are discredited by many, but so great 
a man as Schultze has come to ac- 
knowledge the importance of massage 



in these cases. I have tried it in two 
cases particularly, in which there was 
that .intense hardness of the roof of 
the pelvis that lasted a variable 
length of time in such cases. In one 
instance, after two or three weeks the 
hardness was still present and I be- 
gan gentle massage, gradually increas- 
ing as I found it well borne. To my 
gratification absorption went on very 
rapidly. I have a case now under 
treatment to which I was called five 
or six weeks ago, in which I did not 
for a time use massage, but I found 
the exudate not absorbing. Today I 
gave the third treatment of massage 
and I can move the parts consider- 
ably. Of course we have absorption 
which begins sooner than this, and of 
course it might be the same if I had 
not used massage, but the woman 
tells me that she feels relieved after a 
treatment. When she can come to 
my oflBce I shall begin another form 
of treatment which has not beeiv 
mentioned, except incidentally, to- 
night, and that is electricity. W^e 
have three factors in this. First, the 
electrolytic. This seems to melt the 
exudate. Second, I may call the gal- 
vano-chemical effect due to the acids 
set free by the chemical action ; and 
third, the cataphoric effect seems ta 
me the most important. Tissues can 
be softened amazingly by the passage 
of the electrical current. I think by 
a combination of galvanism and mas- 
sage, much can be done in a pelvic 
inflammation that does not proceed 
to pus formation, and I am beginning 
to think more and more that even 
where there is pus the patient can be 
made comfortable and sometimes 
cured by the negative electrode ap- 
plied in the tube or against its uter- 
ine mouth, as I have before advo* 
cated. 

Db.Longybar.— There is one point 
I perhaps did not make quite clear. 
I do not wish to be understood to say 
that all cases of pelvic inflammations 
are due to gonorrhoea. Young girla 



Digitized by 



Google 



200 



SOCIETY PROCEEDINGS. 



may have it due to suppressed men- 
straation, and these attacks will often 
cause adhesions. I have had good 
results in dissolving these adhesions 
by electricity. 



WEDNESDAY, DECEMBER 5, 1894. 

The president Dr. E. T. Tappey in 
the chair. 



SUBINVOLUTION. 



Dr. EMMA D. COOK. 



The subject of subinvolution is 
one which should ever remain of 
of great interest to the gynaecolo- 
gist on account of its frequency, 
its persistency against remedial 
measures, and the fact that radical 
cures are seldom recorded, if per- 
chance they are made. 

An arrest of involution, one of 
the most interesting physiological 
processes of nature, by which the 
uterus, enlarged by conception, may 
resume again its normal size, is in- 
<Jeed a subject worthy of the most 
oareful research as to cause and 
treatment. 

The term subinvolution, as ap- 
plied to the sequelae of this disease, 
has received criticism by some of 
our able authors, the results as as- 
serted beng similar to those of con- 
gestion long kept up from mechani- 
cal causes ; as displacements by 
fibrous tumors or other formative 
products ; conditions which exist 
where there is no history of preg- 
nancy. 

Classing these diseases as the 
same, although resulting from en- 
tirely different causes they have re- 
ceived various names among which 
are the following: ''Engorgement," 
"irritable uterus," "metritis," "dif- 
fuse proliferation of connective 
tissue," " in farctus," "chronic paren- 
chymatous inflammation of the 
womb." 

Thomas, in bis "Diseases of 
Women," discusses its nomenclature 
at some length, and believes that 



this pathological condition, together 
with all others which result in en- 
largement of the uterus, ' inflam- 
mation of its mucous membranes, 
engorgement of its lymphatics and 
blood vessels should be classed as an 
areolar hyperplasia, arguing that this 
terra signifies the true conditions 
found more fully than any given by 
other authors, believing it to be an 
hypertrophy of the areolar or con- 
nective tissue, and in no sense a true 
inflammation. 

To understjind our subject more 
fully, let us briefly review the com- 
ponents of a healthy uterus: 

Histologically, Schafer gives the 
following : — 

First. A serous layer, derived 
from the peritoneum and composed 
of the same elements. This layer 
covers a greater part of the fundus. 

Second. The muscular layer 
composed of plain muscular fibi'es 
disposed in two imperfectly sepa- 
rated strata. Of these the outer is 
much the thinner and its fibres are 
disposed partly longitudinally and 
partly circularly. The inner muscu- 
lar layer is very thick ; its fibres 
run in different directions, and it is 
prolonged internally into the deeper 
part of the mucous membrane. 

Third. A mucous membrane 
which is very thick and is com- 
posed of soft connective tissue con- 
taining a large number of spindle 
shaped cells. 

It contains long, simple, tubular 
glands which take a curved or con- 
voluted course in passing through 
the membrane. 

These glands are lined by ciliated 
epf thelium continuous with that which 
covers the inner surface of the mu- 
cous membrane. 

In the cervix the mucous mem- 
branv5 is marked by longitudinal and 
oblique ridges ana the glands are 
shorter than those of the body of 
the uterus. 

The mucous membrane is exceed- 



Digitized by VjOOQ IC 



SOCIETY PROCEEDINGS. 



201 



ingly Yascular throaghoat and con* 
tains large numbers of lymphatic 



'* Under the stimulus of concep- 
tion the uterus developes rapidly, 
partly by growth of already existing 
Btructiires and partly by new forma- 
tions." 

The cells increase in size the 
mnscular elements are also much in- 
creased and lymplatics and blood 
vessels are dilated to properly nour- 
ish the existing pregnancy. 

Xncceeding parturition a retroprrado 
evolution begins: the fibres undergo 
a fatty degeneration: absorption takes 
place and the organ rapidly dimin- 
ishes to its original size and weight. 

'J'homas stiites that if unarrested 
this absorption is completed at the 
end of the eighth week. 

Skene says, giving as his au- 
thority observations made by Dr. 
Sinclair of Boston, who took care- 
ful measurments in one hundred 
and eight cases after delivery, 

In the majority of these cases the 
uterus had reached its normal size 
b three weeks. In one the uterus 
measured two and one-half inches 
on the twelfth day after delivery. 

Influences may check this normal 
process, absorption no longer goes 
on and we have the condition known 
as subinvolution. 

The pathology as given by Skene 
is as follows : 

. In uncomplicated cases there are 
no inflammatory products nor are 
there any new tissue formations, 
other than those which occur in 
normal gestation. 

When the uterus has been af- 
fected by puerperal metritis the 
products of inflammation are found. 
These products are inflammatory, 
exudations and hyperplasia of the 
cells of the areolar tissue. A gen- 
eral enlargement and engorgement 
of blood vessels and lymphatics. 

ITie symptoms are not easily dis- 
tinguished from other hyperplasias. 



The history of a trouble dating- 
from. confinement, of bearing down 
pelvic pains, together with the local 
examination revealing a uterus en-- 
larged displaced, undergoing a de- 
generation of its mucous membranes, 
confirms the diagnosis of subinvolu* 
tion, because of an arrest of 
absorption after parturition at full 
term or non-absorption after a mis- 
carriage. 

The treatment of these cases 
forms an important part of the 
subject bronght before you at this 
time and I hope that the discussion 
which follows may bring out many 
points of interest in this regard. 

All will agree that the most 
potent factor in restoring this un- 
fortunate condition is rest. 

A second and equally important 
factor is to learn if possible the 
cause sind remove it. Should this 
be a lacerated cervix restore the 
laceration ; if due to a ruptured 
perineum an operation is always 
indicated. A retrovertcd organ 
should if possible be restored to rts 
normal position and kept there 
until the recuperative forces of 
nature can act sulliciently to hold 
the organ in place. 

Another factor of no less import- 
ance is the building up of the gen- 
eral health. Anemia, neuroses, con- 
stipation, indigestion are usual com- 
plications in this trouble. 

These disorders should if possible 
be remedied. 

The case whose history I will 
relate is as follows : 

Mrs. U, aged twenty-four came ta 
me for treatment in October, '93. 

Two years beforo. had a miscar- 
riage after five months gestation,, 
foetus had been dead some time 
before labor, placental tissues were 
removed with dilKculty. Patient 
had fever and slow recovery. 

Since that time had complained 
of pain in the back, bearing down 
pains in pelvis, excessive and pro- 



Digitized by 



Google 



202^ 



SOCIETY PROCEEDINGS. 



longed menstrual period, constipa- 
tion, impaired digestion, dizziness, 
pain in top and back of head. Ane- 
mia and the general nervous symp- 
toms which accompany this class of 
cases were all present to a remark- 
able degree. 

The patient was practically unfitted 
for mental or physical labor^ and 
complained that riding or walking 
-caused intense nervous symptoms. 
Examination showed cervix some- 
what enlarged, uterus prolapsed, 
retroverted, enlarged (measuring 3i 
inches), a glairy discharge escaping 
from the cervix. The appendages 
seemed quite normal. 

I gave her at ohce a general tonic 
treatment. Locally, I applied boro- 
glyceride in the knee-chest position 
three times a week, ordering the 
patient to remove the support, douche 
with very hot water, and assume 
the knee-chest position for several 
minutes each night, previous to 
returning for treatmeet. 

This, with the tonics, relieved the 
aggravated nervous symptoms, but 
the dragging-down pain and discharge 
still continued. 

On Mov. 20, I curretted, removing 
a mass of fungus from the interior 
of the uterus, washed out with bi- 
chloride of mercury one five thous- 
andth, and ordered the patient to 
remain in bed for one week At the 
end of that time I made an intra- 
uterine injection using a few drops 
of a mixture of two parts of iodine 
to one of carbolic acid after first 
syringing the cavity with bichloride 
of mercury, my object in using the 
antiseptic douche being to remove 
if posssblc any fungus still within 
the cavity, the syringe acting as a 
dull curette. 

I treated once a week during each 
inter-menstrual period. Giving the 
different forms of iron, cod liver oil, 
hypophosphites, etc., asgeneral tonics 
until the general health and vigor 
seemed restored. 



Continuing with maganese binox- 
ide as an uterine tonic until June 
94, when my patient was discharged 
comparatrvely strong and well. 

The uterine cavity at this time 
was somewhat diminished in size 
though not normal. The discharge 
had ceased the uterus was nearly 
normal in position. 

The patient herself feels confident 
of a radical cure. I am only glad 
that the condition has thus far been 
improved. 

I do not give this as a guide in 
the treatment of these troubles. 

I believe each case must be 
treated according to the conditions 
found. 

If there is one point which I 
would urge more strongly than all 
others it is this: 

That the obstetrician be more 
careful in warning patients against 
getting up too soon after confine- 
ment, particularly in diflBcult labors, 
and miscarriages. 

I am confident* that one week 
longer in bed at time of confine- 
ment would save many women from 
years of suffering. 

DISCUSSION. 

Dr. Spbagub. — The doctor has 
very fully covered the ground, and 
it seems to me that there is not 
much left to say, though I have 
some ideas differing from Dr. Cook 
in regard to treatment. Speaking 
first of the pathology, the descrip- 
tion given would be as applicable to 
metritis as subinvolution. In the 
early stages of the latter we do not 
have inflammatory changes ; it is an 
arrest of the retrograde process iu 
which the muscular tissue partakes 
most largely. Of course the blood 
vessels participate in this process, 
and many of them become mere 
cords from occlusion, and the areolar 
tissue shrinks from lack of blood 
supply; but the muscle fibres seem 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



208 



to undergo a fatty degeneration which 
results in rapid retrograde meta- 
morphosis and great reduction in 
the size of the individual fibres, but 
not total destruction. Thus the 
whole process of involution is the re- 
sult of diminished blood supply, an 
atrophy of all the tissues of* the uterus. 
This diminished blood-supply is the 
result of uterine contractions, hence 
anything that interferes with firm 
contraction tends to cause subinvolu- 
tion. This is perhaps the most usual 
condition. But we may have the 
diminution of blood supply interfered 
with by an endometritis, and this is 
the condition we often find after an 
abortion of which endometritis is the 
cause. I believe it may also exist 
after labor at full term, if there has 
been a previous endometritis. 

With regard to treatment I think 
that the doctor's is quite as rational 
as any we find in most of the text 
books of today, but I have very de- 
cided views on this subject. Skene 
describes the treatment much as Dr. 
Cook has given it, and then says, if 
this fails he uses electricity and be- 
lieves electricity is the best means 
of curing sub-involution. I fully 
agree with him in this opinion. I 
have had considerable experience 
with it. I think Massey has treated 
of it more fully than anyone else. 
There is no more rational way of 
curing a sub-involution, due to feeble 
or imperfect contraction, than by 
causing firm contraction of the mus- 
cular fibres and forcing the blood 
away and thus permitting the retro- 
grade process to go on, and the 
faradic current is the best way to 
produce these contractions. This is, 
perhaps best accomplished by the 
intra-uterine bipolar electrode. We 
can often in half a dozen treatments, 
bring the womb down to the natural 
size. I have seen it done a number 
of times. Now that is quite opposed 
to the very first statement of Dr. 
Cook's paper and to the generally 



received opinion, but I know of no 
case in gynaecological electro-therapu- 
tics where so few treatments will 
produce such marked results. In 
those cases which are due to the 
retrograde changes being interfered 
with by too great endometrial blood 
supply, I should use the galvanic 
current, usually the positive intra- 
uterine electrode with the current 
sufficiently strong to destroy the 
mucous membrane and all shreds of 
decidua that may have beeux retained, 
and that treatment should also be re- 
peated from two or three to a dozen 
times in order to bring about a satis- 
factory condition, and then the cu- 
rette is not necessary. I do think, 
however, that we have cases of 
endometritis resulting in fungous 
growths in which the use of the 
curette is to be commended. In ad- 
dition to destroying the membrane 
the current acts beneficially in two 
other ways, by its cataphoric and 
electrolytic effect, bringing about 
retrograde changes and absorption 
of fluids. There is another effect, 
and toat is its influence upon the 
nutritive functions, but the rationale 
of this process is very indefinite in 
our minds, though that it has this 
effect seems to me very apparent. 
I am heartily in accord with Dr. 
Cook's ideas, that the patient should 
be watched more carefully after 
labor. There is great fault among 
physicians to-day in that respect. 
I believe that no patient should be ' 
dismissed under three weeks, and then 
a very careful examination should be 
made, and if a laceration of any 
considerable size has taken place, 
it should be repaired or carefully 
watched until it is certain that repair 
is unnecessary. 

Dr. Warner. — I should like to 
say a word about the aetiology. I 
have no doubt, in Dr. Cook's case, 
that the retroversion was the cause 
of the subinvolution. I have seen 
that cause a great many times. A 



Digitized by 



Google 



204 



REVIEW OP GYNECOLOGY. 



woman gets up while the womb is 
still heavy, and in making some quick 
movement will cause a retroveraion. 
I think that it is generally six or 
eight weeks before the womb is down 
to the normal size. If these cases of 
retroversion are taken at the time, 
they will not need lengthy treat- 
ment, or require the application of 
electricity or anything else. Place 
the womb in its proper position, and 
involution will go on. 1 think elec- 
tricity is indicated in an old subin- 
volution, but I never found the 
electrode equal to the curette. The 
curette takes out all the bad tissue 
at one sitting instead of making an 
esehar and leaving it to slough 
away. 



Dr. Cook. — I am aware of the fact 
that electricity is the ideal treat- 
ment ; but I fthad no means of using 
it, and I reported this case to eIiow 
what can be done with medicines. 
I think it is very difficult some- 
times to tell whether a case is one 
of endometritis or subinvolution. 
We have a case in the clinic at 
Harper Hospital, which has eveiy 
symptom of subinvolution, but the 
Avoman e^ives no history of ever hav- 
ing been pregnant. 1 think these 
cases have j^enerally passed that 
condition which would be properly 
called subinvolution before they come 
into the hands of the gynaecologist. 



REVIEW OF GYNiECOLOGY. 



A Case op Hydatid Cyst op the 
Uterus. By De. CAREAaA. 

A woman, aged thirty-two, has had 
four children, three of whom are liv- 
ing, of medium size and good health, 
has missed her menses for the past 
five or six months, and during this 
time experienced no inconvenience 
excepting an increase in the size of 
the abdomen. The uterus was found 
three finger breadths below the um- 
bilicus and was dull on percussion. 
The finger introduced into the vagina 
could penetrate into the cavity of the 
cervix and a soft mass could be felt, 
which was certainly not a fcetal head 
or other parts, but Avhich could have 
been mistaken for the unruptured 
membranes. As there was no haem- 
orrhage or other alarming symptoms, 
and as the frequent and energetic 
contractions were most similar to 
those of labor, expectant treatment 



was carried out. Shortly after, the 

[)atient expelled in three pieces a 
arge quantity of spherical hydatids, 
their size being nearly that of a fist; 
they were completely separated fi*om 
each other and without being en- 
veloped in a sac. Their total volume 
was about the size of a child's head 
at term. As soon as the mass was 
expelled the patient felt better. The 
author remarks that in the cases 
mentioned by Park, Blat, Barrd and 
Lsennec, the hydatids did not form in 
the interior of the uterus as in bis 
case. (Arch, de gynoecopathia^ oh^tet'- 
rica y p6diatriay Aug. 15, 1894. 
Review in La Revue intemationale de 
M6d. et de Chirurgie, Sept. 25, 1894. 



The Cystitis op PREGNANCir. 
Prof. Taunier. 



By 



The writer establishes in the first 



Digitized by 



Google 



REVIEW OF GYNECOLOGY. 



205 



place the difference between cystitis 
of pregnant women and the so-called 
irritable bladder. The hitter is above 
all characterized by a frequent and 
imperious desire to urinale. It ap- 
pears either at the comra^cement or 
at the^ end of pregnancy. At the 
beginning of pregnancy the frequent 
desire to urinate is partly due to com- 
pression of the bladder, but especially 
to the congestion of the entire pelvis, 
which is very vascular during gesta- 
tion, propagating itself to the bladder, 
and thus irritating it. At the end of 

Testation, the symptoms of irritable 
ladder are due to compression of the 
bladder by the uterus and especially 
by the foetus. But the symptoms 
are not alarming and ceiise by rest in 
bod, SI bland diet and if necessary a 
sitz bath. 'J'his is not the case in 
cystitis of prrgnarvcy, and the charac- 
teristic points in this complication are 
frequent and most painful micturi- 
tion. The desire to urinate is frequent 
and acconipanied by pains, which 
radiate to the neighboring parts; the 
pains are increased by pressure over 
the liypogastric region, by fatigue, 
and cease or diminish by rest. The 
urine is changed in quality. By 
vaginal examination pain is produced 
when the ureter is pressed on. The 
urine, which is always normal in 
cases of irritable bladder, presents 
variable changes in the cystitis of 
pregnancy, thus distinguishing it 
from simple hsemorihagic or purulent 
cjstitis. In the first instance, the 
urine only contains mucus and dSbrin 
of vesical epithelium; in hfiemorragic 
cystitis, the urine is more or less red- 
colored and contains red blood cor- 
puscles ; and lastly, if it is purulent, 
a whitish deposit is found at the 
bottom of the glass and by the micro- 
scope pus cells are found. If the 
ammoniacal odor is very strong, it 
indicates a more serious condition. 
Wlien purulent cystitis has become 
gangrenous, fragments of necrobic 
vesical mucous membrane may be 



found in the urine. As causes, com- 
pression of the bladder or ureters and 
pyelo-nephritis with consecutive cys- 
titis have been invoked. But Prof. 
Tarnier believes that it is more likely 
due to retention of urine, so frequent 
during pregnancy, because retrover- 
sion of the gravid uterus can produce 
the same symptoms. The cystitis of 
pregnancy is only serious by its com- 
plications, which for that matter are 
incident to any kind of cystitis, and 
especially by abortion or premature 
labor that it may provoke. In de- 
livered women, it sometimes has a 
fearful tenacity, and weakens the 
patient exceedingly, and if not follow- 
ing the cystitis it can only be attri- 
buted to the accoucheur, but a per- 
fectly aseptic catheterism will not 
endanger the patient to this affection. 
Once developed, cystitis should be 
treated by the balsams, the following 
pills being often followed by an ex- 
cellent result: — 

R. 

Camphor, 0.10 

Opium, 0.01 

M. F. pil. No. 1. D. tal dos. No. XX. 

8. Take five or six pills daily. 

If the cystitis is purulent, vesical 
antisepsis should be practised by 
means of injections of a 2 per cent, 
boracic acid solution. {Cllnique Ob- 
stetricale, Aug. 1894. Review of La 
Revue internationale de M6d et de 
Chirurgie, Sept. 25, 1894.) 



Abdominal Supra- Vaginal Hy- 

STEllECTOMY FOR FlBROIDS OP 

TUB Uterus; Retroperitoneal 
Treatment of the Pedicle. By 
Dr. Leonte op Bucharest. 

Since 1887 the writer has operated 
twenty-six cases of interstitial and 
submucous fibroids of the uterus by 
the above named procedure. The 
indications for operating were fur- 
nished by the abundance of the hsdm- 



Digitized by 



Google 



206 



REVIEW OF GYNECOLOGY. 



ortage, the increasing size of the 
neoplasm, pain, symptoms of com- 
pression, and, among these, especially 
those noticed in the genito-urinary 
system. Profound and progressive 
anaemia was never an obstacle prevent- 
ing the operation, and no unfavorably 
consequences were noted. The tech- 
nique of the procedure employed by 
Dr. L^onte is as follows : The tumor 
having been detached from any exist- 
ing adhesions is drawn out of the 
abdominal wound and a long forceps 
is placed on each broad ligament on 
the outer side of the ovaries. A flap 
of the serous membrane is then cut 
from one broad ligament to the other 
on the anterior aspect of the neoplasm 
by means of an incision made at sev- 
eral centimetres above the insertion 
of the vagina ; then the same flap is 
made and detached from the posterior 
surface of the growth. When the 
flaps are dissected out, the fibroid is 
pedicalized. The broad ligaments 
are first tied ofiE by a '^ chain stitch " 
with silk, but, instead of cutting them 
at once, large pressure forceps are 
placed on the tumor at the insertion 
of the ligaments, which are then sev- 
ered between the last named forceps 
and the silk sutures. The neoplasm is 
thus little by little pedicalized. The 
pedicle is traversed in its antero-pbs- 
terior axis at one centimetre above 
the vaginal insertion by a strong 
blunt needle carrying a strong double 
thread of twisted silk. Both liga- 
tures are crossed and tied on the sides 
of the pedicle and this is then cut 
through above the ligatures and. the 
tumor removed. The section is 
• oblique, in such a manner that the 
incision of the stump which results 
presents an excavation, limited by 
two flaps, — one posterior, the other 
anterior. The endometrium is cu- 
retted or excised and a ten per cent, 
solution of chloride of zinc is applied. 
Now comes the suture en sujet of 
the uterine flaps, which is done with 
catgut and then the stump is covered 



by suturing the peritoneum over it as! 
well as the incision left in the broad 
ligaments. In^ this way, the peri- 
toneal cavity is completely closed 
below and the stump of the uterua 
becomes in reality extra and retro- 
peritoneal. The adnexa are always 
removed. The abdominal incision is 
closed without drainage. This pro- 
cedure has been employed in twenty- 
six cases, and all were successful both 
as to operation and result. The after 
results were in most cases normal. 
Only one patient presented symptoms 
of peritonitis, but, on re-opening the 
abdomen, nothing abnormal was dis- 
covered. Consequently it may be 
affirmed that supra-vaginal hysterec- 
tomy is to be preferred to total hys- 
terectomy. {Revue de Chirurgie^ June^ 
1894. Reviewed in La Revue inter* 
nationale de MSd, et de Vhiruryie,) 

FOBMDL^ FOB DV8MEN0RUBCEA (O. 
VAN ROKITANSKY.) 

R. Ext. opil., 0.50 

Camphor, trit., 0.30 

Vitel. ovi., No. 1 

Aq. dest., 150.0 

M. D. S. For one enema which should be 
retained. 

The following is used by Dr. Cum- 
ston for imbibing cotton tampons, 
which are placed against the cervix, 
in cases of cervical endometritis or 
cancer : — 

R. Thiol., 25.0 

Terebenipur. . 10.0 

Two per cent, carbol. iod. tinct., 5.0 
Glycerini, 40.0 

M. D. S. Soak a tampon in th« solution 
and apply to the cervix uteri. 

Dr. Wm. P. Derby employs the 
salicylate of soda in cases of dysme- 
norrhoea not produced by any me- 
chanical obstruction. He formulates 
as follows : — 

R. Sodse salicylat. 0,30 

M. F. pulv. D. tal. dos. No. XXIV. 

S. Two powder? to be taken after each 

meal for the four days preceeding the expected 

time of menstruation. 



Digitized by 



Google 



BOOK REVIEWS. 



Dr. Derby has found this treatment 
most excellent in both private and 
hospital practice. 



General Paraxysis in the Fe- 
male. By Dr. Idanow. 

The author of this excellent mem- 
oir comes to the following conclusions: 
First, general paralysis is more often 
met with in women than was formerly 
thought. Analysis of 104,000 insane 
taken from different hospitals of 
eight European countries shows 8 
women to 10 men having this affection; 
second, the reason of this difference 
from the older writers is because 
general paralysis is becoming more and 
more frequent, especially in the fe- 
male sex; third, the etiology in its 
principal traits does not differ in the 
female from that of the male sex. In 
both sexes one fact is characteristic, 
namely, the necessity of these simul- 
taneous etiological elements (excess 
of mental emotion, hereditary 
syphilis, etc.), among which syphilis 
plays in both sexes a rSle equally 
predominant and important. Of the 
total number of female paralytics, 
sixty-eight per cent, had a history of 
syphilis; fourth, the most favorable 



age is from thirty to forty years 
fifth, the different forms of evolution 
are the same in both sexes, and it is 
absurd to consider a form special to 
the female ; sixth, the rSle of 
syphilis in general paralysis is double. 
Usually it only prepares the ground 
on which, with the aid of other etio- 
logical factors, acting simultaneously, 
general paralysis is produced. In 
other much rarer cases syphilis acts 
in a direct manner, for, in producing 
changes in certain parts of the brain, 
it may provoke a clini<ial picture, 
similar to general paralysis. This 
latter is the pseudo-general paralysis 
of syphilitic origin ; seventh, the dif- 
ferential diagnosis of pseudo-general 
paralysis is most frequently very 
difficult to make. Among the most 
faithful diagnostic symptoms is the 
termination of the disease by a cure 
under specific treatment. From this 
fact results the last conclusion of the 
author, that in all cases of this affec- 
tion a moderate anti-syphilitic treat- 
ment should be tried, especially in 
cases where a syphilitic history can 
be found, and in cases where former 
syphilitic accidents have been ne- 
glected as to treatment. {Annalea 
medicO'psychologiques ; Review in 
Archives de Neurologie^ Aug.^ 1894.) 



BOOK REVIEWS. 



C. G. C. 



Travaux D'Electro-therapie Gy- 
NECOLOGiQUE. Founded and Pub- 
lished by Dr. G. Apostoli. Vol. I. ; 
fascicules I. et II, 1894. SociSlS 
d' Editions Scientifiques^ Paris. 

This new and important publica- 
tion, undertaken by Dr. Apostoli of 
Paris, so well known for his work 
and writings on electro-therapeutics, 



is to be a most complete review of 
the treatment of diseases of women 
by electricity. The fii*st volume con- 
tains papers in extenso taken from 
the English, Belgic, American, Rus- 
sian, Italian, German, Danish, Aus- 
trian, Polish, Hungarian and Cana- 
dian literature. Gynaecological elec- 
trotherapeutics is an entirely French 
sgience and the famous Dr. A. 



Digitized by 



Google 



208 



BOOK REVIEWS. 



Ti ipier was its fatlter. Dr. Apostoli 
las founded tliis work with tlie idea 
of collecting all memoii-s and clinical 
reports appearing in all countries, in 
■order that the surgeon may have a 
complete book of reference of this im- 
portant and rather neglected branch 
of medicine. Tlio fii-st volume has 
717 pa^es and is most excellent in 
'every detail. Wo conorratulate Dr. 
-Apostoli on his great undertaking and 
^ish him the great success which he 
will no doubt achieve. 



A MANCJATi OP Modern Suroery. 
By Joiiy CuALMKRS da Costa, 
M. D., Demonstrator of Surix«My, 
Jefferson Medical College; Cliief 
Assistant Surgeon Jefferson Medi- 
cal Collegr^ Hospital, etc. B. W. 
Saunlers, 025 Walnut St., Phila- 
delphia, 189i. 

Tlii3 admirable little volume is one 
of Mr. Saunder's '-New Aid Series." 
The aim of the manual is to present 
in clear terms and concisely the fund- 
amental principles, principal opera- 
tions and the^/i de sicale methods of 
surgery, and the author has succeeded. 
11ie first chapter is on bacterioloiry, 
tiie principal organisms producing les- 
ions, surgical being passed in review. 
Iiiflammation,repair of tissues.surgical 
fevers, terminations of inflammation, 
are treated veiy well. 'J'he other 
subjects treated are Jis follows : Ulcer- 
ation and fistula, gangrene, thramboiis 
and, embolism, sepiicaBraia and pyae- 
mia erysipelas, tetanus, tuberculosis 
and scrofula, rickets, contusions and 
wounds, syphilis, tumors, diseases and 
injuries of the heart and vessels, dis- 
eases and injuries of the bones, mus- 
^iles and tendons orthopoedic, sur- 
gery, diseases and injuries of the 
nerves Jind head, surgery of the spine 
and respiratory organs, dise«ases of the 
digestive tract, abdomcu, rectum and 



anus, ansBsthesia, burns and scalds, 
diseases of the skin and nails, band- 
ages, pListic surgery, diseases of the 
genitourinary organs, amputations, 
asepsis and antisepsis. From this 
enumeration it will be seen that the 
volume comprises everything pertain- 
ing to surgical art excepting gynae- 
cology and to special subjects such as 
the eye, larynx, etc., which the author 
has very properly not included. 
Special praise is to be given to the 
excellent description of the diseases 
and injuries of the bones. The art of 
bandaging is most pratically and 
clearly dealt with, and the plates are 
well done. The book contains 
thirteen full-page plates and many 
figures, original or taken from the best 
French, (lerman and American 
authors. The book is a success and 
we recommend it most heartily to the 
student and general practitioner. 



Transactions op tftb Micftigan 
SrATR Mkdiual Society for 1894. 
Published by the Society. Detroit. 

The handsome volume of 689 pages 
is full of interesting matter. Tuber- 
culosis forms the gieater part of the 
medical section. However there are 
many other interesting papers on vari- 
ous subjects by different authors. In 
the surgical section, abdominal sur- 
gery was an important feature; several 
papera on genito-urinary surgery, one 
on the radical cure of hernia, one on 
laryngotomy, one on the suppurative 
diseases of the accessory sinuses of 
the nose, and three pertaining to 
opthalmic science are of value. In 
the section of midwifery and gyna>- 
cology, fibroid tumors of the uterus 
were discussed as to the surgical and 
non-surgical treatment. Several 
memoirs on different obstetrical 
operations, including symphyseotomy, 
were read. Two papera on electricity 
in gynaecology, gynaecology among the 



Digitized by 



Google 



book: reviews. 



209 



Insane and its relation to insanity, 
bacteriology in obstetrics and ergot 
in the bands of ignorant midwives, 
-complete this most excellent volume. 



Syllabus op Lectcjres on Human 
Enbuyology. By W. P. Manton, 
M. D., Professor of Clinical Gyn- 
CBology and Lecturer on Obstetics 
in the Detriot Medical ColIeo;e of 
Medicine, etc. The F. A. l3avi3 
Co., publishei-s, Philadelphia, 1894. 

This neat little book is a general 
arrangement, followed in the autlior's 
course of lectures, delivered during 
the last ten years. In revising his 
notes the author has consulted the 
works of His, Kolliker, von Baer, 
Hertwiz, etc., as well as other current 
literature on the subject. The sub- 
jects treated are as follows : Anatomy 
of the female organs of generation, 
spermatozoid, ovum, menstruation 
oogenesis, the general development of 
the embryo, and special organs, the 
heart, blood vessels and blood; the 
uterine and foetal membranes, the 
placenta and utero-placentul circu- 
lation ; changes in the maternal 
organisms incident to pregnancy; 
illustrations of practical work, the 
volume terminating with a glossary 
of terms and words employed in em- 
bryology. The book is interleaved 
for notes, and a number of figures 
taken from the best text-books illus- 
trates the text. 

The work is good and will be found 
useful to the student. The publish- 
ers deserve much praise for their 
excellent work. 



Lectures on the Diagnosis of 
Abdominal Tumous. By \Vm. 
OsLKR, M. D., Professor of Medi- 
cine, John Hopkins University. D. 
Appleton & Co., New York, 1894. 

This most valuable contribution to 
the diagnosis of abdominal tumors is 



a series of five lectures delivered by 
the author. Tlie subjects considered 
are tlie tumors of the stomach, liver, 
gall-bladder, intestines, omentum, mes- 
entery and kidneys. Sixty-six cases 
are reported, wiili reproduced photo- 
graphs, diagrams, etc. It is unneces- 
sary to say that, from the distin- 
guished pen from which it comes, a 
careful reading of the work will be 
most profitable to all the members of 
our profession. 



Essentials op Diseases op titb 
Eau. By E. B. Gleason, M. D., 
Clinical Professor of Oiolo^'y. Med. 
ico-Chirurgical College. W. B- 
Sannders, Philadelphia, etc. Phil- 
adelphia, 189i. 

This little work forms the twenty- 
fourth volume of Mr. Saundei-s qnes- 
tion-compcMids. It has been written 
for pliy-icians who desire to take a 
post-graduate course in otology, in 
order lo «:ive them the rutlimentary 
facts of this branch with as little pre- 
liminary reading as possible. The 
book is also intended to supplement 
the brief coarse of lectures that un- 
der-graduates receive in the diseases 
of the ear. The work, like all the 
othei-s of the scries, is concise, practi- 
cal and to the ix)int. Special atten- 
tion to exaniination of the ear is 
given, the work ending with formula) 
empli>yed in the diseases of which it 
treats. Illustrations are numerous 
and add greatly to the book. 



The Anxual op the Universal 
Medical Sciences. Five volumes. 
Issue of 1894. Edited by Charles 
E. Sajous, M. D. The F. A. Davis 
Co., publishei-s, Philadelphia, 
1894. 

The "Annual" is without a doubt, 
the most important index of advance 
for all branches of medicine that is 



Digitized by 



Google 



210 



BOOK REVIEWS. 



{)ubli8hed, and its importance grows 
yearly. It forms a veritable encyclo- 
pedia of the healing art, a library in 
Itself. The selection of its contribu- 
tors makes the work most accurate 
in all details, and all that can be said 
for this year's issue, is what we have 
always said it is — hor9 cfmcours. 



A System op Legal Medicine. By 
Allan Mclanb Hamilton, M. D. 
AND Lawrence Godkin, Esq. 
Vol. II., E. B. Treat, publisher, 

• New York, 1894. 

The second volume of this fine 
work has just appeared, thus com- 
pleting it. The same may be said 
of it, as for the first, (see October 
number of the Annals) consequently 
only a mention of the valuable con- 
tents will be given. Duties and 
Responsibilities of Medical Experts ; 
Insanity in its Medico-Legal Bear- 
ings ; Mental Responsibility of the 
Insane in Civil Cases; Insanity and 
Crime ; Relations of Mental Defect 
and Disease to Criminal Responsi- 
bility; Affections of Speech; Trau- 
matic Neuroses; Effects of Electric 
Currents of High Power upon the 
Human Body ; Accident Cases ; Men- 
tal Distress as an element of Dam- 
age; Feigned Diseases of the Mind 
and Nervous System ; Birth, Sex, 
Pregnancy and Delivery ; Abortion 
and Infanticide; Medico-Legal Rela- 
tions of Venereal Disease ; Marriage 
and Divorce, Sexual Crimes'; Surgi- 
cal Malpractice. The volume is 
illustrated by numerous plates, wood- 
cuts and half-tone engravings. 

In closing we desire to tender our 
heartiest congratulations to Dr. Ham- 
ilton and his corps of co-laborers. 



in therapeutics. Its great value ib 
traumatisms of the articulations, acute 
and chronic arthritis, fractures, etc., 
is incontestable. In the diseases of 
the muscular system, massage grows 
. in importance each day. In his chup- 
ter on the treatment of myosites, the 
author studies these cases, so fre- 
quent in practise with much clear- 
ness. 

In this excellent little volume Dr. 
Norstrom gives in detail the tech- 
nigue and the physiological action of 
massage, its application in the dis- 
ease of the articulations, fractures, 
muscular system, nervous system, dis- 
eases of the circulatory and digestive 
systems, the work terminating with 
an excellent discription of massage in 
gynaecology. • The work is clear, con- 
cise arid full of practical and scien- 
tific information, and is to be highly 
recommended to all those interested 
in the subject. 



FORMULATRB DU MASSGB. By Dr. 

G. Norstrom, Paris, 1894. £. 
Bailliire et fils. 

Massage is quicky gaining ground 



A Manual of Obstetrics. . By 
Edward P. Davis, A. M., M. D., 
Professor of Obstetrics in the Phil- 
adelphia Polyclinic, etc. Second 
edition. P. Blakiston, Son & 
Company, publishers, Philadelphia, 
1894. 

The second edition of this excel- 
lent volume has been thoroughly 
revised, a chapter on sypaphyseot- 
omy has been added, as well as addi- 
tional facts regarding palpation and 
the diagnosis of positions. The per- 
sonal experience of the distinguished 
author has guided the choice of 
methods of treatment commended in 
its pages. The abundance of fine 
plates and engravings renders the 
work most excellent for the student, 
as well as the general practitioner, 
for the demonstration of the subjects 
treated in the text, and this second 
edition of the Manual will meet with 
as great success as its predecessor. 



Digitized by 



Google 



BOOK REVIEWS. 



211 



An International System op 

ElECTBO-ThERAPEUTICS : FOB 

Students, General Practi- 
tioners AND Specialists. By 
Horatio R. Bigelow, M. D.; 
AND Thirty-eight Associate 
Editors. Thoroughly illustrated. 
In one large royal octavo volume, 
1160 pages, extra cloth, $6.00 net; 
sheep, $7.00 net ; half-iussia, $7.50 
net. The F. A. Davis Co., pub- 
lishers, 1914 and 1916 Cherry 
street, Philadelphia. 

This excellent treatise is thor- 
oughly practical and full of important 
matter. Written as it is by the 
masters of their respective subjects, 
it is absolutely of highest value to the 
physician, surgeon and gynaecologist.' 
To mention all the names of contrib- 
utors -would be ' too long, but such 
men as Bigelow, Tripier, Jacobi, 
Newman, Rockwell, etc., have written 
largely for it. Electricity, its techni- 
que and indications in treatment of 
disease, is now no longer to be des- 
pised, and should be cultivated and 
recognized by the medical profession, 
and, with such a work as this, there 
is no excuse for the unscientific man- 



ner in which many of the profession 
employ this useful therapeutical 
means. The subjects treated are as 
follows : Electro-physics, animal elec- 
tricity, static electricity, magnetism, 
induced current, electro-magnetism, 
electro-massage, instruments, galvan- 
ism, electro-physiology, electro-diag- 
nosis, cataphoresis, treatment of in- 
testinal occlusion, diseases of the 
alimentary tract, liver and kidneys 
by electricity, gout, rheumatism^ 
heart and lungs, diseases of the uter^ 
us, fibroids of the uterus, methods of 
Apostoli and others, diseases of the 
uterine adnexa, engorgement and 
displacements of the uterus, disorders 
of menstruation, diseases of the fe- 
male urethra ectopic gestation, cancer 
of the uterus, diseases of the skin, 
nose, pharynx, larynx and eye, dis- 
eases of the brain and spinal cord^ 
electro-thermal surgery, strictures 
and hypertrophy of the prostrate, 
abscess, adenomas, incontinence of 
urine, orchitis, hydrocele, sperma- 
torrhoea, gonorrhoea, electricity in 
obstetrics and diseases of children 
and adhesions in the acute and 
chronic inflammatory disorders of the 
female pelvis. 



Digitized by 



Google 



ANNALS 



-OF- 



GYNECOLOGY AND PJEDIATRY. 



DEPARTMENT OF P-^DIATRY. 



The So-called Idiopathic Purulent Peritoaitis in Children. 



BY CHARLES GREENE CUMSTON, B. M. 8., M. D. 



In this short review the writer only 
desires to call attention to two re- 
cently published cases of the so-called 
idiopathic purulent peritonitis and at 
the same time to make a few remarks 
gathered from medical literature. 
Although a certain number of cases 
like the following have been published 
since Gauderon's thesis in 1876, there 
is no doubt but that this memoir still 
remains the best and most complete 
on the subject on which I am writ- 
ing. 

Idiopathic peritonitis is commoner 
in infancy than in adults. Duparcque 
(1) described what he termed an 
essential peiitonitis, which he met 
with most frequently in young girls 
of from eight to eleven years of age. 
The disease appeared spontaneously 
in the midst of health, without other 
cause than exposure to cold or an 
indigestion. Ihis spontaneous type 
of the disease has also been observed 
by Legendre, Rilliet, Marten, Althaus 
and others. Twenty-five cases have 
been collected by Gauderon in chil- 
dren of five to eleven years of age 



living in boarding schools, etc. Fif- 
teen of them were girls, the remain- 
ing ten being boys. Gauderon 
attributes the disease to cold after 
moderate exercise, while Legendre 
mentions iced drinks and lying on 
wet earth as a cause. 

The first case, which is reported 
by Prof. Grancher, of Paris, (2) is 
as follows: A little girl, aged eleven, 
entered the hospital on March 19, 
1894. Bom at term, she was brought 
up on the breast and had never 
had any affection which could ac- 
count for the peiitonitis. Her* 
malady commenced three months 
previously with fever, insomnia, con- 
stipation and abdominal pains, par- 
ticularly in the right iliac fossa. 
For three weeks she remained in 
bed, when these symptoms ameli- 
orated; the mother then thought 
that there was a tumor in the left 
iliac region. The patient got up, but 
walking was painful. On March 1, 
the pain was more acute, and a most 
important symptom appeared, namely, 
a bloody purulent discharge from the 



Digitized by 



Google 



CHARLES GREENE CUMSTON. 



218 



yagina. From this time this symp- 
tom has been about constantly pres- 
ent. Prof. Grancher examined the 
child on the twentieth and found the 
entire sub-umbilical region hard and 
pasty and dull on percussion ; the 
part was painful, and on pressure a 
great quantity of bloody pus could 
be made to ooze out from the vagina 
Tliere was no fever nor vomiting* 
However, two days later fever ap, 
peared, (39**) the urine became puru- 
lent and at the same time the skin 
over the umbilicus became ulcered, 
then perforated, allowing the issue of 
a little pus. 

Prof. Grancher waited for a week 
before operation was deemed advisa- 
ble, because there are cases of this 
kind in which spontaneous cure has 
taken place. During this time there 
was fever every evening, abdominal 
pains became more severe and the 
vaginal dischaige was not so free. 
Laparotomy was done by Dr. Breen 
on April 4. The Ustula was opened 
up and on incising the peritoneum 
a great quantity of pus escaped. The 
cavity was explored and found to be 
limited above by adhesions, while be- 
low there were none, the uterus and 
adnexa being easily explored; the 
operation was terminated and drain- 
age established. The dressings were 
found to be soiled by urine, conse- 
quently indicating a communication 
between the pocket and the bladder. 
A permanent sound was placed in 
the bladder, with the result that on 
April 28 all urine was passed by 
the bladder, and on May 4 the ab- 
dominal wound was completely 
healed. 

The second case is reported by 



Dr. Tapie (3) and is especially in- 
teresting from the fact that the pa- 
tient was only twenty-nine months 
old. The case was diagnosed by 
Dr. Saund as peritonitis, and after 
three weeks pus came away from 
the umbilicus, below a hernia which 
had formed at this point, followed 
by great amelioration. However, the 
patient's condition began again to get 
much worse, and about two months 
later Dr. Tapie was called. He found 
the patient in a very bad state, the 
abdominal walls were distended by 
a large collection. The orifice from 
which the first pus had issued was 
sought for and with diflBculty a 
female catheter was inserted through 
a punctiform opening, letting forth 
about three pints of pus. A stick 
of lomaria was then introduced and 
the cavity was washed out with a 
boracic acid solution for several days. 
The patient improved rapidly and a 
complete cure was obtained. It has 
often been argued that these cases are 
perhaps sub-peritoneal abscess, but 
doubt is hardly possible and to-day 
we are less astonished than formerly 
at seeing a peritonitis recover. 

The special point in these twa 
cases is the opening at the umbil- 
icus, which fact has been observed 
ten times out of twenty-five cases 
collected in Gauderon's thesis and ia 
apparently benign, as out of twelve 
cases (including the two given in 
this paper) only two deaths occurred. 
The rapid recovery of both cases 
cited after evacuation of the pus is 
most striking, for the patients were 
in a very bad condition.' As to the 
terms of idiopathic or essential puru- 
lent peritonitis of children, they only 



^\d\tfi^6h 



v'Google 



?u 



SOCIETY PROCEEDINGS. 



signify that it is not due to perfora- 
tion of the intestine or appendix or 
to tuberculosis. When these two 
great classes of peritonitis are elimi- 
nated we are in presence of a doubt- 
ful and uncertain etiology, but one 
T^hich bacteriology is clearing up, and 
it is only a question of time before cold 
etc., will be put aside as a cause 
and something definite found. 



BIBLIOGRAPHY. 

The numbers correspond to those 
in the text : 

(1) Duparcque. Annals d' Ohstetri- 
que, vol. I, page 241, 1842. 

(2) Gaucher. La Presse MSdicahy 
Sept. 8, 1894. 

(3) Bulletin de la SoeiStS de MSde- 
cine de Toulouse, Review in Jour- 
nal de MSdecine et de Chirurgie 
Pratiques. Aug. 25, 1894. 



Meeting of New York Academy of Medicine. 

November 8, 1894. 



Section of Paediatries, 



Joseph E. Winters, M. D., chair- 
man. 

A paper was read by Dr. A. 
Campbell White, entitled: — 

THE ANTI-TOXINE TREATMENT OF 
DIPHTHERIA BASED UPON A SERIES 
OF OASES TREATED AT WII.LARD 
PARKER HOSPITAL. 

Attempts have been made for a 
long time ta obtain immunity from 
the infectious diseases by artificial 
n^eans. The first practical result was 
obtained by Jeuner in 1798 in small- 
pox. Attempts have constantly been 
made during recent years to accom- 
plish similar results in other diseases. 
The work is based upon the principle 
that cultures of the various micro- 
organisms can be made less and less 
virulent, until finally they are capable 
of producing only the mildest form of 
the disease when injected into the liv- 
ing body, but however carefully this 
process is carried out there is always 
some danger that this reaction may 
be greater and more pronounced than 
is desired or safe. Recognizing this 
danger, workers have labored to ob- 



tain similar powers of immunity 
without using the disease poison itself. 
It has been found that the blood of 
animals rendered immune is capable, 
when inoculated in susceptible ani- 
mals, of granting the same immunity. 
This method is followed by no reac- 
tion. Whether the serum thus ob- 
tained acts directly upon the toxine, 
or whether it causes some reaction in 
the tissues of the body, is a question 
of dispute. The latter theory would 
seem to be the more correct. What- 
ever its action, this inoculation of 
serum obtained from an artificially 
immunized animal is preferable to 
the attentuated bacilli method. 
Thus there are two methods of bac- 
terio-therapy. It is upon the last 
that treatment by anti-toxine is 
based. To Behring, of Berlin, is 
chiefly due its discovery and de- 
velopment. 

This serum is obtained as follows: 
First, a pure culture of the diphtheria 
bacilli must be obtained. A poison- 
ous culture having been prepared and 
its strength determined, it is injected 
into the animal which is to furnish 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



216^ 



the serum, beginning with very small 
doses, which are gradually increased 
until the most powerful poison can be 
resisted by the animal. It requires 
many months to obtain such immu- 
nity, with the constant liability of 
losing the animal from an over-dose. 
The horse, being slightly suscepti- 
ble and furnishing muchanti-toxine, 
is recently being used. The ani- 
mal, when it has developed a high 
degree of immunity, is ready to 
furnish anti-toxine. Blood is drawn 
and the serum is separated. This 
serum contains the anti-toxine. . To 
insure accuracy of dose, the amount 
of anti-toxine in the blood must be 
determined. This is successfully 
done by a rather elaborate method 
devised by Behring. To under- 
stand the action of anti-toxine a 
<5lear idea of the disease must be 
obtained. Age is a very important 
factor as shown in the death rate 
of diphtheria. In one hundred and 
eighty-eight cases over sixteen years 
•old, treated at the hospital, less 
than three per cent, have died. The 
mortality between five and sixteen 
jears, although higher than in 
adults, is surprisingly low for a dis- 
ease comnjonly considered so fatal. 
The mortality at this age during 
the past year was thirteen per cent. 
The mortality in five hundred and 
six children under five years was 
forty -two and seven-tenths per cent. 
Diphtheria is, therefore, as far as 
mortality is concerned, a child's dis- 
ease. Treatment should be directed 
therefore, against the disease as it 
occurs in young children in order to 
judge of its eflBcacy. It is well 
known that the mortality is higher 
during certain months of the year, 
the highest rate usually being in 
February. It is higher also in cer- 
tain epidemics than others. 

If a fatal result is due directly to 
diphtheria, i. «., to infection by the 
Loeffler bacillus, the patient dies 
^during the first ten days from toxic 



infection, membrane extension, and 
occasionally from paralysis. In 
those cases who die later than the 
tenth day death is due generally to 
pneumonia or paValysis. Taking all 
the facts into consideration, the 
remedy for diphtheria which will 
prolong the life of the patient beyond 
the thirteenth day has carried him 
almost beyond the danger of death, 
and can truly be called a specific. 

Studying still farther cases which 
died from diphtheria, we find the 
mortality almost entirely confined to 
those patients who had false mem- 
brane, not on the tonsils and pharynx 
alone, but, added to this, diphtheria 
of the posterior nares and larynx. 
Cases which did not have false mem- 
brane in the nares and larynx, gener- 
ally recovered. Proper treatment of 
these cases undoubtedly aids largely 
in saving life. The essentials of the 
treatment pursued are as follows : — 

First. Absolute rest in bed in re- 
cumbent position. 

Second. A fluid diet. 

Third. A room kept at a rather 
high temperature (76*» to 80^ F). 

Fourth. Thorough, frequent, and 
complete washing of the nasal, and 
throat cavities with a normal salt 
solution. 

Fifth. Tincture of the chloride of 
iron in large doses. 

' Sixth. Stimulation and catharsis as 
indicated. 

In addition to this treatment we 
have depended almost entirely in the 
laryngeal cases upon calomel subli- 
mations and moist heat applied ex- 
ternally, with operative interference 
when necessary. This treatment 
certainly has an effect in preventing 
extension of membrane. Still, in 
opposition to all our efforts, there is 
a certain class of cases which furnish 
a frightful mortality and make diph- 
theria the most dreaded of the in- 
fectious diseases. These are the 
cases in which the disease has invaded 
the larynx and naso-pharynx. Such 



Digitized by 



Google 



216 



SOCIETY PROCEEDINGS. 



cases are always dangerous at any 
season of the year and in any epi- 
demic. It >vas from this class of 
cases that patients were selected at 
the hospital for anti-toxine treat- 
ment. U1ie serum used was that 
made by Aronson, and was furnished 
by Schering and Glatz, the agents 
in this country. In no case were 
the injections followed by signs of 
local inflammation. Twenty cases 
were treated during August and Sep- 
tember, 'i hey were all serious cases 
with an unlavorable prognosis, one 
only beinj]^ over five years of age. 
Tiie tnatment consisted entirely of 
injections of anti-toxine, with the 
exception of irrigating each case once 
on admission. Stimuhition was 
given as indicated. Five of these 
patients (25 per cent.) died. Their 
averiige age was three years. In 
seven, the tonsils, pharynx, audnares 
were involved. There were three 
intubations and one trachteomy. 
Three had albuminuria and four 
paralysis. Fourteen were laryngeal 
cases, with membrane also in the 
throat or nose. In the remaining 
cases the naso-pharynx was involved. 
Theoretically, the anti-toxine could 
Lave prevented but one of these 
deaths, for in four cases death was not 
directly duo to the diphtheria toxine. 
One died on the twenty-fourth day 
of lobar pneumonia ; another on the 
thirty-fourth day of bronchopneu- 
monia, long after the bacilli had 
disappeared ; another from pneu- 
monia, twenty days after the bacilli 
had disappeared. It would probably 
bo more just to exclude these cases, 
which would leave one death in six- 
teen, or a mortality of six and two- 
tenths per cent, among cases se- 
lected on account of their severity. 
Ihe effect noticed upon the pulse 
is importnnt. In nearly all cases, 
nine hours after the injection tho 
pulse was much improved in strength, 
volume, and frequency. Tho dipth- 
eictic membrane disappeared in the 



average on the ninth day of the dis-^ 
ease — about the ordinary time. The 
persistence of the bacilli, as would be 
expected, was not apparently influ- 
enced. Anti-toxine given«early should 
prevent post-diptheretic paralysis. 
The paper concludes with an extended 
report of the results gained by others 
under the same treatment. The writer 
reports in all four hundred and eighty- 
six children treated for true diphtheria 
by various observers with different 
strengths of anti-toxine solution. 
One hundred and sixteen died, a 
mortality of twentj'-three and eight- 
tenths per cent, in a class of cases in 
which about fifty per cent. ahvaj'S 
die. It should be understood that in 
many of these cases treatment by 
anti-toxine was begun late. The 
paper concludes that, when we add to- 
our own casts the results obtained by 
others we cannot but believe that we 
have received in anti-toxine not only 
a remedy that will grant immunity 
for a short period of time, but a 
specific, which in eveiy case given 
early in the disease in sufiicient 
quantity prevents death by the ab- 
sorption of the toxine of diphtheria. 

Du.Herman M. Biggs had studied 
the action of anti-toxine for several 
weeks during the past summer in 
Berlin. It is an important fact that 
this method of treatment is not a 
simple discovery, but a logical devel- 
opment, the result of several years of 
bacteriological study, and at least 
three years directed to this special 
purpose. He was struck by the fact 
that in Berlin there seemed to be no- 
doubt in the minds of the most com- 
petent observers of the value of this 
remedy. They seemed to be con- 
vinced that the period of experiment 
has passed and that anti-toxine ranks 
as an element of the greatest value. 
Infectious diseases, it is well known^ 
are due, not diiectly to germs, but to 
the products of germs. Death is due 
to the effect of a chemical poison. 
The action of anti-toxine is not pecu* 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



2ir 



Jiar; it is a true chemical antidote. 
It has the power of neutralizing thfe 
toxine outside of the body; the 
amount thus neutralized determin- 
ing its strength. The dose is, there- 
fore, gmded by the age and body 
weight of the patient. 

Db. W. I-I. Park said that toler- 
ance for an infectious disease in an 
animal is slowly produced by injec- 
tions of the toxine, if only given in 
sufficiently attenuated form. As the 
anti-toxine develops, stronger and 
stronger doses of the toxine may be 
administered. The amount of anti- 
toxine may thus be enormously in- 
creased. Toxine and anti-toxine may 
both be present in tlie blood at the 
same time. As the toxine increases 
during the course of the disease, the 
amount of anti-toxine must also be 
increased as the time after the in- 
oculation increases. If the patient is 
seen on the first day, one or two doses 
may be sufficient. If the treatment 
is begun on the fifth or sixth day, 
many doses may be required. There 
is a tendency to compare anti-toxine 
with the lymph used in tuberculosis. 
There is one marked difference be- 
tween them. In tubeiculosis the 
toxine is itself employed with the 
expectation that it will produce the 
anti-toxine in the body. In diph- 
theria the anti-toxine is produced in 
other bodies and no toxine is used. 
The use of the anti-toxine does not 
prevent other treatment, nor the use 
of other drugs. It is not a general 
antiseptic and does not effect the 
bacilli in any manner. ' It simply 
neuti-alizes the poison produced by 
the bacilli. 

Dr. Geobge F. Shbady said that 
he had passed through several epidem- 
ics of new remedies for diphtheria. 
When diphtheria first appeared in 
New York over thirty years ago the 
mortality was ninety per cent. This 
has largely decreased and much is 
now accomplished by treatment. 
Many special plans of treatment have 



been lauded as specific, but have* 
failed. He believes that the present 
method by anti-toxine will probably 
be proved to be a specific. It seems- 
likely that medicine is soon to mnk 
with surgery as regards advance*- 
through our knowledge of bacteria. 

Dii. W. P. NoRTHQP said that so>^ 
much 4^pend3 upon the character oV 
the epidemic prevailing, that a sim- 
ple statement of percentages cured 
means little. During the pr*isent 
summer and fall the number of cases^ 
were rare and the number of recov- 
eries large. The cases, however^ 
reported by Dr. White were appar^ 
ently severe. A very important 
point was the very good effect of 
the treatment upon the pulse. 

De. L. Fischer reported his ex- 
perience with the treatment in Berlin 
during the past summer, where he 
became convinced of its value^. 
Marked improvement was not ex- 
pected until forty-eight hours after 
the first injection. - 

Dr. II. W. Berg said that it was 
difficult to tell cleariy in advance 
which would be mild and which 
severe cases. These cases reported^ 
however, seemed severe. 

Dr. J. Lewis Smith asked if the 
anti-toxine had any effect on pseudo- 
diptheria. Dr. Fischer replied that 
it had not. 

Dr. Andrew H. Smith said that 
at least one good result from the use 
of anti-toxine would be the preven- 
tion of over-zealous local treatment, 
which he believed was capable of 
much harm. 

Dr. Winters said that in cases 
of mixed infection the course of the 
disease was not favorably affected 
by anti-toxine. It is rare to lose a 
case by septic infection in which the^ 
naso-pharynx is not involved, tha 
cause of death in septic cases being^ 
almost without exception naso-pha- 
ryngeal infection. 'J'he death rate 
in Europe from diphtheria is enor- 
mously high; it seems to be a more- 



Digitized by 



Google 



218 



REVIEW OF PEDIATRY. 



virulent type of disease. In this city 
the average death rate cannot be 
over thirty per cent. Rest in bed 
is a most important element in treat- 
ment. Failure to put the child in 
bed and to keep him there from 
first to last is the cause of extension 
in many cases. While he is strongly 
impressed with the favorable results 
obtained by antitoxine, he ddes not 



believe that the number of cases is 
yet suflBcient to warrant an abso- 
lute statement. 

Dtt. White said that the death 
rate reported from Europe was 
mostly that of the hospitals in which 
the number of young children pre- 
dominates. The death rate here of 
the same class of cases is equally 
high, viz., almost fifty per cent. 



REVIEW OF PiEDIATRY. 



Tbional in the Insomnia of Chil- 
dren. By Dr. A. Glaus, Gent. 

Trional was introduced into thera- 
peutics by Barth' and Rumpel, and 
since that time numerous reports 
have been published, the most im- 
portant being by Schultze, Horvath, 
Schsefer, Ramoni, Boettig^r, Raimodi, 
Mariottini, Brie, Bayer, Hammer- 
schlag, Randa, CoUatz, Pelanda, 
Gainer, Krass, and Mabon. 

The majority of the observations 
that have appeared up to this time 
deal with the employment ef trional 
in mental diseases. The results ob- 
tained are very remarkable, and the 
observations collected by us with 
reference to its use in insane asylums 
are equally satisfactory. 

As mentioned above, we were in- 
duced to test trional in pedisetric 
practice in consequence of its innocu- 
ousness as regards the intellectual, 
.digestive, circulating and respiratory 
functions, and on the ground of our 
experience we were led to prefer it to 
all other remedies which are in 
general employed for the insomnia of 
children. It is not our intention in 
this article to discuss this conditions 
in detail ; suffice it to say that in- 
somnia is of frequent occurrence in 
children, and is always a symptomatic 



disorder. In cases where it exists 
there is always an anomaly of the 
functions of the infantile organism 
which we should seek to discover. 

Insomnia from anomaly or an affec- 
tion of the nervous system. It seems 
needless to discuss in detail the dan- 
gers arising from the use of trional 
in meningitis, meningael or urebral 
haemorrhages, encephalitis, congestion 
of the brain and spinal cord-diseases, 
which are all accompanied by obsti- 
nate insomnia. In cases in which the 
prognosis is absolutely hopeless, and 
which are attended with terrifying 
dreams and obstinate wakefulness, the 
use of a hypnotic is occasionally to be 
considered. This is a matter of pe^ 
sonal opinion. In cases where a hyp- 
notic seems indicated, however, we 
would recommend trional, because 
its action is the most reliable and 
associated with the least risk. 

In other nervous affections at- 
tended with sleeplessness trional is 
extremely serviceable. Among these 
affections we would mention espe- 
cially chorea, convulsions, and, above 
all, the night terrors of children, a 
frequent disorder. 

Chorea. July 15, 1894, a girl, six 

. years old, suffering from severe 

chorea, of three weeks' duration, 

hereditary disposition present, the 



Digitized by 



Google 



REVIEW OP PEDIATRY. 



219 



father being an alcoholic subject and 
the mother a nervous woman ; one of 
the sisters had died from infantile 
paralysis. The upper and lower ex- 
tremities of our little patient were 
actively moved to and fro in an ir- 
regular manner. The general health 
was disturbed, and there was great 
restlessness at night. Scarcely had 
the child fallen asleep when it was 
roused up by frightful dreams. The 
appetite was completely lost. 

In view of the violent excitement 
of the child and the injurious in- 
fluence which this excitement ex- 
erted upon the general health and 
upon the choreic movements, we at 
once resorted to the use of trionul- 
bayer, in the dose of 1.0 gm., with 
the direction to give the powder, in 
a little confection, ten minutes be 
fore retiring to sleep. The neigh- 
boring apothecary had no trional 
and we substituted chloral, which 
we employed for two days without 
much relief. The child slept for 
about two or three hours, but the 
sleep was restless and the choreic 
movements continued. After trying 
chloral for two days we were able 
to obtain some trional, and from the 
time of its administration a decided 
change ensued in the condition of 
our little patient. The nights were 
quiet, the child slept for about six 
hours, without the least excitement. 
During the day the movements were 
less irregular. The appetite gradu- 
ally returned. We continued the 
use of trional in the same dose 
for eight days, and then administered 
it in doses of 0.5 gm. for three 
weeks, at the end of which time 
the child had almost completely re- 
covered. ' 

Trional, therefore, proved an ex- 
cellent auxiliary in the treatment 
of this severe case, since it removed 
the insomnia from which the patient 
suffered, and had a favorable influ- 
ence upon the digestion. In two 
other less marked cases of chorea, 



trional was employed with equally 
satisfactory results. 

Pavomoeturntu. It frequently 
happens that we are called upon to 
prescribe for a pedicular morbid 
condition designated as pavornoc- 
turnus (French, terreurs nocturnes. 

It is a difficult undertaking both 
for physician and patient to combat 
a dream. These frightful night- 
mares which convert the period of 
physiological rest into a period of 
excitement and unendurable discom- 
fort are capable of affecting in the 
course of time, both the condition 
of the mind and body. 

We subjoin a few formulas 
among those hitherto recommended. 
Dujardin-Beautmetz prescribes : — 



Aqo. chloroformi, 
** aurantu(ior., 
" tiliae, 
Potass, bromidi., 
Syrup papaveris, 



i50.0gin. 
1.0 
20.0 



Jules Simon first resorts to opi- 
ates in fractional doses, beginning 
with small doses, gradally increas- 
ing, and watching the effect. He 
orders tinct. opii crocata, tinct. opii 
benz., syrup codeini, potass, bromid. 
for children with an excitable nerv- 
ous system. If the opiates are con- 
traindiciited he prescribes chloral 
per OS or per rectum. 

Huchrad gives to young children :— 

Urethan, 0.2 gm. 

Aqu. tiliae, 

Aqu. aurant flor., 

Syrupi, aa 20.0 

In place of these, in part very 
dangerous remedies, we have em- 
ployed trional with success. Among 
the seven or eight successful cases 
treated we communicate the follow- 
ing : — 

A child two-years old, ill-nour- 
ished, starts up suddenly from sleep 
at night. The face wears an expres- 
sion of fright ; the child clings closely 
to the mother, seeking protection, 
and is unable to fall asleep again* 



Digitized by 



Google 



220 



REVIEW OF PEDIATRY. 



On the advice of a neighbor the 
'mother prepared a decoction of poppy 
heads, a remedy much in use among 
the working classes. At our first 
Tisit we found the child in a condi- 
tion of stupor. We took pains to 
«nake clear to the mother the danger 
^o which she exposed the child and 
the responsibility she was taking 
«pon heiielf, and ordered a warm 
9)ath at ni^^ht and especially inter- 
dicted the dtfcoction of poppy-heads. 
Jn three days the mother returned 
:nnd stated that the child resisted 
i)athing and requested a prescription. 
IVe advised the pack, but on the fol- 
lowing morning she reported that she 
tad employed it without success. It 
is likely, however, that she never 
made use of this measure, as it is 
•difficult to teach the lower classes 
that certain affections should be 
treated by other means than the ad- 
oninislration of drugs. 

We now prescribed trional in 
'doses of 0.5 gm., with the condition 
that she sliould bring tlie child for 
inspection every day. During the 
"firet four or five nights the effect of 
Irional was not perfectly satisfac- 
tory ; the child had an attack of ex- 
'Citement, but fell asleep of its own 
-accord. After the sixth day the in- 
somnia disappeared, and since then 
the child has enjo3ed quiet sleep. 
Wo continued trional in the same 
•dose for the three following weeks 
without noting injmious aftereffects. 
The child's health lias greatly im- 
:proved, both physicially and men- 
tally. During the hist four weeks 
^he mother has found it necessary to 
-administer the remedy on only two 
-occasions when the child seemed un- 
usually excited. 

In the case of a child, eight years 
'Old, suffering from epilepsy we em- 
ployed trional in 1.0 gm. doses in the 
•evening, and observed that sleep was 
imore restful. Diminution of the epilep- 
^tic attacks w,as not, however, noted, a 
tfact which does not excite surprise. 



We regard it as unnecessary to 
say any more with regard to the 
value of trional in those forms of 
insomnia which accompany disturb- 
ances of the digestive, respiratory 
or circulating organs, as well as in 
reference to its value in the infect- 
ious or toxic variety of insomnia. 
We have given it in several cases 
of gastritis, in cases of sleeple3sness 
due to disturbances of dentition, in 
cases of insomnia from measles, and 
always noted considerable relief. 
In several cases of insomnia arising 
from disturbance of the digestive 
functions, we observed improvement 
under the influence of trional 
This experience is not new. It lias 
already been made in mental dis- 
ease, and Dr. Vermenlen and I 
have often obtained the same results 
from the use of sulfonal. 

After-efftctB. Case L A child, 
five years, suffering sleepnessness 
during convalescence from a bron- 
cho pneumonia, which had gi*eatly 
impaired the general health. Tri- 
onal in doses of 0.75 gm. adminis- 
tered. On following morning the 
mother, an intelligent woman, ob- 
served that tho child walked with 
difficulty and had a staggering gait 
indicative of a certain amount of 
ataxia. Suspecting that the dose 
had been too large we gave 0.5 gm., 
with the result that the child slept 
well and no ataxia followed. At 
the end of eight days sleep was 
normal. 

Case II. A child six yeai-s old 
suffered from a phlegmon of the 
neck, which was very painful on 
pressure. We prescribed 0.3 gm. 
without effect, and on the following 
day increased the dose to 0.5 gm., 
which was followed by excitement, 
the pains preventing sleep. After 
incision a dose of 0.2 gm. produced 
refreshing sleep. If we would draw 
a conclusion from the latter case it 
would be that trional fails to act 
in the presence of pain. 



Digitized by 



Google 



REVIEW OF PEDIATRY. 



221 



We would also mention that in 
three cases of incontinence of urine, 
trional was given without success, 
while in a fourth case it had a 
favorable e£fect during the time the 
patient was under observation. 



DOSB AND MANXEB OF ADMINISTRATION. 

0.2-0.4 Qtl* 
0.4-0.8 " 
0.8-1.2 " 
1.2-1.5 '• 



From ono month to ono year, 
*• ** year ** two years, 
** two years, •' sLt ** 
** six •• " ten ** 



Trional is best given one-half hour 
After the evening meal, at the latest, 
fifteen minutes before retiring. It 
may be administered in warm milk, 
although we prefer to give it in con- 
fection or honey. 

Conclusions: 1. Trional, in doses 
of 0.2 o 1.6 gra. according to the 
child's age, is an exeelleut hypnotic. 
On the morning following its admin- 
istration, no headacho or dulness 
is observed. It favoi-s physiological 
sleep. Habituation does not occur. 
Sleep ensues in from ten to fifteen 
minutes after its exhibition. 

2. Trional has no marked influ- 
ence in the insomnia due to the 
pains. 

8. Trional does not affect the 
intellectual circulating and respim- 
tory functions, and has a favorable 
effect upon the digestive process. 

4. In the insomnia of toxic and 
especially alcoholic origin, chloral 
4ippears more efficacious. The latter 
statement is based upon two obser- 
vations made by us. {La Flandre 
Medicale, Oct. 28, 1894.) 

SuBPHUEMic Abscess in a Boy 
ABOUT 6. By Du. Holme. 

The author relates a case of this 
]cind, in which incision of the cav- 
ity gave exit to 800 c. c. of pus. 
Introduction of the finger showed 
that the abscess was under the dia- 
phragm, being limited below by 
the liver, stomach, and other ab- 
<lominal organs. . The seventh rib 
was resected posteriorly in the aux- 



iliary line, a drainage tube inserted, 
and the wound dressed aseptically. 
The cavity gi-adually contracted, and 
the patient was discharged cured in 
tliree months. No tubercle bacilli 
wei-e found in the pus. {BospitaUr 
Tidende. 1894; Review in the Uni- 
versal Medidal Journal, Oct., 1894.) 

UkTICUUIA PlCMENTOSA. By De. 

AuviD Apzeuus. 

Author describes a case of this 
affection in a girl about three. 
When four months old the mother 
noticed a number of disseminated 
red swellings on the chest and extrem- 
ities, usually appearing after a bath, 
and resembling gnat bites. Three 
months later the author was called to 
see her, as the swellings had become 
very numerous, particularly on the 
upper part of the back, the posterior 
part of the right leg, and the scalp. 
Tlie spots were situated close together 
and were irregular in form and size 
and light brown in color. They did 
not disappear on pressure, but urti- 
caria factitia appeared when the spots 
were pricked with a pin. Itching 
wjis slight. The number increased 
gradually, the old spots becoming 
darker in color and uniting one with 
the other. {Hygieai Review in tJie 
Universal Medical Joumal^OcLy 1894.) 



Diagnosis of Tubekculosis ts 
CiiiLDUEN. By Du. E. Weill. 

The author has observed a special 
syndroma in three cases of infantile 
pulmonary tuberculosis, which he be- 
lieves to have been as yet unnoted. 
It consists in a sensation of cold with 
perceptible lowering of the peripheral 
and central temperature, marked cya- 
nosis of the extremities, with noticea- 
ble modification of the radial pulse, 
considemble alteration in the number 
of red cells in the cyanosed portionSi 
and in the composition of the urine. 
These conditions are readily produced 
by having the patient leave his bed, 



Digitized by 



Google 



222 



REVIEW OP PiEDIATRY, 



^nd they slowly disappear when he 
lies down. They are transitory symp- 
toms of an intermittent character, 
independent of the clinical form of 
the tuberculosis, of the stage of the 
disease, of the season, or of the diet. 
(Lyon MSdicale, May 20, 1894. Re- 
view in the Universal Medical Jour- 
nal, Oct., 1894.) 



Tbeatment of Alopecia Abeata 
IN Children. By Dr. Feulard. 
Cut off hair with scissors, as closely 
as possible; apply following oint- 
ment every evening : — 

Salphur prescrip., 8.0 grammes. 

Acid, salicvlat., 1.0 grammes, 

pi., 



Ung. simpl. . 

Yaselini aa.' 

H. D. 8. Ointment. 



15.0 grammes. 



Next morning wash head with 
salicylic acid soap; rub with soft 
4>rush dipped in the following: 

R. 

Sublimate. 0.80 centigrammes. 

Tlnct. rosmnrinl. 

Alcohplls aa. 100.0 grammes. 

if. D. S. For external use only. 

Once a week paint the affected 
«reas with essence of wintergreen and 
ether of equal parts. {Jour, de MSd. et 
de Chic, pratiques; {Review in the 
Universal Medical Journal, Oct., 
1894. 



more frequently in girls than in boys. 
The etiology is often obscure. In m- 
fantile cystitis the urine is not always 
alcaline and may have an acid reac- 
tion. This latter condition of the 
urine of cystitis is considered by the 
author as due to an infection from 
the bacterium coli. In the treat- 
ment of cystitis with alcaline urine 
Prof. Escherich always irrigates the 
bladder twice daily with a tepid 
solution of boracic acid at one per 
cent, or two per cent, or thymol at 
five per cent. At the same time he 
gives one of the following potions: — 



R. 



TbBATMEKT op CySTITSI in CHIIy 

DB£N. By Prop. Eschriche. 

Cystitis is not an uncommon affec- 
•toin of childhood, being met with 



Potass, chlorat., 2 to 8 grammes. 

Aq. dest., 150 grammes. 

M. D. S. Take a tableapoonful every two 
hours. 



R. 



Pol. UV8B ursL, 15 grammes. 

Infus. In: 

Aq. bull., 150 grammes. 

Add: 

Syr. saccbar., 10 grammes. 

Take a teaspoonf ul every two hours. 



When the urine is acid, the writer 
obtains excellent results from vesical 
irrigations with weak solutions of 
creolin (10 to 15 drops of creolin in 
250 grammes of tepid water), and, in- 
ternally, small doses of salol. {In 
Semaine MSdicale, Aug., 1894; re- 
view in La Revue intemationale de 
MSd. et de Chirurgie pratiques. Sept 
25, 1894.) 



Digitized by 



Google 



ANNALS 



—OF— 



GYN/ECOLOGY AND PiEDiATRY. 



Vol VIII. 



JANUARY, 1S95. 



No. 4. 



What has Sewer Gas Got to Do with Bad Results in Obstetrics and 

Gynaecology ? 



A. LAPTHOEN SMITH, B. A., M. D., M. B. C. 8., 

KKOLAND. 

Fellow of the Obstetrical Society of London^ Fellow of the American GyncB- 

cological Society^ Gyncecoloffist to the Montreal Dispen- 

sary^ Surgeon to the Western Hospital, 

Montreal^ Canada. 



Ak article from the pen of one of 
the master minds of the profession, 
Dr. Jacobi, of New York, having re- 
cently appeared, in which the opinion 
is forcibly expressed that sewer gas 
is not nearly so injurious as is gener- 
ally supposed, and that the various 
diseases which were generally attrib- 
uted to it are conveyed to the patient 
in totally different ways, I believe 
that it is but right that some clinical 
facts which have come under my 
notice should be reported, for there 
is no doubt in my mind that sewer 
gas is the medium for conveying sep- 
tic bacteria to the raw surfaces of the 
genital tract after labor or plastic 
operations, and to the abdominal 
wound after coeliotomy. 

To begin with, allow me to briefly 
refer to the remarkable immunity 



from puerperal fever at the Preston 
Retreat, in Philadelphia, and at the 
Sloan Maternity in New York. Any 
one who has visited these institutions 
could not fail to remark that there is 
not one sewer pipe within the build- 
ing proper, all closets, bath-rooms, 
sinks or basins being situated in 
towers or buildings, having no con- 
nection, except by galleries, with the 
main building. 

Let me also remark that in several 
outbreaks of diphtheria, in this and 
other cities, the greatest percentage 
of cases occurred in the houses of the 
rich situated on the heights or upper 
portions of the city, and in which 
many of the rooms were provided 
with the luxury of permanant marble 
basins. 

Not that I maintain that sewer gas 



Digitized by 



Google 



224 



A, LAPTHORN SMITH. 



itself is poisonous, but that it is gener- 
ally loaded with bacteria given off 
from the infected . culture medium 
contained in the sewers while it is 
being dashed about on its way to the 
outlet. 

Then again we find the New York 
Women's Hospital, where the work is 
carried out in the most scientific and 
careful manner possible, having a 
high. death rate after cceliotomy and 
frequent failures to heal by first 
intention of abdominal and other 
wounds, until the surgeons of that 
institution demanded pavillions away 
from the costly and expensively 
drained main buildings, when their 
results immediately began to im- 
prove. 

Then we have the experience of 
one of the first surgeons of Canada, a 
gentleman of a European as well as an 
American reputation, losing his first 
nine coeliotomies, until he refused to 
ojierate in the well-drained hospital/ 
and demanded a separate building 
devoid of plumbing, since he obtained 
which his results immediately began 
to equal the best. 

Then comes my own experiences, 
which were as follows : Three years 
ago I took the service of a colleague 
who was absent on a summer holiday 
and obtained union by firnt intention 
almost invariably both in the abdom- 
inal incisions and in my operation on 
the cervix and perineum, and after 
removal of the breast. A few months 
later the absent one returned, when 
the autumn winds rendered it more 
pleasant to have the windows closed. 
What was the result? Suppuration 
was occasionally seen in the wounds, 
and now and then a cervix or a perin- 



eum failed to unite. In my own 
mind I attributed this difference in 
healing to my friend being a little 
less scrupulous in the exercise of 
aseptic precautions. But in this I 
wronged him, as it was afterwards 
made cleaf . My regular term of ser- 
vice came round on January 1, when 
the double windows were on and all 
the cracks were pasted up with paper 
or stuffed with cotton, it being diffi- 
cult even then in very cold weather 
to keep the building comfortable. 
Taking especial pride in getting my 
wounds to heal without suppuration I 
redoubled my aseptic precautions, bat 
they did no better than my col- 
league's, who had just finished his 
term of service. First, in a case of 
Alexander's operation, which at my 
private hospital always had healed by 
first intention, at the other institution 
the edges next day became a little 
red and around the stitches there was 
a little thickening, and a day or two 
later the wound was suppurating. 
Then I learned from my friend in 
charge of the obstetrical department 
on the top flat of the building that in 
spite of every precaution* he was hav- 
ing a series of high temperatures in 
every woman who was confined. Next 
a case of curretting and repair of the 
cervix and perineum under my care 
suddenly developed a high tempera- 
ture, — an almost unheard of thing 
heretofore. She looked so ill and her 
pulse became so rapid that a thorough 
examination was made, when a diph- 
theritic membrane was found cover- 



^Theae preoanttons consisted in steininK ilia 
bands almost blaok in strong permanganate solu- 
tion, then whitening them in oxaUe aeld, and then 
washing them with bichloride solution, similar pre- 
cautions being Uken with the patients. 



Digitized by 



Google 



EFFECTS OF SEWER GAS. 



225 



ing the cervix and perineum. This 
was thoroughly cleaned with strong 
bichloride of mercury and frequently 
douched with the same, and the pa- 
tient was placed on a very supporting 
diet. I felt sure that there was some- 
thing wrong with the drainage and 
requested the authorities to have it 
examined. Several of the authorities 
took a different view of the cause of 
the outbreak, attributing it to a visitor 
who had a child sick with diphtheria 
having visited a patient in another 
ward. Besides they claimed that 
they had had the drainage overhauled 
during the previous summer. Then 
several other non-operative cases 
developed sore throats, as did some of 
the resident staff. Then three cases 
of midwifery on the top flat developed 
diphtheria of the womb and vagina, 
one of them dying very quickly of a 
sort of grangrene of the uterus, an- 
other one dying a week later, both in 
spite of the most active treatment 
vrith peroxide of hydrogen, etc., and 
a third one being cured with great 
difficulty. Then all the patients were 
sent home and attended there by 
their respective surgeons and phy- 
sicians, where all recovered. Then 
the authorities had the plumbing ex- 
amined by means of the smoke test, 
which consists in placing a box on 
the roof of the building near the 
ventilating soil pipe, with which the 
smoke box is hermetically connected. 
Some cotton waste impregnated with 
some oleoresinous material is lighted 
and gives out a great quantity of 
pungent yellow smoke, which is forc- 
ibly pumped down the soil pipe until 
it reaches the sewer. If there is the 
slightest leak of sewer gas in any of 



the pipes, of 'course this smoke will 
escape equally as well. The sewer 
gas cannot be seen or even some times 
smelled, but the smoke of the smoke- 
box can be both seen and smelled as 
it pours forth from any defect. In 
the case under notice the pipes were 
found to be all staunch and faultless^ 
but a vast stream of smoke was seen 
to emerge from a three-inch hole in 
the concrete floor of the laundry, and 
on further investigation it was found 
that this hole connected directly 
without any trap whatever with the 
soil pipe running into the sewer. 
This was a plumber's blunder, but it 
cost two lives and a great many more 
long and tedious convalescences, both 
of gynaecological and obstetrical cases. 
This defect was at once remedied and 
work begun again, wounds all healing 
as a rule by first intention and a high 
temperature in the obstetrical ward 
being the exception. 

During a recent visit of the distin- 
guished editor of the Annals op 
GYN-fflCOLOGY to Montreal, I had the 
honor of showing him some eight cases 
of coeliotomy and of allowing him to 
inspect the wounds, all of which had 
healed by first intention. They were 
buried in boracic acid and lightly cov- 
ered with a gauze pad and a piece of 
strapping, practically exposed to the 
air. I also had the pleasure of show- 
ing him the list of operations for 
two years and a half, mostly ccslio- 
tomies, with three deaths. I attrib- 
uted my good results to the care with 
which I have had the plumbing ex- 
amined by the above mentioned 
method every summer before com- 
mencing work. At the same time I 
related the history of a case of puer- 



Digitized by 



Google 



226 



A. LAPTHORN SMITH. 



peral fever which was then givmg me 
a great deal of anxiety, but which 
has since made an excellent recovery, 
the patient being the daughter-in-law 
of one of our wealthy citizens liv- 
ing in a new brown-stone house 
provided with the best of sanitary 
arrangements, all the plumbing in 
the bath-room, which was situated 
next to her bed-room, being nickel- 
plated and exposed to view.' In 
order to make quite sure that there 
would be no sepsis, I engaged a 
nurse who was thoroughly trained 
in aseptic work, having been present 
and taken part in at least fifty suc- 
cessful coeliotomies in my private 
hospital. She had also had a great 
deal of experience in the mater- 
nity. All the abdominal sections 
that I had performed for six months 
previously, and even one performed 
the same day, had recovered without 
suppuration. I used bichloride 1 
in 1000 with a nail brush for my 
hands, and even then only made 
two or three digital examinations, 
although it was the patient^s first 
confinement. I might add that I 
had not had a rise of temperature 
in a confinement case for at least 
three months previous to this con- 
finement. Everything went on well ; 
dilatation was so natural that the 
finger was never once soiled with 
blood, and an examination made a 
month after the confinement showed 
a cervix absolutely without a sign 
of a laceration. The head was lifted 
forward, while the perineum was 
supported, and the progress of de- 
livery retarded somewhat by means 
of an anaesthetic, but in spite of this 
there was a laceration of half an 



inch, which was promptly sewed up 
with one stitch of iodoform silk, 
and which healed by prit intentum. 
The placenta was gently squeezed 
into the vagina, when it was easily 
lifted out intact by the cord and 
without introducing the finger. A 
vaginal douche of Condy's fluid was 
then given, and this was repeated 
once a day afterwards. The labor 
might have been called an ideal 
one. A day or two later there was 
some trouble with the breasts, al- 
though they had been prepared for 
three months with glycerine of tan- 
nin. They cracked, however, and the 
mother could not bear the baby, nor 
could it obtain any milk from them. 
The infant had to be weaned and 
the breasts were treated with iodide 
of lead ointment and bandaged, and 
in a few days were practically 
healed and soft and gave no further 
trouble. In spite of the daily 
douche and free catharsis, the pa- 
tient's tongue became coated, and its 
lochia be^an to have a strong odor, 
until on the fifth day the patient 
had a slight chill and rise of tem- 
perature, necessitating three douches 
of permanganate a day, but in spite 
of this it continued to rise, until it 
reached 106^ The husband also 
had a slight rising temperature. I 
noticed a peculiar smell in the 
house once or twice, and, on men- 
tioning my suspicions to several 
others in the house, they all ad- 
mitted that they had noticed it. 
I insisted that the sanitary authori- 
ties of the city should be asked to 
test the drainage, as I have nearly 
always found a defective sewer pipe 
in these cases, and I could find no 



Digitized by 



Google 



EFFECTS OF SEWER GAS- 



227 



other reason to account for my pa- 
tient having puerperal fever. This 
was done with the smoke test, when 
it was at once discovered that there 
wa9 a crack in the soil pipe of the 
water closet just above the floor. 
The plumbers who had fitted up 
the house were sent for, and, after 
testing it themselves, they admitted 
that there was a leak. This was 
promptly repaired and the patient 
gradually recovered, but not until 
I had curetted and put in several 
gauze drains and washed out the 
uterus many times with strong per- 
manganate of potash solution. I 
need hardly say that the most rigor- 
ous precautions as to cleanliness, 
both of bed, patient and nurse, were 
observed throughout. I have no 
doubt whatever that the cause of all 
this patient's very serious symptoms, 
and my consequent anxiety, was the 
escape of bacteria-laden sewer gas 
into the home and its entrance into 
the genital tract. 

I can recall another case of puer- 
peral fever where the source of infec- 
tion was clearly traced to defective 
sewer pipes. This patient had had an 
ideal labor, and everything was going 
on well, so that I only visited her 
every second day, when suddenly 
without any warning she was taken 
with a rigor, and, on being hastily 
summoned, I found the temperature 
106% and the pulse correspondingly 
high. I used intrauterine douches of 
permanganate, and gave large doses 
of quinine, and in a few days her 
temperature had fallen to normal. I 
made careful inquiries about the 
previous history of the house, and 
found that it had been a hotbed of 



diphtheria and scarlet fever for more 
than a year, and for that reason sev- 
eral families had moved out of it be- 
fore the expiry of their lease. The 
health office was communicated with, 
and then it was discovered that there 
was a straight flow of sewer gas 
directly into the house, owing to the 
absence of a suitable trap. 

Moreover, it is the experitmce of 
every one who has had anything to 
do with puerperal fever, and it is also 
borne out by the figures of -the statis- 
ticians that this disease is much more 
common in winter than in summer. 
The reason for this is exceedingly 
evident to my mind, viz. : that in 
summer, when all the windows are 
.open day and night, there may be a 
great escape of sewer gas into a house, 
and yet very little harm be done, be- 
cause the fresh air is constantly 
blowing through the house and dilut- 
ing or carrying away the poison as 
fast as it is being made ; while in 
winter, the doors and windows being 
securely fastened, sewer gas can reach 
every part of the house in a more 
concentrated form. Moreover the 
hot air from the furnaces and radia- 
tors carry the gas toward the upper 
flats, as was the case in the upper 
flats of the institution referred to. 
Also the vacuum caused in the base- 
ment by the upward current in the 
furnaces and chimneys may explain 
the more ready entrance of this dan- 
gerous air. 

It is also a noteworthy fact that 
according to the register general's 
reports, puerperal fever is at its 
minimum in August, when all the 
windows are open, and at its maximum 
in February, when the doors and 



Digitized by 



Google 



228 



A. LAPTHORN SMITH. 



windows are kept carefully closed. 
The relation of sewer gas to puer- 
peral septicaemia is so well known 
that it hardly requires any further 
argument. But as there are still 
some who do not realize the impor- 
tance of an annual testing of the 
plumbing of hospitals and private 
^houses, where women are to be con- 
fined or to be subjected to abdominal 
surgery, I might quote from the last 
edition of Flayfair, edited by Harris, 
in which, this standard author says : 
*' Exposure to sewer gas may, I feel 
sure, produce the disease. In two 
cases of the kind I had the opportu- 
nity of watching an untrapped drain 
opened directly into the bed-room, in 
the one instance into a bath, and in 
the other into a water closet. Both 
cases were undistinguishable from the 
ordinary form of the disease, and in 
both improvement commenced as soon 
as the patient was removed into 
another room." He then quotes 
Carl Braun, who ascribes a recent 
mortality in his clinic of 8.87 per 
cent, to bad sewerage, his wards being 
in direct connection with the sewer- 
age of the general hospital and near 
the closets of the adjoining barracks. 
Playfair concludes in the following 



terms: "The whole question of the 
influence of defective sanitary condi- 
tions on the puerperal state deserves 
much more serious study than it has 
ever yet received, and I have long 
been satisfied that they have often 
much to do with certain grave forms 
of illness in the lying-in state, the 
origin of which cannot otherwise be 
traced." 

For my own . part I would much 
rather do a cosliotomy in a wood-shed 
or a hovel where there was no sewer 
or plumbing of any kind, than in the 
finest hospital operating room or 
private house where there was a 
direct connection with the sewers of 
a great city, owing to a defect in the 
plumbing or the syphonage of a trap. 
I would therefore lay it down as a 
wise rule to follow that whenever we 
have suppuration of our wounds or 
high temperatures after confinements, 
notwithstanding that we have em- 
ployed the most rigorous aseptic and 
antiseptic precautions, we should in 
every case suspect the plumbing, 
until it shall have been proved inno- 
cent, and for this no test should be 
accepted as sufficient except the 
smoke test. 

284 Bishop Street, Montreal. 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



229 



Parietal Fibro-Myomata of the Uterus, and Professor VulUet's Operation 

for their Extraction. 



CHARLES GREENE CUMSTON, B. M. S., M. D., 
BOSTON, MASS. 

Instructor of Clinical Gynoeeology, Faculty of Medicine, Tufts' College. 



When assistant in Geneva, I bad 
the good fortune to operate with Pro- 
fessor Vulliet at many of his gyn»- 
eological operations, and having wit- 
nessed the excellent results of an 
operation devised by him for the 
radical treatment of parietal fibro- 
myomata of the uterus, I thought 
a paper on this subject might be of 
interest to my confreres here. I will 
divide this paper into two parts. 
The first will treat of the setiology 
and pathology of the neoplasm under 
consideration; the second includes 
the diagnosis and indications for 
operating, according to the teachings 
of Professor Vulliet, a description of 
his operation, and notes on cases 
treated. 

PART I. 

What I understand by parietal 
fibro-myomata are those encased in 
the wall of the uterus, and 
neither sub-serous nor intra-uterine. 
These fibro-myomata may be covered 
on one of their sides by only the 
endometrium or the peritoneum. 
Their clinical physiognomy consists 
in the fact that they project a little, 
or not at all, in the state of an inde- 
pendent tumor, into the uterine or 
abdominal cavity. It is to be noted 
that I do not report in the cases 
given in this memoir any cases of 



abdominal fibrous tumors that we 
removed by laparotomy, or those of 
well-marked intrauterine polypi. 

JEtiology. The setiology of fibro- 
myomata of the uterus is surrounded 
by obscurity, as much as is the origin 
of all other neoplasms. Camber- 
mon (1) attributes the formation of 
" fibrous bodies" and '^ polypus of the 
uterus" to a non-fecundated ovum, 
continuing to live by its own organic 
life and transforming itself into a 
fibroma after passing between the 
crypts of the uterine walls. Vir- 
chow (2) says that the pathological 
processes of the formation of fibro- 
myomata must be explained either 
by an abnormal intensity of local 
infiammation, as in the case of partial 
irritation of the mucous membrane 
gaining on the contiguous paren- 
chyma, or to a debilitated condition 
of the uterine walls occasioned by 
constitutional troubles, as chlorosis 
or local diseases. Winckel (8) and 
Gottscbalk (4) also uphold local and 
long-continued irritation as a cause. 
Cohnheim ($) attributes the origin 
of all tumors to the ulterior develop- 
ment of embryonic germs which have 
not served for a foetal development. 
According to this writer there are 
germs in the uterus capable of devel- 
oping under the influence of a phys- 
iological irritation, namely, preg- 



Digitized by 



Google 



230 



CHARLES GREENE CUMSTON. 



nancy. It is possible that these 
germs can develop also without this 
physiological irritation, for it is to be 
remembered that many fibro-myomata 
occur in women never having been 
pregnant, and end in a regular and 
typical formation. He brings for- 
ward the same argument as Cam- 
bermon, — that fibroids develop only 
after puberty, consequently, after the . 
formation of the ovum. 

Galippe and Laadowzy (6) sterilized 
the surface of two fibrous bodies of 
the uterus and cut them with an 
aseptic knife. The pieces from the 
centre, being placed in different cul- 
ture-media, showed spherical micro- 
cocci united two by two in large 
colonies or in long chains, and also 
small bacilli, isolated or united two 
by two, forming long filaments. The 
uterine fibro-myomata appear to these 
writers to be the result of a prolifera- 
tive irritation produced by a micro- 
organism. The presence of micro- 
organisms in the tissues is such a 
common fact that their action can 
only be determined by isolating them 
and by their inoculation in animals. If 
experiments should prove that inocu- 
lation produces, the formation of a 
tumor similar to that in which the 
suspicious organism was found, then 
only have we the right to attribute a 
pathological rSle to any one of these 
minute beings. 

Certain peculiarities supporting 
Galippe and Laudowzy's theory were 
pointed out at different times by Prof. 
Vuliiet. Some small localities situated 
at the foot of the Jura Mountains fur- 
nished us with a large proportion of 
the cases treated, while in those com- 
ing from other regions to Prof. Vuliiet 



for uterine troubles the number of 
fibro-myomata was much smaller. The 
genesis of these tumors might be ex- 
plained in the same manner as that of 
oitre, which centres itself in certain 
districts and appears also to result from 
a micro-organism. Further on I shall 
furnish another argument in favor of 
this theory. 

It is in the prime of life that fibroids 
develop with the greatest frequency. 
Gusserow has collected nine hundred 
and nineteen cases, as follows : 



10 years.. 


.. 1 case 


of fibro-myoma. 


14 years . 


.. 1 »* 




(t 




16 years . . 


.. 1 ** 




ti 




17 years. 


.. 1 " 




(1 




18yeai-s., 


. . 3 cases 




«( 




19 years. 


.. 8 " 




n 




20 to 30 years. 


..156 " 




(I 




30 to 40 years. 


. .357 ** 




n 




40 to 50 years. 


..388 *' 




t( 




50 to 60 years . 


.. 36 '* 




it 




60 to 70 years.. 


..12 " 




ii 




70 and above . . 


... 5 '' 




«4 





Winckel, with 527 cases other than 
those of Gusserow, gives the following 
table : 

20 years .... cases of fibro-myoma. 

20 to 30 years.... 98 " '* *' 

30 to 40 years.... 180 ** *' ** " 

40 to 50 years.... 180 •* *' ** ** 

50to60year8 ... 52 " ** " " 

60 to 70 years.... 6 ** ** ** *' 

70 and above 2 ** *' ** " 

From these tables we see that the 
maximum of frequency is between 
thirty and fifty years, and from thig 
period the frequency of the affection 
decreases progressively towards the 
two extremities of life. Unmarried 
life, abstention from coitus, sterility^ 
do not seem to exercise any influence 
toward the pi*oduction of this neo- 
plasm, contrary to the affirmation of 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



231 



certain authors, for they are met with 
more frequently in married women. 
Dupuytren (7) was of this idea. Of 
fifty-eight cases of fibro-myomata col- 
lected by him, fifty-four were married, 
or at least not virgins. Of fifty-one 
cases, nine women had not been de- 
livered of children. Among nine- 
hundred and fifty nine cases men- 
tioned by Schroeder, Hewitt, Marion 
Sims, More Madden, Engelmann and 
Gusserow, we find six hundred and 
seventy-two married woman, two hun- 
dred and eighty-seven unmarried, but 
not all virgins; and of the six hundred 
and seventy- two married subjects, four 
hundred and sixty-four were mothers. 
Pathological Anatomy. A natomic- 
ally, fibro-myomata are composed of the 
same elements as those of the muscular 
layer of the uterus; consequently it 
is made up of striped muscular tissue 
and a variable quantity of connective 
tissue. Bard (8) gives the follow- 
ing description : "The cellular fibers 
are much elongated, very narrow and 
striation is hardly evident, if at all 
so. The nuclei are seen as long, 
slightly sinuous rods. The muscular 
nature of these tumors is sometimes 
difficult to appreciate in sections that 
have simply been hardened ; it is not 
to be doubted, however, when the 
cells have been dissociated by the ac- 
tion of a forty per cent, solution of pot- 
ash. The cells are juxtaposed and 
are not bound tightly to gether. They 
remain single or form bundles of only 
slight thickness, ordinarily woven to- 
gether, taking every direction possi- 
ble. Quite often they take on a sin- 
uous form and they rarely remain rec 
, tilinear for any length of time. Inter- 
stitial connective is only slightly 



abundant and may be completely ab- 
sent. If the connective tissue pre- 
dominates over the muscular, the 
tumor is harder, more circumscribed 
and independent of the organ and 
less vascular. If, on the contrary 
the muscular fibres are in greater 
number, the neoplasm is softer, more 
diffused and intimately mixed with 
the uterine muscular tissue, and more 
vascular." 

Virchow states that the sub-mucous 
type is softer and contains less con- 
nective tissue than the sub-serous, but 
in the numerous specimens that I 
have examined I have never been 
able to make this distinction. An 
anatomical distinction between fi- 
broma and myoma is not admissible, 
because there is never a complete 
absence of either of the two constitu- 
ent elements. 

The soft myomatous tumors are 
much less frequently met with than 
the harder varieties ; they are often 
single and are generally situated at, 
or in the neighborhood of, the fundus. 
It is certain that all fibro-myomata 
have an intra-parietal origin. They 
arise in the center of homologous 
tissue, sometimes near the serous, at 
others near the mucous membrane, and 
occasionally in the central zone of 
the wall. Later, the tumor becomes 
either sub-peritoneal or sub-mucua 
or interstitial in type, according to the 
direction of its growth and the di- 
rection in which the contraction of 
the muscular walls push it. If the 
external and internal uterine layer 
are of equal strength, the neoplasm 
remains indefinitely inti*a-parietal ; 
but if this equilibrium is disturbed, 
the tumor will be forced either inta 



Digitized by 



Google 



282 



CHARLES GREENE CUMSTON. 



the abdominal cavity or that of the 
uterus itself, according to the direc- 
tion of the greater force, and the final 
result of this migratory action is the 
formation of a pediculated tumor, 
which is either sub-serous or sub- 
mucous. Single interstitial tumors, 
having developed to a considerable 
size, may protrude beneath the peri- 
toneum and also under the endo- 
metrium, and in a certain sense might 
be considered sub-serous as well as 
sub-mucous. This form of neoplasm 
develops more rapidly than when 
situated elsewhere, probably on ac- 
count of its great vascularity, and 
in its early stage is often in such 
close connection with the surrounding 
tissues that the capsule is with diffi* 
culty to be made out. 

Certain circumstances, I thinks 
retard or prevent migration of the 
tumor. This is the case in fibromata 
which are originally soft, because the 
muscular element predominates over 
the connective tissue element, and in 
those which become so often oedema- 
tous or undergo some form of degenera- 
tion, as well as in diffused fibro-myo-' 
mata. Lastly, migration .cannot take 
place when the entire uterine wall 
undergoes a nbroid transformation in 
such a manner that there no longer ex- 
ists any contitictile force. Every fibroid 
has not consequently a tendency to 
migrate. I believe that there is in 
the parietal contractility an expul- 
sive force, the vis medicatrix naturae^ 
by which the organ endeavors to rid 
itself of^the foreign body. Fibroids 
of the uterus are separated from the 
walls of the organ by a fibrous cap- 
43ule; the more apparent, the older the 
date of the neoplasm, the larger its 



size and its richness in muscular 
fibres. Exteriorly it is enveloped 
by a loose layer of connective tissue, 
in such a manner that it may be com- 
pletely detached from the uterine 
tissue. The vascularization, which 
depends entirely on the rapidity of 
the growth of the neoplasm, differs 
according to the type of tumor. 

Garrigues (9) says that fibroids are 
not so apt to be bound to the peri 
toneuDCL of the abdominal wall or 
other organs as ovarian cysts, but 
that if they do form such adhesions, 
these are often broad and contain 
very large blood-vessels, so much so 
that the neoplasm to a great extent 
derives its nourishment from the ad- 
hesions, and that in course of time 
may be severed entirely from the 
uterus and are found attached exclu- 
sively to another part of the abdom- 
inal cavity. They may even lie loose 
in the abdomen as necrobiotic masses 
without forming new adhesions. 
Fibroids are very frequently accom- 
panied by a local peritonitis, and may 
also cause cellulitis as well as acites 
usually of a serous nature; sometimes 
chylous, rarely bloody. 

Hsemorrhage is considerable as long 
as the sub-mucous tumor is within the 
cavity of the uterus, but when it is 
expelled through the cervix in form 
of the so-called polypus, this symp- 
tom may no longer exist, although 
the pressure exercised by the cervix 
often impairs the circulation of the 
neoplasm and a venous oozing ensues. 
Duncan describes a case in which 
death occurred from rupture of a 
venous sinus in an interstitial fibroid ; 
the sinuses were so large that a small 
crow's quill could be introduced. 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



233 



The endometrium covering the 
neoplasm is altered. It is congested^ 
the capillary network is engorged 
with blood, this being due to the de- 
lay of the venous current, a cell 
hyperplasia takes place with prolifer- 
ation of epithelium, escape of leuco- 
cytes, etc., and this catarrhal condition 
is quite characteristic of the intra- 
uterine type. When the neoplasm is 
very large, the endometrium as a wholer 
is changed. The utricular glands are 
often profoundly altered by venous 
stasis occurring in the organ. 

Modifications of fihro-myomata. 
All neoplasms encased in the uterine 
wallsjproduce symptoms of stagna- 
tion in the vessels of the endome- 
trium, as I have already said. These 
symptoms are the more pronounced 
the nearer the neoplasm is situated to 
the uterine cavity. Prof. VuUiet has 
often found in the uteri which he di- 
lated that, when the endometrium 
could be traced by the eye as far 
up as the parietal neoplasm, this mem- 
brane was red, swollen and cedema- 
tous. It is readily understood how 
streptococci and staphylococci intro- 
duced on to the endometrium in such 
a condition of congestion could easily 
produce a real inflammation, and, when 
this is once installed, it would invade 
the underlying tissue, the endome- 
tritis becoming metritis, and these in- 
flammatory lesions would naturally 
become more marked in the tissue of 
the neoplasm, which, on account of its 
poor vascularization, would offer less 
resistance than the normal paren- 
chyma. This inflammation can go 
on to necrosis. But the most fre- 
quent cause of inflammation of fibroids 
is undoubtedly due to traumatism 



produced during explorative or oper- 
ative attempts and pregnancy. Ac- 
cording to Gottschalk, long-continued 
sexual excess, etc., may produce in- 
flammation. (10.) Inflammation of 
a fibroid must not be confounded with 
the momentary increase of volume to 
which they are subject at the ap- 
proach of menstruation. Pure and 
simple inflammation is rare, and is 
nearly always followed by suppura- 
tion. 

Suppuration. G. Braun (11) ob- 
served putrefaction of a fibro-myoma 
which distended the uterus 17 centi- 
meters. Hecker (12) withdrew by 
puncture several litres of pus from a- 
so-called ovarian cyst; the autopsy 
showed it to be a large fibro-myoma. 
Charles Carter (13) showed at thie 
Obstetrical Society of London a uter- 
ine fibro-myoma 8 inches long by 6 
inches wide, from a woman of sixty- 
nine years. In the anterior wall of 
the neoplasm was found an excava- 
tion, from which three pints of pus 
had issued. VuUiet withdrew by 
puncture four litres of pus, and a 
second time by incision abdut twelve 
litres. The causes of suppuration of 
uterine fibro-myomata cannot all be 
explained with certainty. I could, 
however, mention cases of purulent 
discharges in the region of the neo- 
plasm where the putrid inflammation 
had propagated itself beyond the 
tumor. Suppuration and breaking 
down of these tumors have been ol> 
served in the gravid uterus. (14.) 

Necrosis, In necrosis, spindle- 
shaped purulent infiltrations exist at 
the border of the necrosed tissue. As 
has been stated, traumatism and sub- 
sequent entrance of streptococci or 



Digitized by 



Google 



234 



CHARLES GREENE CUMSTON. 



staphylococci is the probable cause of 
suppurating fibroma, althbugh I have 
not been able to find reports of 
bacteriol(^ical examinations made of 
the pus found in these neoplasms. In 
case X of our series, the purulent 
transformation took place after a neg- 
ative electro-puncture. Calculous 
transformation has also been accused 
of predisposing the neoplasm to sup- 
puration. Necrosis is more often met 
with in cases of interstitial or sub-muc- 
ous fibroids, and is probably the result 
of pressure exercised upon the vessels 
round about the capsule, thus lessen- 
ing or entirely preventing nutrition 
of the growth, with resulting necrosis. 
In the sub-mucous type, the endome- 
trium covering the neoplasm is thus 
often ulcerated and spontaneous enu- 
cleation follows. 

Cornil (16) has recently demon- 
strated the presence of zones of necro- 
sis in fibro-myomata in the gravid 
uterus, having undergone in certain 
portions a marked softening, situated 
in the midst of fibrous tissue. These 
zones of mortification are due to the 
compression of hypertrophied bundles 
of muscular tissue in the tumor, and 
may produce a notable atrophy or 
even disappearance of a more or less 
considerable portion of the neoplasm 
after labor. It is by necrosis of the 
pedicle, compressed between the lips 
of the " boutonni^re " through which 
the neoplasm issues that spontaneous 
detachment of polypi is produced^ 
having passed from the interstitial 
state to that of a pediculated growth. 

Fatty Degeneration. This rarely 
involves all the elements of the neo- 
plasm. The retrogressive meta- 
morphosis is usually followed by dim- 



inution in the volume of the tumor, 
its consistence becoming more firm 
because the connective tissue does not 
undergo any change. This process is 
met with especially after the meno- 
pause or after oophorectomy. Fatty 
degeneration, which has been ob- 
served during post puerpural involu- 
tion, may exceptionally end in the 
total resorption of the 'neoplasm; 
sometimes cystic formation results. 

Calcification, This transformation 
is more apt to occur in interstitial 
and sub-serous fibroids. (16.) It is 
composed of phosphate, carbonate and 
sulphate of calcium. It commences 
in the centre of the growth in a series 
of isolated bundles, running in differ- 
ent directions and separated by 
fibrous masses. Calcification may in- 
vade the entire neoplasm, and in this 
case it may become detached and be 
eliminated by the bladder, rectum or 
through the abdominal wall. In the 
advanced stage bone-like masses may 
form, which old writers look upon as 
an osseous transformation. Calcifica- 
tion is the consequence of modifica- 
tions in the nutrition of the tumor. 

CardnomatouM and Sarcomatotu 
Degeneration. '* Whether carcinoma- 
tous degeneration specially affects 
fibroid tumors is a disputed point." 
(17.) Several writers, among them 
Klob (18) and Foerster (19) upheld 
the view of a carcinomatous trans- 
formation taking place in certain 
fibro-myomata, but it is very possible 
that these writers were mistaken in 
their diagnosis and that they had to 
do with sarcomata proceeding from the 
connective tissue. De Sin^ty (20) 
says that cancerous transformation 
of fibroids has been admitted by some 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



235 



writers, but at a time when histology 
was in its infancy. He does not 
think that there exists a single case 
which can demonstrate this fact, and 
Klob's writings do not appear to him 
as at all conclusive. He adds, how- 
ever, that cancerous infiltration can 
consecutively invade a fibroid, but 
this is a question of an invasion and 
not of a transformation which has 
never been demonstrated. Carcino- 
matous degeneration may also be 
found in uteri from which a polypus 
has on a former occasion been re- 
moved. 

Mucous Degeneration, Mucous de- 
generation is sometimes associated 
with dilatation of the vessels of the 
neoplasm. It is characterized by the 
appearance of abundant liquid in the 
interstitial connective tissue. This 
liquid resembles that of oedema, but 
the microscope shows a proliferation 
of round cells with a nucleus, and 
reagents prove the existence of 
mucin. (21). 

Cystic Degeneration. This form of 
degeneration is incompletely under- 
stood as to its origin. There are 
several varieties. The best defined 
•one is known as lymphangiectode 
myoma (Leopold). It consists in an 
exaggerated development of the lym. 
phatics of the neoplasm with cystic 
dilatations. The lymphatics are seen 
as a series of pockets and sinuses 
filled with a clear, transparent fluid, 
which coagulates when exposed to air, 
and is nothing more than lymph. As 
they become larger, the pockets may 
break down and form one large 
cavity. The characteristic of a cystic 
cavity of lymphatic origin is that it 
is lined with .end othelial cells, thus 



distinguishing it from other kinds of 
intra-myomatous cysts. 

Baraban (22) recently upheld the 
hypothesis as to an epithelial origin 
of tlie cystic cavities of certain cysto. 
myoma. He examined tWo small 
myomata which had developed at the 
origin of the tube. In these tumors, 
he found small microscopic cysts, lined 
with a ciliated cylindric epithelium, 
much like the epithelium of the tubes 
and he considers this the result of an 
inclusion of the elements of this 
organ. Baraban mentions the studies 
of Riedel and Fischel on the persis- 
tence of the remains of the canal of 
Wolff in the muscular tissue of the 
uterus and vagina ; also a case reported 
by 'Diesterweg, who found in the 
interior of a uterine polypus of a 
myomatous nature a cavity lined 
with ciliated cylindric epithelium, and 
he advances the theory that the origin 
of cystic cavities found in certain 
cysto-myomata, developed in the walls 
of the uterus, may be a congenital or 
acquired inclusion of tubal* uterine or 
wolffian epithelial elements. The 
cases cited by Babds, Ruge and 
Schroeder, in which cysts lined with 
cylindric epithelium were found in 
the centre of fibroids, confirm the 
opinion of Baraban. All cysto-my- 
omata do not enter into the two 
preceding groups. There are some 
having only one cystic cavity, with 
regular walls, lined with little fila- 
ments and shreds more or less thicks 
crossing the cavity in different direc- 
tions and adherent to the walls, thus 
dividing it into pockets. The con- 
tents of these cysts is a serous, some- 
times bloody, occasionally hsemorr- 
hagic liquid. The internal surface of 



Digitized by 



Google 



286 



CHARLES GREENE CUMSTON. 



the cyst shows no trace of epithelium ; 
in the hsemorrhagic cysts a layer of 
fibrin, colored with blood, is found. 
Dilated lymphatics are never found 
in the neighborhood of these cysts. 
(28.) 

These writers claim that some in- 
tramyomatous cysts are the result of 
cyBtic degeneration of apoplectic foci 
which had occurred in the neoplasm. 

Another hypothesis attributes 
the formation of cystic cavities to 
the appearance of foci of granulo- 
fatty molecular di%itegration^ which 
may be produced in the centre of 
large tumors whose nutrition is ob- 
structed. It consists in a necrobiosis 
with formation of soft, phymatoid 
masses, which later fall to pieces 
and give place to cavities filled with 
a more or less liquid substance 
(Pozzi). Cystic transformation is 
found more often in sub-peritoneal 
and pediculated myomata, and it is 
admissible that under the influence 
of an obstructed circulation in the 
midst of the neoplasm, a stasis with 
oedema takes place, and later an 
alteration of the nutrition of the 
muscular tissue, resulting in their 
disintegration and liquefaction. 

Amyloid degeneration is very rare, 
only one case being on record and re- 
ported by Stratz. 

Inflammation of the capsule is ordin- 
arily the result of a lesion of conti- 
nuity in the endometrium, and easily 
produces necrosis of the tumor,usually 
ending in serious peri-uterine inflam- 
mation and septicemia. (24). The 
following statistics from Martin give 
an idea of the frequence of the dif- 
ferent degenerations. Of 201 cases 
of fibro-myomata he found : 



Fatty degeneration 10 times. 

Calcification 3 times. 

Suppuration (sub-mucous tu- 
mors) 10 times. 

CEdema 11 times. 

Cystic degeneration 8 times. 

Telangiectasic degeneration.. 3 times. 
Sarcomatous degeneration ... 6 times. 

If I have entered at soniej length 
upon the pathology of fibroid tumors, 
it is only to be the better able to ex- 
plain certain interesting particulars 
of some of the cases which are to 
follow. 

PART II. 

Diagnosis and indications for opera- 
tion. It is generally not very diffi- 
cult to recognize the presence of a 
fibroid, nor to determine its approx- 
imate size. It is much more so to 
determine its situation, consistence, 
contours, its relations to the walls of 
the uterus, to estimate the thickness 
of the tissue covering it. A diag- 
nosis of this degree of exactitude is 
only possible when the uterus is 
dilated, so that the interior may be 
palpated directly by the finger. But 
even the most careful anatomical 
diagnosis leaves certain things un- 
known. It reveals to us what the 
tumor is at the time of exam- 
ination, but it does not inform 
us of its tendency or its future be- 
havior. Only by repeating the ex- 
amination several times can we 
elucidate the important question, viz.: 
if the neoplasm tends to approach the 
peritoneum or the endometrium. The 
method of dilatation by progressive 
tamponing is the only one susceptible 
of keeping the uterus open for a long 
enough time to make a series of com 
parative examinations. 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OP THE UTERUS. 



237 



It is to be specially recommended 
in cases of fibroids of the uterus when 
an examination is to be made. The 
other methods of examination usually 
leave us uncertain on points which are, 
however, of first importance as regards 
our thera peutical decisions. Persis- 
tent dilatation facilitates topical treat- 
ment as well, whether it be electricity 
or parenchymatous injections of ergo- 
tin. Prof. Vulliet is in the habit of 
giving electricity to all patients that 
he has dilated, wtile they are tinder 
observation, and this has permitted 
him to follow by touch the progress of 
a spontaneous enucleation, determined 
or accelerated by the electrical cur- 
rents. 

Hcemorrhage. In principle, it may 
be said that the more a fibroid ap- 
proaches the endometrium, the more 
the haemorrhages that it produces are 
intense and difficult to stop. Haem- 
orrhage is generally considered the 
principal indication for removing, by 
laparotomy, fibroids that are inopera- 
ble by the natural passages. Prof. 
Vulliet does not believe this. He be- 
lieves that the haemorrhages are not 
due, as many think, to inertia resemb- 
ling that which occurs after labor. 
The welfare of the patient may con- 
sequently be obtained by means other 
than the removing of the foreign 
body that is supposed to produce the 
perturbation in the uterine con- 
tractility. In the first place this 
inertia has never been proven by 
anyone; in the second the haemorr- 
hage appears to be due to a cause 
materially demonstrated and * more 
simple ; in other words it is due to al- 
terations of chronic inflammation, by 
which the endometrium is always 



affected when the fibroid is situated 
in the neighborhood of the cavity 
(vascular dilation, stasis, congestion) ; 
the uterus bleeds on account of its 
diseased mucous membrane ; inertia 
has nothing to do with it. Local 
haemostatic treatment will usually 
control even the most serious flow- 
ing. A persistent haemorrhage 
is a sign that the neoplasm is near the 
cavity of the uterus, and thus can give 
us hopes of its extraction by the nat- 
ural passages, for even in cases where 
it is completely interstitial, a fibroid 
growing near the cavity increases the 
thickness of the walls, so that the 
tissues behind which it lies can have 
acquired sufficient height so that when 
once opened it will give room enough 
for the neoplasm to be expulsed. 

Increase in volume of the uterus 
and compression. If a uterus with a 
fibroid develops by a gradual and 
vertical ascension like a pregnant 
organ, the symptoms are no worse than 
in the latter condition, but if it grows 
in the horizontal position, and this is 
the case usually in fibroids situated 
in the lower portion of the uterus, 
symptoms of compression appear as 
soon as the pelvic walls, nerves 
vessels, intestine or urinary organs 
are reached, and indications for a 
radical operation via the abdomen 
may become urgent. 

Incarceration and malposition of the 
uterus are points which have not 
received the attention that they 
should. Whether they preexist or 
come about after the development of 
a fibroid, they can be the cause of 
serious and precocious accidents* 
Posterior- deviation and fixations are 
especially of great danger. Whether 



Digitized by 



Google 



288 



CHARLES GREENE CUMSTON. 



the organ be in retroyersion or flexion, 
the cervix rises behind the symphysis 
as the tumor grows and the fundus 
falls into Douglas' cul-de-sac. Under 
these conditions, both uterus and 
tumor end by being enclosed under 
the promontory, and then begin most 
serious accidents from compression. 

When a uterus in this condition is 
examined, the pelvis is found com- 
pletely obturated to such an extent 
that the finger cannot feel the orifice 
of the cervix up against the symphysis, 
nor be passed behind the fundus, 
pressed as it is against the sacrum. 
These are cases in which it is urgent 
to act, for a condition of things such 
as these produces dangero.us com- 
pression of the intestine and urinary 
organs. By rendering movable or 
reducing a uterus thus deviated • or 
fixed, all accidents necessitating a 
radical operation may be overcome, 
if by error of interpretation, they are 
eonsidered due only to the develop- 
ment of the neoplasm. (See cases 
XI.) Retroversion is a well kfiown 
complication of pregnancy, and when 
it occurs in a uterus with fibroid it 
produces a similar condition demand- 
ing the same treatment, viz.: reduc- 
tion of the organ in its normal direc- 
tion and accomplished by a kind of 
massage and taxis. The uterus may 
also be deviated to one side ; this is 
usually the case when the fibroid 
springs from the sides and develops 
between the folds of the broad liga- 
ment. 

I shall not give a rSsumS of the 
different operations devised for re- 
moval of fibroids nor of their medical 
treatment, but will immediately de- 
scribe Prof. Vulliet's operation for 



interstitial fibroids. If these tumors 
are large, they are at once recognized ; 
but, if they are small, their syroptomi 
are not sufficiently characteristic to 
indicate an examination. However, 
they are often the cause of insidious 
hdemorrhages ; the menses become 
more abundant, the patients are ansB- 
mic and fall into a condition whose 
cause cannot be found out unless a 
careful questioning concerning men- 
struation is made. Once the atten- 
tion is drawn to ttiem it is rare that 
other peculiarities do not show 
themselves, thus furnishing presump- 
tions in favor of a uterine trouble 
necessitating a complete examination. 
The practice of dilating the uterus 
for searching the cause of lesions of 
obscure character has often made 
Prof. Vulliet discover small latent 
intra-parietal fibroids, and when found 
they should be removed, because this 
variety is the one that furnishes the 
largest specimens of fibroids, that can 
only be removed by laparotomy when 
once developed. 

As to large interstitial fibroids, they 
can develop without changing the 
dimensions of the uterine cavity, and 
it is in this case that the cavity is too 
small to allow the extraction of the 
neoplasm through an incision which 
would have to be made the entire 
length of the uterine cavity, and under 
these circumstances it is better to per- 
form laparotomy. But if the cavity 
is enlarged so that its depth is in pro- 
portion to the greatest diameter of 
the tumor, it may be removed by the 
operation that is about to be de- 
scribed. However, when a maximum 
dilatation has been made, and the 
tumor is found to be so large that 



Digitized by 



Google 



PARIETAL FIBRO--MYOMATA OF THE UTERUS. 



239 



there is no means of reaching its 
upper limits with the fingers intro- 
duced into the organ, all operation 
per vaginam is out of the question, 
for if infection should take place, the 
impossibility of forced enucleation of 
the tumor, which is the only thing in 
such a case, renders the position very 
dangerous: consequently when the 
tumor is so large, it is better to per- 
form a laparo-myomectomy at once. 
VuUiet's operation is composed of 
three st^ps: (1) dilatation; (2) "d^. 
bridement " of the neoplasm ; (8) 
after treatment. 

Dilatation. In order to ra^ke the 
diagnosis, dilatation must have been 
great enough to allow the entire fin- 
ger to penetrate easily into the cavity 
of the uterus, and, to operate, still more 
space is required. If the cavity is 
not lengthened, dilatation to the nec- 
essary degree for the introduction of 
the index finger and instruments is 
sufficient. If the cavity is lengthened 
the index will not be sufficient, and 
the index and the medius will be 
necessary in order to enter far enough 
into the uterus. If the fibroid is very 
high up in a deep cavity it will be 
necessary to introduce the hand as far 
as the root of the thumb. It pust be 
understood that before performing 
such a dilatation, the physician has 
tried to utilize the access given by 
drawing down the organ and pressing 
on it through the abdominal walls, and, 
to do this, complete narcosis is neces- 
sary. Great dilatations cannot be 
made in every uterus with intra- 
parietal fibroids, but the greater the 
sub-mucous surface of the neoplasm, 
the greater is the possibility of con- 
derable dilatation, this being due 



to the special changes produced by 
the fibroid. 

There are cases in which progressive 
tamponing is alone sufficient means of 
dilating; there are others where it is 
necessary to substitute for cotton sub- 
stances which give a more regular 
dilatation. Sponge tents or laraina- 
ria, such as are found in commerce, 
are not large enough to dilate the 
entire depth of very deep uterine 
cavities. Vulliet uses in certain cases 
male urethral sounds of laminaria, 
cut the length of the cavity, sev- 
eral being inserted together. When 
sponge is to be used, it should be 
selected for the size of the cavity to 
be dilated, and should be most care- 
fully prepared. The sponge is cut 
like a cone. In order to obtain a 
large dilatation at the fundus as well 
as the orifice two are inserted; one 
is introduced, the base being at the 
orifice, the other is the reverse. 
Operation should never be per- 
formed immediately after removing 
the cones ; the cavity is irrigated and 
packed with cotton, which is left in 
place for two days; aft^r this we 
are sure that the field of operation 
is sterile. When sufficient dilatation 
is obtained, the patient is ansesthized, 
the uterus is brought down and one or 
more fingers are introduced to the 
fundus. 

Debridement. The incision ought 
not to be either a simple scarification 
or a "boutonniere." To accompli:ih 
the end, the direction and length 
should be proportional to the direc- 
tion and length of the greatest diam- 
eter of the neoplasm, and its depth 
should be that of the tissues covering 
the tumor. The direction and length 



Digitized by 



Google 



240 



CHARLES GREENE CUMSTON. 



of the greatest diameter of the tumor 
are sometimes difficult to establish, 
but the more one is familiar with 
intra-uterine examination, the less it 
is to do. Vulliet has invented a bis- 
toury having a concealed blade. It 
is introduced like a uterine sound, 
and, when brought to the upper limits 
of the tumor, the blade is pushed out 
to the desired length. The end of a 
finger is placed over the back of the 
instrument, a counter-pressure is made 
over the abdomen with the free hand, 
and the incision is made from the 
top to the bottom limits of neoplasm ; 
this done, the blade is hidden, and 
the instrument withdrawn. It is 
not well to incise the capsule of the 
tumor, for as long as the fibroid is 
not opened, necrosis is not to b^ 
feared. 

The ideal operation consists in pro- 
ducing a gradual descent of the 
tumor towards the uterine cavity, and 
not in bringing about its immediate 
expulsion out of the walls. It is a fact 
that fibrous polypi, which are enucle- 
ated and delivered spontaneously 
without opening of the capsule, are 
those which cause the least trouble. It 
is better to try debridement two or 
three times rather than go too deeply 
the first time. The higher up the 
fibroid, the greater must be the pre- 
cautions. When a knife such as has 
been described is not at hand, a 
button-poinied one may be used ; the 
blade is covered by adhesive plaster 
so that only the end of the blade 
is exposed. Sometimes long scissors, 
curved on the flat, may be used, 
and they are necessary when the 
tumor projects irregularly into the 
uterine cavity; the incision is then 



made from the lower to the upper 
limits as far as possible. When dil- 
atation is such that the interior of 
the cavity may be seen, the incision, 
which is not painful, may be done 
without narcosis. Debridement 
causes quite a haemorrhage, but this is 
of short duration. This fact may as- 
tonish those who do not know the 
haemostatic effects of scarifications in 
cases of loss of blood due to a fibroid. 
After debridement, a long intra-uter- 
ine irrigation of some disinfectant, 
the cavity and vagina are packed 
with iodoform gauze and the patient 
put to bed. 

After-treatment, On the next 
day ergotin is given and electric- 
ity applied. The packing is re- 
newed every forty-eight hours. 
Neither the finger nor foreign body 
excepting the cotton and the irriga- 
tor should be introduced into the 
uterine cavity. Three eventualities 
can happen after incision : First, 
enucleation is immediately' done ; 
secondly, the endometrium unites 
and the tumor slowly develops into 
a polypus protruding into the uter- 
ine cavity; and lastly, no modifica- 
tion may take place, the neoplasm 
remaining in the same position. 
The length and depth of the de- 
bridement, the more or less intimate 
connections of the neoplasm with 
the muscular layer of the organ, 
the consistence of the fibroid, the 
degree of contractility of the exter- 
nal layer, are certainly the circum- 
stances which determine the final 
result of the operation. Enucleation 
is generally announced by charac- 
teristic pains of labor; if there is 
no indication of infection, the ex- 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



241 



pulsion should be allowed to con- 
tinue without any interference on 
the part of the surgeon. When the 
efforts of the uterus are thought to 
bo exhausted, a digital examination 
should be made. After such a labor, 
so to speak, the neoplasm will be 
found at different degrees of de- 
scent; sometimes it is partly in the 
vagina, at others it may not have 
passed the external orifice, and 
Vulliet has also found it engaged 
between the lips of the incision. 
Comp'ete enucleation has never been 
seen to occur at once ; ordinarily the 
parts expelled are adherent to the 
remainder of the tumor buried in 
the walls of the uterus, and it is 
necessary to intervene in order to 
complete the expulsion. 

Elimination may also take place in 
the form of shreds, separated from 
the rest of the neoplasm, and these are 
generally flattened discoid masses 
with even edges. Separation takes 
place in the cellulur tissue which 
unites the islands which form the 
whole of the tumor. With good 
asepsis and intra-uterine irrigations 
and dressings, the organ can be kept 
from all contamination. In two 
cases in which the tumor took three 
weeks for its elimination, no fever, 
bad smell or any sign of decompoM- 
tion was noted. Prof. Vulliet has 
seen enucleation commence the day 
following debridement, and it may 
not commence before six, eight, fif 
teen and even twenty-one days later 
If at the end of three weeks no symp- 
toms has been observed, it is pro- 
bable that the incision has closed and 
that elimination will not take 
place in this manner. 



Polypu9 Formation. Even if no 
shreds have been passed at the end 
of three weeks, the surgeon should 
not be discouraged at the result of 
his incision, for the growth can still 
pass into the uterine cavity surrounded 
by the mucous membrane and trans- 
formed into a polypus. The incision 
closes, but the weakness of the deep 
layers remains. The incision has 
thinned it, and consequently the 
growth may advance towards the 
cavity of the uterus. This fact is 
illustrated in case V. 

Negative Jlesult. Vulliet has in- 
cised the mucous membrane when 
this was in sight, and he was able to 
make the incision the necessary 
length and depth, and in spite of this 
the fibroid did not budge from its 
place. Had the external layer lost 
its contractility, or were the connec- 
tions between the growth and the 
walls too intimate? This is not pos- 
sible to determine. Vulliet thinks 
that fibroids are subject to oedema or 
degeneration, that all those not pos- 
sessed with a slightly greater consis- 
tence than the uterine wall do not 
undergo sufficiently the effect of the 
contractions, and it is to this that he 
is inclined to attribute negative re- 
sults. Hut in this last category of cases 
he has never regretted the incision, 
for in all his cases he has obtained a 
diminution,and in some even complete 
cessation of the haemorrhages, as well 
as an arrest of development of the 
neoplasm. 

Contra-indications, This procedure 
is absolutely contra-indicated in all 
cases in which the dimensions of the 
growth are such that an incision the 
entire length of tte uterine cavity is 



Digitized by 



Google 



242 



CHARLES GREENE CUMSTOM. 



not large enough to allow the prodac- 
tion of spontaneous enucleation. 
Also, even when the uterine cavity 
is large enough to permit of a 
sufficiently long incision, the upper 
limits of the tumor are too high up 
in the abdomen, thus preventing 
forced enucleation in case commenc- 
ing infection might appear. And 
lastly, any symptom indicating a 
yirulent process in the uterine cavity 
is an absolute contra-indication. 

BIBLIOGKAPHY. ' 

The numbers correspond with 
those in the text. 
(1) Considerations sur les causes 

de la rSquence des corps et 

polypes fibreux de V uterus. 
{2) " Pathologie des tumeurs." 

Tome III, page 343. 
-(8) " Uber Myoma des Uterus," in 

Volkmann's Klin. Vortrag. No. 

98. 
^4) Gottschalk. Archiv. fUr Ghyn^ 

Ukologie., Band XLIII. 
^5) Cohnheim. Vorlesungen iiber 

allgemeine Pathologie. Berlin, 

1877. 
"(6) Galippe et Landouzy. "Note 

sur la presence de parasites 

dans les tumeurs fibreuses de 

Tuterus." Soci^t^ de Biologie. 

Paris, Feb. 18, 1887. 

(7) Dupuytren, in ''^Journal de 
MSdedne. Tome V., page 
198. 

(8) Bard. " Precis d'anatomie 
Pathologique." Paris, 1890. 

^9) Garrigues. " Diseases of 



Women." Philadelphia, 1894, 
page 456. 

(10) Gottschalk. Op. cit. 

(11) G. Braun. '' Wiener med. ZSU- 
chriftr 1868, Nos. 100 and 101. 

(12) Hecker. Klinik de Geburtr 
skunde^ Band II., page 108. 

(13) Carter. Ohstet. Transactioni^ 
1872, Vol. XIII, page 167. 

(14) Ribemont-Dessaignes et Le 
page. Precis d'Obstetrique." 
Paris, 1894, page 994. 

(15) Comil, in Ribemont^Dessaigues 
et Lepage, op. cit. 

(16) Bonnet et Petit. ''Traits pra- 
tique de GynsBCologie," Paris, 
1894, page 399. 

(17) Hart and Barbour. ** Manual 
of Gynaecology." Edinburgh, 
1890, page 412. 

(18) Klob. *^ Pathol. Anatomic 
der weiblichen Sexual Organ- 
en." Wein. 1864, page 163. 

(19) Foerster. '' Specille Pathol. 
Anatomic." Band II, page 425. 

(20) de Sin^ty. *' Traite^ de Gyn^- 
cologie." Paris, 1879. Page 
392. 

(21) JuUiard and Cumston. Dub- 
lin Journal of Med, Science. 
1890. Page 309, vol. 90. 

(22) Baraban. " Contribution k la 
pathogenic du cysto-fibrome," 
in Jlev. mSd. de VEsU 1891, 
Page 609. 

(23) Gross, Rohmer et Vautrin." 
Elements de Pathol, et de 
Clinique Chirurgicales." Tome 
III, page 498, Paris, 1893. 

(24) Bonnet et Petit. Op. cit. page 
399. 

(To be continaed.) 



Digitized by 



Google 



PELVIMETERS. 



248 



Pelvimeters, and the Practice of Pelvimetry as a Means of Discovering 
Irregularities of the Pelvis which are Likely to Embarrass Parturition. 



PHILANDER A. HARRIS, M. D. 

PATBBSOK, S. J. 



It is probably safe to assert that of 
the women now pregnant one or two 
of every thousand have pelves so 
small, flattened, or otherwise dis- 
torted, as to render it impossible for 
their children to be born alive at 
term in the natural way. 

It may be further said that of 
every one thousand cases now preg- 
nant, there is an additional small 
group possessing sufficient pelvic con- 
traction or deformity to arrest the 
progress of the child, who may be de- 
livered only by the aid of the forceps. 

In the first group of cases fcetal 
and maternal mortality will figure in 
large proportion, except for the 
timely intervention of art. In the 
second group foetal and maternal in- 
jury and mortality are again likely 
to figure, although the embarrass- 
ments consequent to failure and un- 
skill may be less pronounced than in 
the first or more limited group of 
cases. 

Those who have intentionally mu- 
tilated or destroyed children to effect 
delivery have, with few exceptions, 
acquired a most pronounced feeling 
of repugnance and disgust for such 
procedures. Fortunately modern art 
has brought most encouraging relief 
to these unfortunate women, and 
there is consequently less excuse for 
U8 to soil our hands with the blood of 
unskill and disgrace. Modern art. 



indeed, has so greatly enhanced the 
possibilities of both maternal and 
fojtal safety, that we should well con- 
sider the means whereby these un- 
fortunates can be discovered in time 
to be saved. 

A very large proportion of the 
cases of Csesarean section and 
symphisiotoniy present a previous 
history of unsuccessful, and often re- 
peated, attempts at delivery by the 
forceps. These are the cases which 
have swelled the mortality percent* 
ages of pubic and abdominal section. 
In many of them only failure to 
effect delivery by the forceps re- 
vealed the presence of osseous impedi- 
ment to delivery, or established the 
necessity for resort to other measures. 
The maximum degree of maternal and 
foetal safety depends upon our early 
discovery of these deformities. 

Our duties in this relation should 
be remembered at our introduction to 
each case. Women whom we shall 
then find to have given birth to small 
children only, who present the his- 
tory of long labor, especially of a 
prolonged second stage, or, who have 
been delivered by version or the for- 
ceps, should be at once, or at our 
early convenience, subjected to at 
least the common external measure 
ments of the pelvis. 

External measurements of all 
primiparse should be carefully made 



Digitized by 



Google 



244 



PHILANDER A; HARRIS. 



when our services are engaged, or 
shortly thereafter. For the purpose 
of making these external measure- 
ments of the pelvis, calipers, or the 
pelvimeter, are indispensable. In for- 
mer times the English inch was the 
only unit of measure for pelvimetry 
in this country. At present I believe 
a majority of the obstetrical teachers 
and writers here prefer and employ 
the French centimetre as a unit of 
measure, and its extensive employ- 
ment in other countries should lead 
to its general adoption here. Many 
continue to '* think," as they say, 
" in inches." Such may be reminded 
of the following simple method of re- 
ducing inches to centim**tres: Mul- 
tiply the number of inches by ten, 
divide the product by four, and the 
result is centimetres. Thus : 7i inches 
X 10, divided by 4, equals 18.6 cm. 

To reduce eighteen and six-tenths 
centimetres to inches, multiply by 
four and divide the product by ten, 
and the result is seven and one half 
inches. Thus : 18.6 centimetres x 4, 
divided by 10, equals 7i inches. 

In the selection of a pelvimeter 
certain qualities are requisite : First, 
accuracy ; second, that the instru- 
ment shall span sufficiently to take 
the various measurements of stout 
women. Two or three of the instru- 
ments in my collection are markedly 
deficient in this latter quality. An 
intimation of their deficiency in this 
respect is clearly shown by the ac- 
companying illustration. 

Almost any pelvimeter will span to 
the iliac crests or spines by anterior 
or posterior approach, but not so 
when we attempt to take the ex- 
ternal conjugate. 




The seductive little instrument of 
Collin, and also that of Robert and 
Collin, as sold here, do not span suf- 
ficiently to measure the external con- 
jugate in stout women. Flattened 
pelves in such women — the very 
ones we must determine — only in- 
crease the incompetency of these in- 
struments. 

Neither the arm, nor any part of 
the instrument, except the points, 
should exert pressure upon the pa- 
tient. 

For the purpose of studying and 
comparing the spanning capabilities 
of the various pelvimeters in my col- 
lection, I have secured the contour of 
a stout patient, and reproduced it, 
Ufe-size, on accomanying drawing. 
It was obtained by moulding a lead 
tape to the patient, on a line corres- 
ponding with the projection of a 
plane, which intersected the body at 
the lumbo-sacral joint posteriorly; 



Digitized by 



Google 



PELVIMETERS. 



245 




aiir^ nt^Jir the upper bfirdtn* of tlu* 
sympliysis pubis anteriorly. The tlis- 
tance aroiuul the patipnt on the con" 
tour line was one hundred and one 
centi metres* She weighed one him* 
dred and ei^lity-five pounds, and was 
of the following genera! dinien- 
sious : — 



Heigbl 

SliouJilers ., 

Crest iUac, .,....., 
IlUe spines =.,.,..,= 
External c«injugate, , 
Internal troclia . . . , 



,lfJt,5era. 
.*ai) cm. = 
^M em, - 
.28 cm. = 
,,2l cm. ^ 
. 30 cm. - 



5 tU 41 in- 

tl^itt, 
H In. 
Uii in. 



The reproduction of this patient's 
contour — life-size — on a nnniUer of 
card board?*, and tlie application and 
traciuf^ of the sevt^ral pelvimeters all 
in position for taking the external 
conjugate, and, of course, open to 
twenty -one centimetres, affojtk a 
ready meann of eon^parini^ the form, 
size, and spanning capabilities of the 
various instruments hereafter deline- 
ated. The iilustratfons are all photo- 
lithographed from the original trac- 
ings, and are thus relieved of any 
suspicion of error. 

The relations of the various instrii- 
ments to a stout person with a large, 
but flattened, pelvis, is illustrated by 
tracings of the several pelvimeters 



with points approximated to fifteen 
eeuti metres. Only a portion of the 
arms of the various instruments ap- 
pear in this part of each drawing. 




Figures 1 and 2 represent the pelvi- 
meters of Collin* and of Robert and 
Collin, instrument makers, Paris. 




These instruments were made in 
New York ; they span insufficiently, 
and must, on that account, be con- 
detoned as universal external pelvi- 
meters. Both are graduated from 
taking internal diameters. The ex- 
pression of measure is in centimetres. 



Digitized by 



Google 



246 



PHILANDER A. IIAURIS. 




Figiirii $ leprestfjits a pelvimeter of 
Bantlelftcqiu^ in my poH^estsion. It 
spans iniiufficiently. 




Figure 4, repivsputnig ilit^ instru- 
ment of Doctor Bullitt, seems a goo<i 
deal sliort in spanning, but tlie shuft- 
age might, to some extent, be (over- 
come by apply in|r it upside dnwju or 



from the other side, in indivithml 
cjises. The relation of the arnii^ thus 
applitd to model is shown in the 
aecompunying illtist ration. This very 
ingenious instrument is adapted to 
eertain internal measurements, I 
liave not used the instrument for 
internal measurement, and am there- 
fore unable to judge of its merits for 
this .service. 




Ki|::nre -'>, or tlie instrument of 
Selmll^.e, is siinrt in spanning effect, 
but wi.l measure most, cases. 





I iT 


(f 




PIG. 6. \ /\ 


PKOR^STeOBSilS, ' 



Digitized by 



Google 



PELVIMETERS. 



24T 



Figure 6, Dr. Byford's pelvimeter^ 
spans snfficientlv- 




Figure T4 of true IJnuiit»loeque type, 
but lai^ger than figure *S, spaim 
amply. 




Figure 8, representing Dr. Diivis' 
impi^oved pelvimeter, spanss very 
amply. 

Figure 9 represents the reader's 
instrument. Its general conforma 
tioD has not been altered since the 
first one was made eighteen months 




]Hjiiits aix* di>'t^lia[ii'(J, ilitii luring re- 
ga lilted as the lii'ht fnnii I'nr liolding 
between tlae tlnindi suul lirbt finger 
iluriijg ineiib-aiatiuii. 







Figure 10 repre&tuitt Dr. lieiujan 
L. Ccllyer's recent invention. 

In addition to the necessary quali- 
ties of accuracy and spanning w^ 



Digitized by 



Google 



248 



PHILANDER A. HARRIS. 



should select an instrument possessing 
as many other good attributes as pos- 
sible. 

WEIGHT. 

Pr. Bullitt's pelvimeter weighs. .400 grammes. 

Dr. Baudefocque^s '* *' H09 '* 

Prof. Schullze's ** *• 279 

Prof. Byford's *' '* 2.V2 

Prof. Davis' ** •* 220 

The author's, in steel " 195 

► •* ** '* aluminum*' 97 

Dr. Collyer's *' '* 229 




RECTANGULAR AREA OCCUPIED BY CLOSED 
INSTRUMENT. 

Baudelocque's Ill square mches. 

Byford's 103 " 

Davis' 84 *• 

Bullitt's 43 

The author's 40 

Collyer's : 39 

Schultze's. 3.5 ** 

THE TIICKEST PART OF 

Collyer's measures 32 millimetres. 

Schultze's ** 31 

Baudelocque's '* 27 " 

Davis' »' 26 

Bullitt's " 26 

Byford's ** 25 

The author's ** ...16 

BAUDELOCQUE'8 CLOSED INSTBL^^ENT MAY 
BE PUT IN A KECT ANGULAR BOX OF 139 CUBIC 
INCHES CAPACITY. 

Byford's in 1 1 1 cubic inches capacity 

Davis' ** 87 ** ** ** 

Bullitt's "44 •* 

Schultze's " 44 •' 

Collyer's " 43 ** " " 

The author's '* 26 '* ** 

Bullitt's pelvimeter has many dis- 
tinct parts ; Davis' has seven, with 
antiseptic lock. 

Baudelocque's 6 parts (screw pivot). 

Schultze's 6 " 

Collyer's,. 6 parts (thumb-screw 

pivot). 

Byford's 4 parts (screw pivot). 

The author's 5 '* ** 

Of the competent instruments in 
my collection, 

Byford's registers in inches and half inches. 

Davis' " ** ** ** " •* 

Baudelocque's** " ** " " •* 
Schultze's...." '• " " 
Bullitt's in centimetres. 
Collyer's in both inches and centimetres. 
The author's in centimetres, but may be ob- 
tained to read in inches. 

Baudelocque's pelvimeter has a 
screw with which an assistant can set 
the points at any degree of separa- 



Digitized by 



Google 



PELVIMETERS. 



249 



tion. This permits the mensurator 
to remove it to better light, or ex- 
amine it at leisure. This feature also 
characterizes the pelvimeters of Pro- 
fessors Byford, Davis and Schultze. 

The pelvimeters of Bullitt, Collyer 
and that of the reader are in no in- 
stance provided with set screws, but 
the graduations are legibly marked, 
and may be easily read by the small- 
est candle light during application. 

Lately much has been said about 
pocket pelvimeters. In addition to 
the weight and dimensions above 
given, I wish to direct attention to 
figure 11, in which are delineated the 
fully-closed and amply-spanning in- 
struments. 

Shultze's pelvimeter (the one in my 
possession), like the two lowermost 
ones shown, is a pocket pelvimeter, 
but it spans insufficiently, and can 
only be employed in some cases by 
perineal approach. 

The external measurements of the 
pelvis of special value, and with 
which this paper mainly deals, are : 

First. The greatest distance be- 
tween the iliac crests and their 
external margins. 

Second. The distance between the 
external margins of the anterior 
superior spinuous processes of the 
iliac bones. 

Third. The so-called external con- 
jugate, or the distance between the 
fossa beneath the spinous process of 
the last lumbar vertebra and the 
middle of the upper border of the 
symphysis pubis. 

Taken from life in the normal pel- 
vis of average size, these three meas- 
urements should be about as fol- 
lows: 



Between iliac crests 28 centimetres- 
Bet ween iliac spines 25 " 

External conjugate 20 *' 

The internal conjugate of such a 
pelvis, or conjupata vera, or distance 
between promontory of sacrum, and 
the posterior surface of the symphy- 
sis pubis, should be about eleven and 
five-tenths centimetres, leaving eight 
and five-tenths centimetres, which is 
made up of sacrum, pubes, and over- 
lying structures. 

For the purpose of approximate 
estimation of the conjugata vera, 
from the conjugata externa, some 
authors have suggested that a certain 
fixed deduction should be made for 
sacrum, pubes and overlying struc- 
tures. Baudelocque, for example, 
mentioned seven and five-tenths cen- 
timetres for spare, and eight and 
two-tenths centimetres for women of 
fleshy habit ; Litzmann made meas- 
urement of the pubes of thirty women, 
post-mortem, with the result that the 
mean amount to be deducted from the 
external conjugate for sacrum, pubes 
and overlying structures, should be 
eight and six-tenths centimetres. He 
remarked,however, that the amount in 
individual cases varied widely, owing 
to the difference in the thickness of 
the bones and integument, the maxi- 
mum amounting to nearly twelve 
centimetres, while the minimum did 
not reach eight centimetres. 

To say that we may, for the pur- 
pose of brevity in expression, con- 
venience in estimation, or for any 
other reason, suggest that a certain 
TSxed deduction shall be made from 
the conjugata externa, to obtain the 
conjugata vera without regard to the 
size of the pelvis, appears illogical, 



Digitized by 



Google 



250 



PHILANDER A. HARRIS. 



and I am sure will prove misleading. 
To avoid error and mi^pprehension 
regarding the relation of the eon- 
jugata vera to the eonjngata externa 
in pelvis of normal conformation, I 
desire to emphatically exclude sug- 
gestion that any given number of 
centimetres may be deducted in all 
cases to arrive at a result. 

A symmetrically formed and ana- 
tomically correct pelvis, with an exter- 
nal conjugate of twenty two cen- 
timetres, measured in life, should have 
a conjugata vera of twelve and five- 
tenth '"entimetres. The deduction, in 
this instance, from the external 
conjugate amounts to nine and five- 
tenths centimetres. The deduction for 
sacrum, pubes and overlying struc- 
ture ill a similarly formed pelvis, hav- 
ing an external conjugate of sixteen 
and five-tenths centimetres, would be 
seven centimetres, while the deduc- 
tion from an external conjugate of 
twenty centimetres would be eight 
and six-tenths centimetres, making a 
conjugata vera eleven and four-tenths 
centimetres. These external meas- 
urements are made with slight, but 
not painful, pressure of the points of 
the pelvimeter during reading. 

A deduction of one centimetre from 
the external conjugate should be 
made for obesity, and at least two 
centimetres for very pronounced 
obesity. 

A deduction from int^r-crest and 
inter-spinal measurements, amounting 
to five-tenths centimetres or one cen- 
timetre is all the allowance which% 
need be made on account of obesity 
or very pronounced obesity respec- 
tively. 

For the purpose of illustrating the 



relations which these three common 
external diameters bear to one 
another in pelves of normal con- 
formation, I wish to direct attention 
to the accompanying chart, marked 
** Pelves of Normal Conformation." 

The space between any two hori- 
zontal lines represents one cen- 
timetre, the figures at the left and 
the right, reading from zero, indicate 
the number of centimetres for antero- 
posterior measurements. At the top 
of the chart there appears a progres- 
sive series of numbers, any one of 
which may be utilized for an iliac 
crest measurement. The lines which 
descend from these numbers termi, 
nate at the bottom of the chart- 
where another progressive series of 
figures indicate the severar companion 
measurements for the anterior super- 
ior spinous process of the ilium The 
average difference between inter- 
crest and inter-spinous process of the 
ilium, with a crest of twenty-four cen- 
timetres is about one and eight tenths 
centimetres, while the difference be- 
tween these companion measurements 
with an inter-crest distance of thirty 
centimetres is about three and six- 
tenths centimetres. Here again the 
distances between companion meas- 
urements are seen to vary according 
to the size of the pelvis. Any point 
of the gradually ascending upper 
broad line, beginning at sixteen and 
five-tenths centimetres on the left, 
and terminating at twenty-two cen- 
timetres on the right, may be taken 
to represent a conjugata exterma of 
any particular case. The . intersect- 
ing vertical lines lead to the corres- 
ponding inter-crest measurement at 
the top, and to the inter-iliac spine 



Digitized by 



Google 



PELVIMETERS. 



261 



«t the bottom ; while the horizontal 
intertecting lines lead to the cor- 



The broad ascending line of the 
chart, beginning at nine and five- 



.5! J^ S "^' 52 ^^'^'''cow "" o -, ^ 



col 

to 

05 
CM 

a 

01 
10 

(M 



w, 



2: 

o 

Otf|3 

> ID 

hJ ^ 

U3 ID 

Ph ^ 
CM 




oCDkD^COCM^ S 



S4' 

IS 



.(> 



& 



CO 
N 

cc 

CM 

S| 

CMC; 
,10 B 

S| 

ID& 

qg 



CM 
CM- 



COH 
CM^ 



CM 

CD 
CM 

CM 

CM 
-CM* 



ffl 



CM -^OOJOOt^CDlO^COCM-^OocOt-CPUSTPOOCM^ok 
CMCM.^-H^-^»-<-^— -^"^^ , 

•saHxawiXNao NrsaxvonrNOo . 

SaHX QNY^WIHa IV H3XaWVia.3SttaASNVHXi 



responding measniement for the ex- 
ternal conjugate. 



tenths centimetres on the left, and 
terminating at twelve and five-tenths 



Digitized by 



Google 



252 PHILANDER A. HARRIS. 

centimetres on the right, is intended and five-tenths centimetres. Let us 

to show the conjugata vera in pelves suppose that we have a plvis 

of varying sizes, according to its in- with an external conjugate of eigh- 

tersection with any descending line teen centimetres. Allow the eye to 

from the intersections above. The ^llow the horizontal line on chart 

other broad ascending line, beginning ant'l it intersects the upper broad 

at sixteen and five-tenths centimetres^ ascending line. From that point the 

on the left, and terminating at twentyl ascending line carries us to the iliao- 

two centimetres on the right, is in- crest measurement at the top of the 

tended to show the conjugata exterma chart, which is twenty-five and five- 

of the pelves of varying sizes, accoid- tenths centimetres, and to the bottom 

ing to its intersection with any two ot the chart, where the distance be- 

lines, one of which must be horizontal tween the anterior superior iliac 

and the other vertical. spines is found to be twenty-three 

The gradually ascending dotted and four-tenths centimetres. jMarked 
line, beginning at eleven centimetres deviation from the indications of 
on the left, and terminating at four- these converging and intersecting 
teen and seven-tenths centimetres on lines is a presumption of asymmetry, 
the right, is intended to demonstrate The deduction for sacrum, pubes, 
the transverse measurement of any and overlying structure is readily de- 
particular pelvis according to its in- termined from the chart, by counting 
tersection with any vertical line in the centimetre spaces on any vertical 
interest. i'"* between its intersections with 

Let us make practical application the two broad ascending lines, 
of this table by assuming that we I be^eve that the chart is laid out 

have measured a pelvis with an inter- <>« lines sufficiently in accord with 

crest distance of twentv-eight cen- nature to render it useful and fairly 

timetres. Follow this line to the reliable as a reference table, to deter- 

bottom of chart, where we read that "ine the relations which certain pel- 

the companion inter iliac spinous vie measurements should bear to one 

measurement should be twenty-five another in such as are of fairly 

and two-tenths centimetres. This normal anatomical form and symme- 

descending line intersects the ex- try. While a large proportion of 

ternal conjugate line at twenty cen- all pelves in their transverse and 

timetres above zero. The intersec- anterio-posterior diameters will quite 

tion of this line, descending from nearly exemplify the relations indi- 

twentytive centimetres, with the cated by the chart, yet the size of the 

dotted line, affords the transverse Pe'vis in many individual cases will 

measurement of about thirteen and ^ ^onnd quite out of proportion to 

five-tenths centimetres. By follow- the height of the individual. For 

ing this descending line to its inter- example: 

CASE A. 

section with the lower broad ascend- ^^.^^^^ ^^^ centimetres. 

ing line, we shall find that the inter- Crest 27 " 

. Iliac spines 24.5*1 *' 

nal conjugate should be about eleven External conjugate .!! i .... 19 ' •* 



Digitized by 



Google 



PELVIMETERS. 



253 



CASE B. 

Height 172.5 centimetres. 

Crest 27 " 

Iliac spines 24.5 ** 

External conjugate 18.8 " 

These pelves of apparently normal 
conformation have about the same 
diameters, yet one is that of a short, 
and the other of a very tall wonaan. 

While the ratio of proportion be- 
tween the size of the pelvis and the 
height of the individual is generally 
maintained, the instances of relative 
disproportion are sufficiently numer- 
ous to deter us from concluding that 
the pelvis of any woman is amply 
large because she is tall in stature. 

Certain terms, such as ''generally 
contracted pelvis," -*aequ»biliter justo 
major pelvis," are employed partly to 
designate — inferentially, of course — 
the sizes of pelves. Dimensions have 
been so infrequently quoted in con- 
nection with the employment of these 
expressions, that the greatest latitude 
of interpretation is possible. The use 
of the expression "' contracted pelvis " 
has been subjected to a variety of, 
and, in some unusual instances, defi- 
nitions. To the ambiguity of this 
expression, rather than to differences 
of experience or observation, is to be 
attributed, no doubt, the conflicting 
statements regarding the frequency 
of this so called condition. In my 
chart of '"Pelvis of Normal Con- 
formation " I have introduced, in the 
gradually ascending scale of distances 
between the anterior superior iliac 
spines, tenths of a centimetre. These 
divisions of a centimetre, as you will 
observe, are necessary for mathemat- 
ical approximation, and I mention 
the fact that no one may attribute to 
me impossible mensuration. 



Not all pelves whose external diam- 
eters are in close keepinor with the 
indications of the chart will be found 
to have the exactly corresponding in- 
ternal diameters. The thin, delicate 
structure of some pelves, and the gen- 
erally thickened formation of others, 
affords a certain latitude of varia- 
tion. The degree of latitude, how- 
ever, will not be considerable. So 
soon as the relative disproportion 
becomes marked, we shall find that 
one or other of the external diame- 
ters is out of its proper relation with 
the other diameter. In just this 
particular does external pelvimetry 
aff^ord valuable and almost uix.erring 
intimation of asymmetry. 

The following case is especially 
illustrative of the value of pelvimetiy, 
because opportunity was offered for 
internal measurement at autopsy : 

CASE c. 

Crest 29 centimetres. 

Iliac spines 29 ** 

External conjugate ! ... 19 *' 

At autopsy, when post-mortem 
symphysiotomy was performed, the 
following internal diameters were 
taken : — 



Direct internal conjugate 6.3 centimetres 

Transverse 13.8 ** 



In this cape I claim that the in- 
creased distance between the iliac 
spinf'S afftnded most pronounced in. 
dication of asymmetry. 

A friend who recently performed 
Csesarean section upon a young 
woman with narrowed pelvis, kindly 
afforded me the opportunity of taking 
the following measurements: 



Digitized by 



Google 



254 



PHILANDER A. HARRIS. 



CASE D. 

Crest 2:^.5 centimetres. 

lilac spines 21.5 '* 

External conjugate 18 ** 

AT AUTOPSY. 

Internal conjugate 10.1 centimetres. 

Transverse 10 2 ** 

I claim tliat the relative lengthen- 
ing of the external conjugate in this 
case, or the relative shortening of the 
inter-crest measureraents, afforded 
Bufficient presumption of asymmetry 
at the pelvic inlet. It was a small 
pelvis, and far from normal in its con- 
formation. 

Another case (E), a handsome 
young woman, with broad hips, pre-, 
rented the following parturient his- 
tory : First labor, very prolonged 
second stage, instrumental delivery 
with dead child weighing seven and 
-one-half pounds; second labor, pro- 
longed second stage, delivery of a 
living child weighing six and one-half 
pounds, without instrumental aid; 
third labor, head rested at the su- 
perior strait, instrumental delivery of 
-a living child weighing seven pounds. 

Crest ,27 centimetres. 

liac spines 22.5 ** 

External conjugate 17.5 ** 

In this instance, one might assume 
the inter-crest diameter at fault, since 
the relation of the inter-iliac spine to 
external conjugate is correct. How- 
ever this may be, it is sufficient to 
ote that the external measurements 
indicated internal asymmetiy. An 
external conjugate of seventeen and 
five tenths centimetres does not be 
long to a crest of 27 centimetres. 

Another case (F), probably rach- 
itic, with the following parturiton 



history and pelvic measurement: 
First labor, instrumental delivery of a 
dead child after a prolonged second 
stage, attended by a professional 
friend of mine; second labor, delivery 
without instrumental aid, after a short 
second stage, of a living child weigh- 
ing five and one-half pounds; third 
labor, instrumental delivery of a liv- 
ing child weighing seven pounds; 
fourth labor, instrumental deliveiy of 
a living child weighing seven pounds. 
This ^^oman was attended by the 
reader in all but her first confinement, 
and her three children born alive are 
still living. 

Crest 26 centimetres. 

Iliac spines 25.5 

External conjugate 17 " 

Comparison of these diameters 
with the indications of the chart, 
shows that no two measurements are 
right in their relation to each other. 

Another case (G), probably also 
rachitic, with the following partu- 
rient history; Prolonged second 
stage, head arrested at brim, delivery 
with the forceps of a dead child 
weighing eight pounds. 

Crest 27 centimetres. 

Iliac spines 26 •* 

External conjugates 21 *' 

Here again the measurements are 
not in accordance with the indica- 
tions of the chart. 

Case A, at the age of twenty -seven, 
after a labor of two days, was deliv- 
ered by the forceps of a living child 
which died in nine weeks. In her 
second labor she gave birth, unaided, 
to a smaller child, weighing six or 
seven pounds, which lived to sixtene 



Digitized by 



Google 



PELVIMETERS. 



256 



months, and died of diphtheria. The 
labor of her third child-bed lasted 
seventy-two hoars; this child born 
without forceps is still living. The 
weight of this child is believed to 
have been between seven and eight 
pounds. Fourth childbed, chloro- 
form, forceps, and a dead child in 
nine hours from beginning of labor. 
Fifth child-bed, labor bngan at 2 A. 
M. on the fifth of the present month, 
membranes spontaneously ruptured 
two hours later ; second stage began 
at 6 A. M. Anaesthesia and applica 
tion of forceps by her physician be- 
fore noon. Another unsuccessful 
effort with forceps by a consultant at 
noon. At request of the attendants, 
I saw the woman at 2 p m. Head 
above the brim, L. O. A., large caput 
Buccedaneum, pains very powerful and 
in quick succession. 

DIMBNSIOirS. 

Weight 185 pounds. 

Height 158 centimetres. 

Crest 29 " 

Iliac spines 27 ** 

External conjugate.. ..20 ** 

OOBBBCTION OP MEA8UBEMENT8 ON ACCOUNT 
OF OBESITY. 

Crest 28.8 centimeters. 

Iliac Spines 26.8 *» 

External conjugate . . . 18.0 ** 

This patient was at once removed 
to the Paterson Genei-al Hospital, 
where I performed symphysiotomy at 
half past five o'clock. Upon with- 
drawal of the ether her pains almost 
immediately recurred, and, without 
farther aid, eflfected the delivery of a 
dead child weighing ten and one-half 
pounds (nude) in less than ten min- 



utes after pubic section. Gonjngata 
vera was found to be seven and six 
tenths centimetres. As this is the 
first report of this case, I wish to 
state, apologetically, of course, that 
although unable to discover fcetal 
heart sounds, the patient experienced 
foetal movement one hour before 
operaii )n. She had not, however, 
with this exception, felt foetal move- 
ment for about nine hours before 
operation. The child's left eyelid 
was swollen, and ecchymosed, but, 
aside from this, no other external 
marks of injury were discoverable. 
This case further exemplifies the 
claim that even moderate variation 
from the typically normal, afforded 
decided indication of asymmetry. 

I will not weary you with further 
reference to notes in this relation. I 
have introduced these cases to show 
that in eveiy instance one or other of 
the external diameters were markedly 
out of their normal relation with one 
or both of the other diameters. 

In addition to the thiee common 
measurements already considered, 
there are two additional measure- 
ments which are important in the 
detection of pelvic asymmetry. They 
are the distances between the poste- 
rior, superior, spinous process of the 
iliac bone on the right side, and the 
anterior, superior, spinous process of 
the ilium on the left side, and the cor- 
responding companion measurement 
from left to right genemlly referred 
to as the right and left oblique. 
These measurements, in pelves of 
normal ccmformation, are equal. In- 
equality of these companion measure- 
ments indicates lateral deflection or 
pelvic obliquity. 



Digitized by 



Google 



256 



PHILANDER A. HARRIS. 



I can conceive the possibility of 
deformity of the pelvic inlet, of which 
common external pelvimetry might 
fail to excite suspicion, but I believe 
that such cases are so rare that they 
will form but a very, very small per- 
centage of the whole number of pelvic 
deformities which embarrass parturi- 
tion. 

In earlier experience I committed 
error, in some instances, by pronounc- 
ing flattening when none existed. 
Flattening of the pelvis, or shorten- 
ing of the conjugates, must not from 
external mensuration be assumed to 
be present in any case until we have 
determined that the transverse meas- 
urements are disproportionately long. 
If the chart of pelves of normal con- 
formation here shown is constructed 
on lines in close accordance with 
nature, it must then be clearly ap- 
parent that many others have com- 
mitted the error which I have just 
confessed. No pelvis can be said to 
be flattened until one or other of the 
transverse measurements are also 
determined. 

A pelvis with the following meas- 
urements 

Crest 24.5 centimetres. 

External conjugate .... 17 *' 

IS a normal pelvis so far as these two 
measurements can determine, but a 
pelvis with crest of twenty-eight cen- 
timetres and an external conjugate 
of seventeen centimetres is a flattened 
pelvis. 

It has been generally considered 
that relative widening of the dis- 
tance between the iliac spines indi- 
cates the rachitic pelvis, and with a 
relatively shortened conjugate, a 



rachitically flattened pelvis ; while a 
wide crest, and relatively shoitened 
distance between iliac spines, and the 
external conjugate, relatively shorter 
fchan the inter-crest measurement de- 
mands, indicates the non-rachitically 
flattened pelvis. As between these 
two varieties of flattening at any 
particular degree of distortion, as 
indicated by external mensuration, I 
have no hesitancy in asserting that 
the so-called rachitically flattened 
pelvis* will present the greater degree 
of osseous impediment to parturition. 

Having discovered, by external 
pelvimetry, a very small pelvis, or one 
presenting indication of pronounced 
asymmetry, how may we render such 
knowledge of advantage to our 
patient? Vaginal exploration is 
clearly the next steps such explora- 
tion is the important test which 
science must interpose. With the 
patient anaesthetized, the promontory 
of the sacrum can generally be reached 
by the index or second finger, especi- 
ally with the hand in the vagina. We 
thus determine the conjugata diag- 
onalis, and make such deduction from 
its measurement in individual cases 
as may seem proper to obtain the 
conjugata vera. 

The fingers may be directed to the 
right and to the left, and such knowl- 
edge gained of the transverse and 
oblique diameters as is possible. The 
size and shape of the sacrum and its 
promontory, the formation of the 
pubes and the approximation of the 
tubera ischii, will appear for estima- 
tion, and, most important of all, the 
location and position of the head, if it 
presents. If, iu labor the os is found 
fully dilated, the membranes rap- 



Digitized by 



Google 



PELVIMETERS. 



257 



tared, tbe pains active, and the head 
«bove the pelvic inlet and not de- 
scending, we have most substantial 
proof of the relative disproportionr of 
•child and pelvis. 

While, by means of external and 
internal pelvimetry, we may reckon 
almost to a nicety the size and forma- 
tion of almost any particular pelvis, 
wfe have, as yet, made but little pro- 
gress toward determining the size of 
the unborn child. 

Living childreq have been born 
through flattened pelves, whose con- 
jugata vera did not exceed seven 
■centimetres. Case C, referred to in 
this paper, gave birth to four living 
<)hildren prior to her death in the last 
parturition. It is needless to say 
that these children, and all born 
under like circumstances, were at 
least small, and probably much be- 
neath the average size of birth. 

Resort to unusual operation for the 
delivery of small children, in pelves 
of moderately limited capacity, has 
brought no little embarrassment to 
certain operators. I think it may be 
plainly stated that in any instance 
where pelvic contraction is not so 
pronounced as to preclude the pos- 
sibly safe delivery of an undersized 
child, it will be well to await the 
occurrence of labor, permitting it to 
advance su£Bciently to enable us 
to determine nature's capabilities. 
This suggestion may be adopted by 
those who ignore the practice of 
premature delivery, or by any who 
may be introduced to a case at, or 
very near, the completion of utero- 
gestation. If, in any such instance 
the child be small, delivery may be 
effected without serious consequences 



to mother or child. The interest of 
the two lives at stake will be far bet- 
ter subserved, if, while awaiting the 
powers of nature, we have placed the 
mother amidst surroundings which 
will enable us to resort to Cresarean 
section, or symphysiotomy uuder 
favorable circumstances. If such 
cases reside in out-of-the-way places, 
if in the houses of the dirty, or the 
very poor, or if in the country where 
the physician is unprepared or unwill- 
ing to operate, or, when he cannot at 
once command the required assistance, 
it is then clearly his duty to commit 
the patient to the care of one skilled 
in the procedure which may be re- 
quired. This may, of course, neces- 
sitate change of residence. When 
such change is decided upon, the 
well-ordered hospital or retreat is the 
haven of maximum safety for the 
lives in jeopardy. 

Most operating obstetricians base 
their treatment of cases upon the 
assumption that so long as the size 
and quality of the child remains un 
determined, they have the right to 
assume that it is at least of average 
size. With this assumption, elective 
CdBsarean section, before a test of the 
second stage, has been done upon 
women with conjugata vera seven and 
five-tenths diameters. 

My only Csesarean section was an 
elective operation, in that I did not 
await a test of the second stage of 
labor. A primipara, aged eighteen, of 
the following dimensions : 

Height 137 centimetres. 

Crest 22 '• 

Iliac spines 21.5 " 

Estemal conjugate.. 16.5 *' 
Internal conjugate.. 7 *' 



Digitized by 



Google 



268 



PHILANDER A. HARRIS. 



Living child, eight and one-half 
pounds, which was taken out of the 
Paterson General Hospital by its 
mother about six weeks from the date 
of operation, both in a condition of 
health. 

This result was, of course, satis- 
factory, but I am inclined to think 
that for cases where we can determine 
the internal conjugate to be between 
six and eight centimetres, and suspect 
a child of average size, it wouldbe bet- 
ter to prepare for the unxisual opera- 
tions, but allow the second stHge of 
labor to afford some demonstration of 
nature's capabilities. If a flattened 
pelvis is definitely determined to be 
five and nine-tenths centimetres, or 
less, and the child believed to be of 
average size, I should then decide 
upon the purely elective Csesarean 
section. 

As to the personal equation of men- 
surators, I should say that there 
should not be much difference be- 
tween the results of the experienced 
who adhere to the same direction. 
Anyone who has not practiced exter- 
nal pelvimetry may, by measuring 
forty or fifty women, especially if he 
records, preserves and studies his 
results, become a fairly expert pelvic 
mensurator. 

I should not expect my measure, 
ments in any particular case to be 
much at variance with his. All who 
practice midwifery should systemat- 
ically practice external pelvimetry. 



The greatest success in detecting 
asymmetry will accrue to those who 
possess the most accurate knowledge 
of normal pelves in their varying 
sizes. I must anticipate and answer 
a question which some of you may be 
waiting to ask me : as to what per- 
centage of women have pelves nearly 
in accordance with the indications of 
the chart of normal conformation. 
Perhaps seventy per cent, or eighty 
per cent, will measure quite closely 
to the lines of the chart. The re- 
maining twenty per cent, or thirty 
per cent, will present various grades 
of departure ; while only a small per 
cent, will present extreme variations 
from the normal. 

The chart of pelves of normal con- 
formation is, of course, the result of 
much study and a considei-able 
amount of personal mensuration of 
women. I have no right to expect, 
nor do I desire, that it shall be re- 
ceived and permanently retained as a 
criterion without amendment. The 
great necessity for some such stand- 
ard, I am convinced, will present it- 
self to all pelvec mensurating obstet- 
ricians. From them, and from such 
aid as cceliotomists interested may 
offer, let us hope that facts may be 
adduced with suflBcient authenticity 
to establish the readings of my chart 
in its present form, or, alter them, 
and bring its lines in closer relation 
with nature. 
26 Church St., Paterson, N. J. 



Digitized by 



Google 



NEW INSTRUMENTS. 



259 



An Aseptic Goodell Dilator ; Lateral Vaginal Retractor. 



CAREY KENNEDY FLEMING, M. D., 

Adjunct Profe99or of Q-yncecology^ Abdominal Surgery and Clinical Midr 

wifery^ Gross Medical College ; Oyticecologiat to St. 

Anthony's Hospital^ Denver^ 

Colorado. 



Thb first inBtrument to which I 
desire to draw the attention of the 
medical profession is one that ap- 
parently needs no introduction, for 
upon a casual ot)serYance it seems to 
be the ordinary Goodell dilator, the 
instrument which is accepted as the 
most perfect uterine dilator extant. 
Upon closer inspection, however, sev- 
eral changes are noticeable. The most 
important is the presence of two new 
parts seen on the shank, which I have 
termed the keys. (See illustration No. 
1.) These keys control two French 




locks which hold the blades and cross 
pieces of the parallelogram to the 
handle. Upon their removal the dif- 



ferent pieces may be separated, thus 
rendering the instrument capable of 
being made perfectly aseptic. The 
handles are fastened by thumb screws^ 
as can be seen in the illustration. 
The instrument has been made a 
trifle longer, stronger and better pro- 
portioned than the ordinary "Good- 
ell." 

It would seem that this aseptic de- 
vise, which is quite easy to manipu- 
late, would be a great improvement 
over the original instrument, convert- 
ing a possibly dangerous dilator into 
a perfectly safe one. 

The second illustration protrays,' I 
believe, an original instrument, which 
has been named * 'Lateral Vaginal 
Retractor". It is designed especially 
to retract the labia in operations on 
the uterus or anterior vaginal wall. 
It is self retaining and should only be 
used when the patient is under an an- 
aesthetic, for otherwise its use is pain- 
ful and unsatisfactory. By its use the 
labia are retracted fully two inches, 
and the necessity of the presence of 
the obstructive hands of assistants is 
obviated. 

From the illustration it can be 
seen (see illustration No. 2) that the 
blades of this instrument are markedly 
hooked, so that when retraction of 
the perineum is desired (rarely neces- 



Digitized by 



Google 



260 



CAREY KENNEDY FLEMING. 



sary) all that is required is to fasten 
a "weight to the handle, as is done with 
the Edebohrs speculm. 

This instrument is made of one 



Length of handles 2>^ inches. 

Length of blades 2^ ** 

Width of blades 1)4 *' 

Space between blades 2)4 '* 




piece of spring wire nickle-plated, 
and in appearance resembles a nasal 
speculum, though many times larger. 
It dimensions are as follows : — 



Both of these instruments were 
made for me by the instrument boose 
of J. Durbin, Denver. 



Digitized by 



Google 



EXTRA-UTERINE PREGNANCY. 



261 



Original Lecture on Extra-Uterine Pregnancy. 

JAMES A. GOG6AN8, M. D., 

▲LBZAITDBR OITT, AUL 

Senior Councellor of the Medical Association oj the State of Alabama; Fellow 

of the Southern Surgical and Q-ynceological Society ; Fellow of the 

British OyncBological Society^ and Vice-President of Tri- 

State Medical Society of Alabama^ Georgia and 

Tennessee. 



Gentlemen: — It is through the 
courtesy of your professor of surgery 
that I have the honor of speaking to 
you to-day, and I wish to assure you 
that it is a privilege that I appreciate 
in the highest possible degree. 

I shall proceed at once to speak to 
you of a disease of .great importance, 
a disease with which any practitioner 
of medicine is liable to encounter, 
therefore much more valuable infor- 
mation may yet be acquired by study- 
ing the clinical history of each case. 
I refer to extra uterine pregnancy. 

This specimen which I show you is a 
three-months foetus and the ruptured 
tube in which it was imprisoned. 

It was removed from a woman 
thirty five years of age, and she pre- 
sented the following history: She 
had had three children, the youngest 
five years of age. Since the birth of 
her last child, she had had two abor- 
tions. I saw her in consultation on 
August 8 1st, and she had had three 
attacks of severe pain in the lower 
abdomen, followed by complete pros- 
tration and a rapid pulse, and pre- 
senting all the symptoms of internal 
haemorrhage. Her menses had been 
regular, but she failed to menstruate 

Deliverd before the sindents of the AtlftoUMedi. 
Ml College, Uocober 13th, 1894. 



on July 23rd, at which time the 
menses were expected to appear. On 
August 15th, she passed a membmn- 
ous mass, which was accompanied by^ 
the discharge of some blood. There 
was not much pain. 

On making a vaginal examination it 
was found that some blood was still 
passing and a small irregular tumor 
could be felt low down in the pelvis, to 
the left side of and behind the uterus. 
This tumor was fixed and very painful 
on pressure. Taking these symptoms 
together, scarcely any pathological 
condition except one could be thought 
of, viz. : tubal pregnancy ^ the tube al- 
ready having ruptured. An operation 
for its removal was proposed, but she 
declined to have it done, unless the 
above symptoms should arise again. 
She grew somewhat better for a week 
or two, and was able to walk about 
her room, but was again attacked 
with the same symptoms, and was 
brought to me, a distance of fifteen 
miles, for treatment. The section 
was made on September 28th. On 
opening the abdomen, blood w**lled 
up in the incision and the neoplasm 
was found bound down by many adhes- 
ions. The foetus and placenta was still 
imprisoned in the tube, and a rupture 
had taken place through which I 



Digitized by 



Google 



262 



JAMES A. GOGGANS. 



could pass my three fingers. This 
mass was tied off close to the uterus, 
and the lisemonhage from the bottom 
of the pelvis controlled by the free 
use of hot water and iodoform gauze 
packing. 

I believe this to be a disease 
of far more frequent occurrence 
than it is generally supposed to be, 
and I wish to refer again briefly to 
the symptoms which will usually 
present thf mselves in a case of extra- 
uterine pregnancy. 

I shall not attempt to describe to 
you the symptoms of all of the gen- 
€1 ally recognized vaiieties of ectopic 
gestation, and will content myself by 
telling you that I believe with Mr. 
Alban Doran and Mr. Tait, that the 
original seat of all foetal cysts is the 
tube. We must remember that the 
symptoms of ordinary uterine preg- 
nancy are not always constant, neither 
are they constant in extra- uterine 
pregnancy. Menstruation at fii-st 
usually disappears and then returns, 
accompanied by the expulsion of a 
decidual membrane. Beside this, we 
may have the ordinary symptoms of 
uterine pregnacy, including the en- 
largement of the uterus. 

The diagnosis, however is based 
mainly upon the presence of a soft 
fluctuating tumor lying one side of, or 
behind, the uterus, which grows grad- 
ually and is more or less fixed and 
painful on pressure. Finally, rupture 
of the sac occurs, accompanied by ex- 
treme ansemia and severe pain, and in 
many cases death soon follows. 

One other point to which I wish to 
call your attention especially is the 
fluctuation of which I have already 
spoken in the cysts of extra-uterine 



pregnancy. Fluctuation cannot ex- 
ist as a symptom in these cysts in 
cases where rupture has already taken 
place. And in the case of the woman 
from whom I renAoved this specimen 
fluctuation was not present. The 
contents of the cyst had already 
escaped into the abdominal cavity; 
hence the tumor was solid, irregular, 
fixed and painful. 

The cetiology of the disease is still 
very obscure, and will certainly re- 
main so until the physiology of im- 
pregnation is better understood. 

The prognosis is very grave, so 
much so that we are justifiable in re- 
garding extra uterine pregnancy as a 
most deadly disease. As to treat- 
ment, when left to nature, the out- 
come is very uncertain. Three- 
fourths of all cases die, and most of 
them from rupture of the cyst. The 
blood may be discharged through the 
tube into the abdominal cavity, 
known as tubal abortion, or the tube 
may be ruptured so that the blood 
may be discharged directly into the 
abdominal cavity or into the broad 
ligament. However this may be, 
death takes place from ansemia or 
peritonitis, but the cause of such 
peritonitis is unknown. From what 
I have said regarding prognosis, you 
will percieve that the treatment of 
all forms of ectopic gestation consists 
in removing the neoplasm by ab- 
dominal section as early as possible 
after the diagnosis is made. 

Much has been said about treating 
this disease by injecting morphine 
into the sac, and about destroying 
the life of the foetus with electricity. 
I must say that I regard those meas- 
ures as unsurgical and fraught with 



Digitized by 



Google 



PUERPERAL FEVER. 



268 



much danger. Only eight or ten 
cases of extra-uterine pregnancy have 
been carried to full terra with satis- 
factory results to both the mother 
and child, so the chances for such a 
happy result are so slender that I ad- 
vise such patients to have the whole 
mass removed just as soon as the 
diagnosis is made certain. Espec- 
ially is this treatment indicated dur- 
ing the firsr three months and if the 
rapture has already taken place. 



After the fourth month, and up to 
the period of false labor, operation 
is not advisable. Operate in all 
cases after false labor and death of 
the child, when the amniotic fluid 
has been absoi bed, indicating that the 
circulation in the placenta has 
ceased. 

Under any circumstances, I would 
advise operation when the life of the 
mother is in danger. 



EDITORIAL. 



Holmes and Puerperal Fever. 



^ Among the honors which are on 
«very liand paid to Dr. Holmes for 
his talents and success, as a poet, wit 
and teacher, we must not forget to 
emphasize the very signal service 
which he rendered to our profession 
and to humanity by his early com- 
prehension of the manner in which 
the infection of puerperal fever is 
<;onveyed, and for his masterly exposi- 
tion of the infectious nature of this 
•disorder and of the means which 
must be taken to avoid carrying it to 
our patients. 

It is now fifty-one years since 
Holmes published his work on *'The 
Contagiousness of Puerperal Fever," 
which was republished in full in this 
journal in June, 1893, soon after our 
venerable friend had received such a 
flattering tribute from the American 
Gynaecological Society at the dinner 
given to that body by another distin- 



guished scholar and man of letters, its 
president, Dr. Theophilus Parvin. 

A great many of the profession 
were then surprised to find that the 
brilliant intuition, laborious collection 
of evidence and masterful exposition 
of this subject by Dr. Holmes ante- 
dated by several years the discoveries 
and publications of Semmelweiss, for 
which the latter, although he suflf»^red 
obloquy in his life time, has received 
abundant honors of late years, and 
for which a monument is now being 
raised to him by international sub- 
scription. There was little discov- 
ered or taught by Semmelweiss which 
he could not have learned by a pe- 
rusal of the pamphlet of Holmes, for 
which the latter also was blamed and 
derided. 

At a time when it was in good 
form for celebrated professors of 
obstetrics, after attending an autopsy 



Digitized by 



Google 



264 



EDITORIAL. 



on a case of puerperal fever, to go to 
lecture, to their students with the 
fresh specimens iu their pockets ; and 
then to attend patients in delivery 
without washing their hands(l), it re- 
quired no small courage for a young 
man to denounce such practices as 
they deserve in these eloquent and 
pathetic words : 

"I have no wish to express any 
harsh feeling with regard to the pain- 
ful subject that has come before us. 
If there are any so far excited by the 
story of these dreadful events, that 
they ask for some word of indignant 
remonstrance to show that science 
does not turn the hearts of its follow- 
ers into ice or stone, let me remind 
th'^m that such words have been 
uttered by those who speak with an 
authority I could not claim. It is as 
a lesson rather than as a reproach 
that I call up the memory of their 
irreparable errora and wrongs. No 
tongue can tell the heartbreaking 
calamity they have caused ; they 
have closed the eyes just opened upon 
a new world of love and happiness ; 
they have bowed the strength of man- 
hood into the dust; they have cast 
the helplessness of infancy into the 
stranger's arms, or bequeathed itj 
with less cruelty, the death of its 
dying parent. There is no tone deep 
enough for regret, and no voice loud 
enough for warning. The woman 
about to become a mother, or with 
her new-born infant upon her bosom, 
should be the object of trembling care 
and sympathy wherever she bears her 
tender burden, or stretches her aching 
limbs. The very outcast of the 
streets has pity, upon her sister in 
degradation when the seal of promised 



maternity is impressed upon her.. 
The remorseless vengeance of the- 
law, brought upon its victim by a 
machinery as sure as destiny, is ar- 
rested in its fall at a word whicb 
reveals her transient claim for mercy. 
The solemn prayer of the liturgjr 
singles out her sorrows from the mul- 
tiplied trials of life, to plead for her 
in the hour of peril. God forbid that 
any member of the profession to 
which she trusts her life, doubly 
precious at that eventful period^ 
should hazard it negligently unad- 
visedly, or selfishly." (2). 

(1) Annals op Gynaecology ani> 

PuEDCATRY. Vol. 6, p. 528. 

(2) Loc. cit., p. 533. 

(3) Loc. cit., p. 534. 

He closes his paper with the clear 
statement that " whatever indulgence 
may be granted to those who have 
heretofore been the ignorant causes 
of so much misery, the time has come 
when the existence of a private pesti- 
lence in the sphere of a single physi- 
cian should be looked upon not as a 
misfortune but as a crime." (3). 
■ Nine years ago it was our good 
fortune and privilege to be able to 
demonstrate to our venerated teacher 
the form and shape of the infectious 
organisms whose malignant activity 
he had realized and emphasized forty- 
two years before. The writer had 
then lately returned from Europe 
deeply interested in bacteriology* 
and had published a paper on the 
Bacteria of Puerperal Inflammations* 
which referred to Dr. Holmes' early 
work. He expressed a desire to see 
the specimens and cultures of these 
organisms, and honored the writer 
with a visit which he will always 



Digitized by 



Google 



VAOINAL HYSTERECTOMY. 



265^ 



treasure in memory as one of the 
felicitous occasion of bis life. 

Years had not blunted tbe vision or 
lessened tbe interest of tbe autbor of 
the ^^Contagiousness of Puerperal 
Fever," nor bad they dulled tbe wit 
or checked the eloquence of the 
"Autocrat of the Breakfast Table." 
In him the eager interest of tbe 
student was blended with tbe deep 
satisfaction of tbe believer whose 



faith is turned to sight, while he 
illuminate^d the medical history of 
two generations with rerainisences 
and anecdotes which sparkled with 
bis never- failing wit. 

In conclusion, then, we would insist 
that in Holmes we have to honor the 
clear thinker and powerful writer 
who first propounded and promul- 
gated the modern doctrine of the 
infectious nature of puerperal fever. 



Professor Richelot and Vaginal Hysterectomy. 



As this operation of vaginal hys- 
terectomy is now becoming d la mode^ 
a few words regarding the results and 
opinions of Professor L. G. Richelot, 
as expressed in his new work on this 
subject, do not seem out of place ; 
and although there are a number of 
8urp;eons who condemn this operation 
without ever having performed it or 
seen it performed, it is, nevertheless, 
a subject interesting to the gynaecol- 
ogist. As to vaginal hysterectomy 
for cancer, Richelot performed the 
operation twenty-four times during 
the years 1885 to November, 1888, 
which formed his first series of cases, 
with nine deaths. Of the fifteen 
remaining cases, eight showed signs 
of metastasis at the time of operation, 
leaving only seven in which some 
hope of success might be had. Now, 
four deaths occurred in from six to 
eighteen months, one after six years, 
and two patients are living, without 
any appearance of the disease, after 
seven yeais. 

These results encouraged Richelot 



to continue tbe operation, resulting 
in a second series of cases, number- 
ing forty-four. Of these, there were 
three deaths, due to the poor condi- 
tion of the patients, occurring respec- 
tively on the fifth, eighth, and ninth 
day after operation. Another pa- 
tient died two months after opera- 
tion, on account of a too hasty oper- 
ation for repairing a urinary fistula: 
three patients could not be found, 
and lastly, two cases in which the 
diagnosis was doubtful. There re- 
main, consequently, thirty-five cases. 
The ultimate result is the most im- 
portant question, and will be now 
given. Of the thirty-five cases, ten 
bad no effect in checking the progress 
of the affection. At the operation 
it was found that the cancer had 
involved the neighboring organs, con- 
sequently the hysterectomy only 
acted as a palliative. 

The twenty five remaining cases 
of tbe second series, to which Dr. 
Richelot adds three of the first series, 
make a total of twenty-eight, whose 



Digitized by 



Google 



266 



EDITORIAL. 



survival is interesting to note. There 
were eleven relapses, and seventeen 
are still alive, without any reappear- 
ance of the disease, llehipse took 
place in from three months to five 
and a half years after the operation. 
Of the seventeen patients still alive 
without the affection, one was op- 
erated on seven years and three 
montbs ago, another six years and 
ten months, a third, four ypars and 
one month, three patients over three 
years, and three over two years ago. 
.Dr. Richelot mentions cases of long- 
continued health after hysterectomy, 
performed by Reverdin of Geneva, Ott 
of St. Petersburg, Olsliausen, Terrier, 
Bouilly. No one can dispute the fact 
of therapeutical success if the patient 
lives six full months after operation 
without reappearance of the affection, 
and Richelot concludes that cancer 
of the uterus is no worse than that 
of the breast, that it is less terrible 
than cancer of the tongue, and that 
when it attacks the uterus, vaginal 
hy terectomy is the best method of 
treatment. 

There are certainly certain acci- 
dents which may occur during the 
operation, such as perforation of the 
bladder, or tear of the rectum, but 
these accidents may be easily re- 
paired at once. If a fistula ultimately 
results in spite of everything, thesur* 
geon should wait before attempting 
to operate it. An important remark 
should here be made, namely: the 
formation of urinary fistula showing 
itself some time after the operation, 
resulting from a small eschar falling 
from the bladder. The clamps can- 
not be accused of this, as it has hap- 
pened after hysterectomy performed 



without their use and in which liga- 
tures had been employed. These 
fistui® are in no way special in hys- 
terectomy for cancer as they have 
been met with in cases of extirpation 
performed for pelvic suppurations, 
etc. Their prognosis is favorable, for 
they'nearly always heal of themselves, 
and, if not, the surgeon should wait 
before undertaking their repair. 

We now come to the important 
question of pelvic suppumtion. Dr. 
Richelot has obtained fifty-six cures 
and five deaths of the sixty-one pa- 
tients he has operated on for this 
affection. It is in these cases that 
be considers vaginal hysterectomy as 
the operation to perform and ex- 
presses himself as follows: "It al- 
lows the pelvic foci to be reached in 
their lowest parts, and to be opened 
outside of the peritoneum without 
contaminating the serous membrane." 
It permits the surgeon to come di- 
rectly on them without hunting for 
them among the many adhesions ; to 
see and radically treat them. And, 
lastly, it allows of their removal when 
possible or only their evacuation, re- 
sulting in the rapid recovery of the 
patient. 

Cases show that after hysterec- 
tomy, total ablation of the adnexa is 
not necessary. to obtain a complete 
cure in every case at least, and drain- 
age and long suppuration are done 
away with. Simple vaginal incision 
in pelvic suppuration's should not be 
compared with vaginal hysterectomy, 
for, he says, ^^ it is not sufiicient for all 
lesions and does not want to be too 
highly recommended, but it is a good 
method, temporarily or definatively, 
when it is indicated by a fluctuating 



Digitized by 



Google 



VAGINAL HYSTERECTOMY. 



267 



prominent cul-de-sac, or when the sur- 
geon cannot act radically on account 
of one thing or another, such as the 
age of the patient, doubt as to a 
bilateral lesion, lapid operation de- 
sired, acuteness of the symptoms and 
probable virulence of the pus, danger- 
ous extent and situation of the puru- 
lent collection ; and, lastly, a point on 
which 1 insist, is a recent confinement 
and the friability of the uterus." 

The ultimate results of vaginal 
hysterectomy in pelvic suppurations 
are excellent in all cases that could 
be followed ; cure was perfect and 
durable, even when the fundus uteri 
could not be removed. 

Dr. Richelot classes among pelvic 
suppuration a form in which there is 
never any pus, but in which, after 
several inflammatory attacks and 
long suflFering, the pelvis is filled with 
thick masses, in the midst of which 
the uterus is gluded as if in putty. 
Dr. Kichelot thus expresses himself: 
" It u a real f.brous process^ invading 
the pelvic cavity." In seven cases 
where vaginal hysterectomy was per- 
formed under these conditions, Kich- 
elot obtained seven cures,and he says, 
with good reason : ** Extensive sup- 
purations and complicated adhesions 
are the bad point of laparotomy and 
the triumph of vaginal hysterectomy, 
but in order to know this, the surgeon 
must have had complete experience, 
that is to say, must have practised 
both methods and to be able to com- 
pare them by experience rather than 
by his imagination." 

In cases of pyo-salpingitis that 
can be enucleated. Dr. Richelot still 
prefers hysterectomy to laparotomy, 
for by the first named method soiling 



the peritoneum is surely avoided. If 
the lesions are non-suppurating par- 
enchymatous, hydropic, etc., varieties, 
which can also be enucleated so that 
the danger of infecting the periton- 
eum is reduced to a minimum, it 
would appear that laparotomy and 
hyfcterectomy are equal in merit. 
Dr. Richelot, however, is in favor of 
the vaginal operation, for he says : 
"The ultimate results are more 
constantly good, the cures more 
plainly visible," 

There is a considerable argument 
in favor of this favorite operation, 
since he was led to perform twenty 
secondary vaginal h3sterectomies, 
that is to siiy, after a laparotomy, 
because the uterus remained in a dis- 
eased condition, although the lesions 
found did not always account for the 
persistent hemorrhages. Now, with 
the exception of a morphinomaniac, 
whose case cannot serve as an argu- 
ment, the removal of the uterus has 
always brought about a complete 
cure. This is a clinical fact, whose 
importance it is impossible to deny. 

What are the indications for lapar- 
otomy in inflammatory lesionc? '• It 
is obligatory if the bilateral lesion is 
not demonstrated and if the woman is 
young." In this case, if there be a 
shadow of doubt, preservation should 
be tried; an exploratory incision of 
Douglas cul-de-sac does not afford a 
means of recognizing the exact con- 
dition of the ovarian tissue of the per- 
meability of the tube. " Let us then 
do lapartomy" says Richelot, which 
is an operation suited to this case 
and allows us to seize the most favor- 
able chances and to surely avoid use- 
less sacrifices." And he adds : "Doubt 



Digitized by 



Google 



568 



EDITORIAL. 



:a8 to the bilateral lesion does not 
exist as often as the adversaries of 
hysterectomy hold. 

As to hematosalpinx, which by 
rupture, become pelvic hsematocele, 



Dr. Richelot simply says : " In this 
case I cannot say that my preference 
is very considerable ; all my lapar- 
otomies for large hsdmatic tumors 
have given me good results." 



The Special Action of Permanganate of Potassium on the Gonococcus. 



In a recent thesis, upheld before 
the Faculty of Medicine of Paris, Dr. 
Lemoyne de Martigny discusses the 
treatment of gonorrhoea by irrigations 
with permag»nate of potassium, and 
Also gives an interesting chapter on 
the action of this antiseptic on Neis- 
ser's coccus. At a lower proportion 
than 1 to 1000, permanganate of 
potassium is endowed with only a 
very weak bactericide action. How- 
ever, the gonococcus is seen to disap- 
pear from the urethral discharge after 
.two or three irrigations of a 1 in 3000 
solution of the drug and cure has 
been obtained by a 1 in 2000 solution. 
Much more powerful antiseptics do 
not eradicate the gonococcus except- 
ing by a much longer continued treat- 
ment. On the other hand, if the dose 
of permanganate is increased, its anti- 
septic action becomes more intense, 
but instead of witnessing its good 
effects increase in proportion, the gon- 
ococcus on the contrary is found to 
proliferate, and the same is true if the 
irrigations are practiced too frequent- 
ly. This fact tends to show that per- 
manganate of potassium does not act 
as an antiseptic in the treatment of 
gonorrhoea. Now, how do the ordi- 
nary antiseptics act? By removing 
4;he gonococci found on the surface of 



the urethral mucous membrane. 
Their action is only present at the 
time of the irrigation, and, what is 
more, if the irrigations produce a 
reaction of the mucous membrane, 
this reaction is rather favorable for 
the development of the gonococcus. 
It is on this principle that is based 
the revealing reaction of tbe. gonococ- 
cus by nitrate of silver. After a time, 
the mucous membrane becomes accus- 
tomed to the irrigations, and the often 
repeated destruction of each succes- 
sive issue brings about an exhaustion 
of the gonococci situated deep down 
in the mucous membrane. This is 
not the case when well regulated 
doses of permanganate are employed, 
because the gonococci disappear after 
the first few irrigations; although 
when the physician is dealing with 
other than specific infections, the ac- 
tion of the permanganate is notably 
inferior to other antiseptics, especially 
corrosive sublimate and nitiate of 
silver. Is this then a special action 
exercised by the permanganate on 
the gonococcus to the exclusion of 
other microbes? This opinion can be 
upheld. Every day we witness the 
development of certain organisms on 
media unfavorable for other kinds, 
and certain drugs are more harmful 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



269 



to certain varieties of organisms than 
to others. But, in the question under 
consideration, Dr. de Martigny does 
not believe it is the case, and the cura- 
tive action of the permanganate 
should be attributed to a special ac- 
tion that it exercises on the urethral 
mucous membrane. Permanganate of 
potajisium, which is not absorbed and 
<ioes not act on the deep layers of 
the mucous membrane, determines, 
however, an oedematous swelling of 
the entire urethra and a serous dis- 
-charge of variable duration. Now, 
this serous media on the mucous sur. 
face of the urethra and even in the 
interior of the walls of the canal, is 



most unfavorable to the reproduction 
of the organism. By irrigations, the 
gonococci are washed away from the 
surface of the urethra ; by the reaction 
produced by them, they can no longer 
be cultivated and proliferate to any 
degree, and the organisms which are 
situated in the depth of the tissues 
are soon expelled by the serous flux. 
It is in this manner that Dr. de 
Martigny believes that the superior 
action of permanganate of potassium 
over other antiseptics should be in- 
terpreted, and we believe that the 
same holds true in gonorrhcsal in fee 
tion of the vagina, as in that of the 
ureshra. 



SOCIETY PROCEEDINGS. 



Boston Society for Medical Observation. 



Regular meeting of the society, 
December 3, 1894. Dr. S. W. Lang- 
maid in the chair. 

Dr. Philip Coombs Knapp read 
a paper entitled, — 

"THE TREATMENT OP CHOREA, WITH 
SPECIAL REFEKENCE TO THE USE 
OP QUININE." 

This paper may be summarized as 
follows : — 

In the spring of 1893 Dr. H. C. 
Wood suggested the use of quinine 
in chorea, on the hypothesis that 
chorea ^as an affection of the spinal 
cord, due to. an impairment of the 
inhibitory functions of the cord, and 
that quinine, as he showed by experi- 
ment, stimulated the inhibitory cen- 
4;res. Acting on this hypothesis, 
quinine was given, in doses of six to 



twenty-four grains daily, in eight 
cases of chorea. In three, cases there 
was recovery at the end of one, three, 
and ten weeks respectively ; in the 
other eases quinine did no good, and 
was abandoned for other forms of 
treatment. In all cases rest, diet,, 
hydrotherapy, etc., were advised, but 
no other drugs were given. Dr. 
Wood's hypothesis that chorea was 
an affection of the cord was not 
accepted, the evidence all pointing 
to a cerebral, and possibly a microbic 
origin, although in some cases the 
cord may also be involved. 

The hypothetical reasons for using 
quinine seem untenable, and practical 
experience shows little benefit from 
it. The best methods of treatment 
consist of rest, whidi can seldom be 
made absolute, a liberal but simple 
diet, in which meat plays but a small 



Digitized by 



Google 



270 



SOCIETY PROCEEDINGS. 



part, and cold salt baths. Arsenic is 
of distinct, altljou<i;h secondary value. 
Sedatives are sometimes beneficial. 

Dr. Putnam said that he had had 
no experience in the use of quinine 
for chorea, but believed in the hygi- 
enic treatment combined with ai*senic. 
He was satisfied that arsenic was 
beneficial. 

Dr. MoKTON Prince remarked 
that, wliile he had had no experience 
in the treatment of chorea by quinine, 
he had no doubt that Dr. Knapp^s 
conclusions were correct. Reasoning 
a priori^ he should have little faith in 
it. He thought there were few dis- 
eases in which it was so diiKcult to 
judge the effect of treatment as 
chorea. He believed chorea varied 
as did other diseases — some cases 
were long, some were short. Judging 
from the apparent effect upon pa- 
tients as they came to the clinic, he 
believed arsenic was beneficial. Dr. 
Prince then pointed out the fallacy 
of drawing conclusions from a limited 
number of cases. He regarded the 
doctrine of chances an important 
factor, and thought that conclusions 
as to treatment could only be drawn 
from a very large number of cases. 
In regard to the pathology of chorea, 
Dn Prince said that if obliged to 
make a guess, he should guess that it 
was due to some form of toxine poi- 
soning. Dr. Prince concluded his 
remarks by saying that most of the 
cases he had seen were hospital cases, 



and said he should like to ask th6 
general practitioners if they saw 
many cases in private practice, or 
whether it is a disease which is 
peculiar to the poor. 

Dr. H AHOLD Williams, in reply 
to Dr. Princess question, said that in 
his experience chwea was by no 
means a disease of poorer childi'en. 
In his summer practice at Nantucket, 
many cases of chorea came under bis 
care, and all children in the better 
class of life; whereas, in the past six 
weeks of his service at the children's 
room at the Boston Dispensary, out of 
six hundred new cases, there had been 
no case of chorea. Dr. Williams 
regarded the anaemia usually associ- 
ated with the disease as the result of 
the malady rather than the cause. 
He was glad to find that the writer's 
experience coincided with his own. 
He had no experience in the treats 
ment by quinia, but regarded rest in 
bed, with a cheerful and pleasant 
room, as the nne qua non of treat- 
ment in these cases. Children with 
chorea are generally fractious, irrita- 
ble, excitable and easily frightened, 
and he had come to rely upon sooth- 
ing the mind by diversion and enter- 
tainment, with physical rest in bed, 
as the most effective forms of treat- 
ment. Under such regimen, his case 
had done extremely well without 
medication, but it was, of course, hard 
to say how much of the improvement 
was due to the sea air. 



Meeting of the Philadelphia Obstetrical Society, Jan. 13, 1894. 



President Dr. Barton Cooke Hirst 
in the chair. 

BEMAHKS ON A SERIES OP CASES OP 
EXTHA-Ul BRINK PUEONA^Oy, BY 
DR. CHARLES P. NOBLE. 

The author's experience embraces 



twenty-five cases, fourteen of which 
were seen within one year. All the 
cases were instances of tubal gee- 
tation. In four cases the tube was 
unruptured; in twenty rupture bad 
taken place, and in one tubal aborti<m 
was under way. 



Digitized by 



Google - 



SOCIETY PROCEEDINGS. 



271 



In nineteen cases the diagnosis of 
ectopic pregnancy was made (includ- 
ing two in which it was strongly sus- 
pected) before the operation. In six 
cases the trouble was supposed to be 
some other morbid condition of the 
appendages. Two of the cases (one 
strongly suspected) were instances 
of unruptured tubal pregnancy. In 
seventeen (two strongly suspected) 
rupture had taken place. These 
inchided the case of tubal abortion. 
In two cases the diagnosis bad been 
abandoned on account of the absence 
of symptoms. Of the cases of rup- 
tured tubal pregnancy with h»mor- 
rhage, the diagnosis was made in 
seventeen. In tliree it was not even 
suspected, and in two it was ruled 
out on account of the absence of 
symptoms. 

It has been Keld that the diagnosis 
before rupture can not be made, but 
the author's experience was that the 
<;ases in which rupture had not taken 
place were as easily diagnosed as those 
in which rupture had occurred. In 
the large percentage of cases the 
symptoms and physical signs are so 
-characteristic that the diagnosis is as 
-certain as in any other condition. 

In the twenty five cases there were 
four deaths, all desperately ill at the 
time of operation. The fii-st case 
was pregnant four months, and the 
abdomen was filled with blood. She 
•died in hyperexia, in thirty-six hours. 
The conditions in the second case 
were similar, except that the preg- 
nancy was not so far advanced. The 
third case was moribund at the time 
of operation, and the abdomen was 
full of blood. The fourth patient had 
general septicaemia, and at the time 
of operation the temperature was 
106**. The hsematocele had sup- 
purated, and the left broad ligament 
and tube were distinctly gangrenous. 
She died at the end of a week of 
general septicsomia. 

Operation should be done as soon 
as the diagnosis is made, and the 



principles which apply to pelvic sur- 
gery are equally applicable to cases 
of ectopic pregnancy. Where opera- 
tion is done with the patient in ex- 
tremis, rapidity in operation is essen- 
tial to success. The opposite ap- 
pendage should not be removed unless 
it is a menace to life. The al)doraea 
should be left full of water, to save 
the time required to remove it and to 
help fill the blood-vessels. Drainage 
should always be used in this sort of 
cases. As these cases die of acute 
amemia, he suggested the use of 
transfusion. 

DISCUSSION. 

Dr. J. Price. — This is so impor- 
tant a subject that I should like to 
make a few remarks. We all know 
that the profession have been edu- 
cated to recognize this malady, and it 
is one of the most frightful and hor- 
rifying troubles that we have to deal 
with aside from appendicitis, and I 
scarcely know of any trouble respon- 
sible for more deaths than ectopic 
pregnancy. Much has been said and 
much written, but much remains con- 
fusing. We all know that this work 
began in America, Ban nam of Vir- 
ginia doing the first operations in 
17JiO and 1799. 

Dr. Noble has taken rather peculiar 
ground from time to time. For in- 
stance, a few years ago, he said posi- 
tively in the Pathoh^gical Society 
that unless the foetus were found, it 
was not a case of ectopic pregnancy. 
That is on record. Dr. Kormad, in 
his thirty-five cases in the coroner's 
office, found a very small number of 
foetuses — less than twenty five per 
cent. It is the exception to find the 
foetus. 

Dr. Noble alludes to fiv<^ cases 
without symptoms, and with an enor- 
mous quantity of blood in the perito- 
neal cavity. Surely the examination 
in those cases was careless, or the 
observer has not given the subject 



Digitized by 



Google 



272 



SOCIETY PROCEEDINGS. 



sufficient attention and study to rec- 
ognize symptoms so marked and so 
common, and always present: the 
inaptitude to conception, prolonged 
sterility, the absence of one or two 
periods, or a delayed period. There 
are some symptoms which are charac- 
teristic; for instance, the cramp-like 
pains which are always present where 
rupture occurs. To-day I asked a 
patient who has borne five or six 
children and has suffered all sort of 
pain incident to child-birth. I asked 
if she had ever experienced pain of 
that character in her labor, and she 
said that she had not. She has had 
several ruptures. She missed May, 
June and July. Rupture took place 
in August, and recurring attacks have 
since taken place. She now becomes 
greatly emaciated, suffering greatly 
and with a huge mass on the left side 
posteriorly, with the uterus pushed 
up. All over the country we now find 
physicians recognizing this trouble, 
and nothing c<aiid be more gratifying 
than the fact that we have shared in 
this education that has gone on all 
over the country, — educating the gen- 
eral practitionar to recognize these 
important cases. 

The mortality of four cases in 
twenty five is large, and the fact that 
some of them died one week after 
operation would rather indicate that 
the toilet or the drainage was not 
complete. The practice of sponging 
to remove the blood in these ea^es is 
bad. I scarcely know of anything 
that will destroy life quicker than 
the pponge applied in these cases, and 
pushed into all the corners and crevices 
of the peritoneal cavity. 

It is only exceptionally that you 
find an absence of objective signs, 
and that only in very acute cases. 
You may be asked to see a patient 
where the hsBmorrhage takes place at 
night. You find the patient exsan- 
guinated, the uterus in position, and 
no boggy mass. You have nothing 
to guide you except the history of the 



case and the characteristic symptoms. 
I have had only two such ca>e8 in 
103 ectopic pregnancies, and both 
were in the wives of doctors. In 
these cases — plainly stated to be 
extra-uterine — we all agreed that 
section should be done. An enor- 
mous quantity of blood was found in 
both cases, and both women made 
speedy recoveries. In these cases 
there is no time to be lost with trans- 
fusion, but the use of a saline solu- 
tion thrown into the cellular tissues 
is sometimes of service. I have done 
that with good results. 

With regard to the removal of the 
placenta, this is still a disputed 
point. One or two success^ful re- 
movals of the necrotic placenta in 
chronic cases emboldens a class of 
men to attempt the removal of the 
placenta in all cases. The man that 
attempts to remove a living and 
growing placenta from the wrong side 
of the uterus will recognize a charac- 
teristic haemorrhage which he has 
never before witnessed. A few 
months ago an old physician of 
Georgia told me of a case where the 
woman had gone through spurious 
labor and was dying of over-disten- 
tion and exhaustion. He recognized 
extra-uterine pregnancy and opened 
the abdomen and delivered the child 
and attempted to remove the plac<*nta. 
At once the haemorrhage was alarm- 
ing. He simply delivered the pla- 
centa and uterus and placed a kceberce 
and removed the uterus and the 
patient recovered. That is an excep- 
tional case, for only rarely do we find 
the placental attachment limited to 
the uterus. It may extend from iliac 
fossa to iliac fossa and involve both 
large and small bowel. The employ- 
ment of other methods, as hermeti- 
cally sealing the sac, or filling it 
with vinegar, is better. 

I am glad that in at least one 
variety of cases. Dr. Noble has 
reached the point of minimizing the 
time, exposure and other things which 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



278 



in a slow operation predispose to 
mortality. 

Dr. Charles P. Noble. — I am 
quite surprised to learn that I ever 
said that extra-uterine pregnancy was 
not extra-uterine pregnancy unless 
the foetus was found. I have no 
recollection of such a statement. If 
I believed that I should have to throw 
out most of the cases reported to- 
night, as the foetus was found in only 
four or five of the twenty-five cases. 

I have no reason to change what 
I said about some cases having no 
symptoms. I observed the cases 
carefully. Two were in the hospital 
for a week, and in neither had I the 
remotest idea that they had extra- 
uterine pregnancy until I opened the 
abdomen. While I agree that in 
general the diagnosis is very clear, I 
am quite certain that in a certain 
percentage of cases symptoms are not 
present that would warrant a diagnosis. 

My paper dealt simply with extra 
uterine pregnancy in the early mouths, 
and did not cover the late cases dis- 
cussed by Dr. Price. 



THE USE OP OPIUM IN SURGICAL 
PEAOTIOE. BY DR. JOSEPH PKICB. 

The author referred to the great 
harm wrought by the indiscriminate 
use of preparations of opium given 
simply for the relief of pain, ihis 
he attributed largely to errors in 
teaching. It is in surgery and in dis- 
eases of the nervous system that the 
use of opium does the most harm. 
In the management of surgical cases 
the convalescence is moi*e satisfactory 
and speedy when opium is not used. 
He felt certain that the use of opium 
was responsible for much of the mor- 
tality in abdominal surgery. He 
never used it except in cases of 
malignant disease. 

In order to illustrate the successful 
management of surgical cases without 
opium he reported the details of four 
cases of angiy acute peritonitis re- 
cently operated on. In these cases 
the treatment consisted of section, 
irrigation and drainage, followed by 
rest and quiet without opium, the 
result being prompt and complete 
recovery. 

Adjourned. 



New York Academy of Medicine, Section in Obstetrics and Gynaecology, 
Meeting of December 27, 1894. 



Malcolm McLean, M. D., chair- 
man. 

DISCUSSION ON DB. P. A. HARRIS'S 
PAPKR, STUDIES IN PELVES, PEL- 
VIMETEBS, AND PELVIMETRY. 

Dr. Simon Marx. — I think we 
should all be very ihankful to Dr. 
Harris for his vei-y elaborate paper. 
I have nothing new to offer, feeling 
that I agree almost entirely with the 
speaker. To start at the beginning, 
1 belieye the statement made as to 
the individuality of the pelvimeters 
is a perfectly correct one. I believe 



the poorest pelvimeter we have to- 
day is the French, — the Collin, not 
the combined one (or Robert and Col- 
lin). It will do very well in women 
with but little pediculus adiposis, 
but in one who is at all extreme in 
these directions it is almost im|^>ossi- 
ble to measure the crest and other 
diameters with it. The second best 
one which I have seen is the reader's, 
but the fatal objection which I have 
to it is its expense. However, I un- 
derstand that it is now sold somewhat 
cheaper than it has been, but it is 
still too expensive. So that in spite 



Digitized by 



Google 



274 



SOCIETY PROCEEDINGS. 



of its good quality and the use which 
■can be made of it, I still prefer the 
instrunoent of Dr. CoUyer, because 
it is so very cheap and so very light, 
and with it you can measure any pel- 
vis you choose. 

Dr. Harris took fully the config- 
uration of the pelvis into considera- 
tion, and also the size of the foetal 
bead. I do not believe that meas- 
urements, either of them alone and 
«eparately, will do us any good. Each 
individual case and each pelvis has to 
be considered. Whilst the external 
measurements will do us a great deal 
of good, still we know that in certain 
women with noriral pelves, but bear- 
ing a large child, it is impossible to 
get the head through, therefore mak- 
ing the case one of relative contrac- 
tion of the pelvis. However, as I 
said before, since external measure- 
ments are very useful, the pelvis of 
every woman should be measured. 
No one has a right to practice modern 
obstetrics who does not do so. 

Regaiding internal measurements, 
I have seldom been able by intro- 
■ducing the index or middle finger 
into the vagina of a pregnant woman 
to feel the promontory. But if in an 
individual case I could not reach the 
promontory I have felt that the pel- 
vis was normal, especially if the 
•external measurements were normal. 
But if in any case there is observed 
to be a disparity between the head 
and the pelvis, there is only one safe 
«node of measuring the pelvis, that is, 
by introduction of the hand, and 
measuring the true conjugate, — not 
•estimating it, but measuring it. Cer- 
tainly you can estimate the size of 
the child's h*^ad. 

I believe the reason why physicians 
•do not use the pelvimeters more fre- 
quently is the fact of their faulty 
construction and the old way in which 
students were taught. They were 
dimply told that there were instru- 
ments of this kind, but were not 
shown in a systematic way how to 



examine the pelvis. Only a short 
time ago, while I was speaking of 
pelvimetry at the post-graduate school, 
one of the students, on seeing a 
pelvimeter, wanted to know what it 
was. He had never seen the instru- 
ment before, and never had occasion 
to use it. 

Dr. Herman L. Collyer. — I 
have been interested in the paper. 
It shows a great deal of hard and 
industrious labor — labor in the dry 
sense of the word. But it brings out 
facts which have been sadly neglected 
in the past. In fact pelvimetry is 
almost in its infancy. In my early 
college days the professor in obstet- 
rics would bring out Baudelocque's 
pelvimeter and say, " Here, gentle- 
men, is an instrument which is so 
wide in its expanse that it requires a 
case of its own to carry it along in 
the streets. It is a veiT good instru- 
ment for measurment, but you must 
depend upon your fingers." 

Now a days instruments are made 
somewhat more handy, but still the 
instrument makers have a somewhat 
mistaken idea of the doctors' pocket- 
book. They think their pocket-book 
is endless, and that an instrument, no 
matter how small or how cheaply it 
can be gotten up, must cost a certain 
price. To charge, as they do, any- 
where from five to ten dollars for a 
pelvimeter is absurd. That is one 
object I had in devising one shown 
here to-night, because of its cheap- 
ness. I know it can be made even 
cheaper than the present price, but I 
cannot get an instrument maker to 
sell ii for less. 

Now I contend that every man who 
attends a confinement should have 
some idea as to the dimensions of the 
pelvis, otherwise he is jeopardizing 
that patient's life. He may have an 
obfecure idea of contraction from 
measurement with the index finger, 
but if he undertakes to record the 
case it is a question whether the con- 
traction is to the extent that he says. 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



276 



With a recording pelvimeter he can 
put it down in black and white a« 
BO many inches or so many centi- 
metres. 

^ Pelves differ in shape and dimen- 
sions, just as do hpads. In Polish 
Jewesses the pelvis . is frequently 
flattened. There is a great deviation 
in their pelves. In Italians, who 
have to carry heavy weights, we 
observe that the pelvis is flattened 
antero-posteriorly and widened later- 
ally. Now, those dimensions are 
exceedingly dlflScult to get. So far 
as external measurement goes, it 
^ves us an idea of whether there is 
internal diminution in measurement. 
These measurements are very diffi- 
cult to get. But by this very in- 
strument, as I mentioned in ra letter 
to Dr. Harris, you can make such 
measurements. You can insert your 
finger into the pelvis. In the major- 
ity of all cases during pregnancy, 
whether at full term or before, aiid 
having got to the promontory, you 
can press the bar of the instrument 
against the symphysis pubes and the 
record on the instrument will tell you 
the exact distance in a straight line 
across the pelvis . antero-posteriorly. 
Now the tranverse diameter is meas- 
ured in a similar manner, simply 
changing the direction of the bar of 
the pelvimeter to the lateral wall of 
the pelvis at the brim. You have 
now one side of a triangle, the base 
of which is known, and by a little 
mathematics you can get the third 
side, which will give you the lateral 
or transverse diameter of the pelvis. 
We have cases where there is no 
contraction, the pelvis being roomy 
and normal, but the head of the 
child is in excess of the normal head, 
and that child has either to be 
sacrificed or symphyseotomy has to 
be performed, or possibly csBsarian 
section. Now at this date the 
preference is for symphseotomy. 
We have come down to that point 
where by modern devices we can 



control sepsis and haemorrhage, and 
we leave csesarian section to cases in 
which symphyseotomy will not 
enable us to extract the child. 

The device Dr. Harris showed for 
lacing the pelvis is unique. It is a 
very good abdominal binder. But I 
have found in symphyseotomy that 
you can take a fairly broad piece of 
webbing, put a buckle on it, and 
buckle it around the pelvis above the- 
trochanters as tight as necessary and 
leave it there, and it will answer th& 
purpose perfectly well. It is out of 
the line of the incision, and out of 
danger of becoming soiled. It holds 
the pelvis together as firmly as a 
plaster of paris bandage.. 

The paper is full of points for 
discussion, but the time is too short. 
I am exceedingly glad to have heard 
it, and think the author is deserving 
of great credit. 

Dr. E. A. Tucker. — I am very 
glad to have heard this paper, but I 
think, as Dr. CoUyer has said, that it 
is one which is veiy hard to discuss. 
One should have time to reflect upon 
the statistics, and compare them with 
his own observations. Such a paper, 
of course, is deserving of the highest 
credit, for it is evident the author haa 
given much time to bringing out the 
many points. Simply the array of 
figures shown would repay one for 
attending the meeting, not to speak 
of the display of various pelvimeters- 
and the demonstration of their re- 
spective merits. As soon as one 
begins the study of the subject at 
all, he wishes to know about ther 
merits and demerits of the different 
pelvimeters. 

The statement that one who pro- 
poses to attend a woman in labor 
ought to be able to perform pel- 
vimetry with reasonable accuracy 
seems self-evident. Yet we know 
such a statement has to be made over 
and over again in order to induce 
action on the part of general practi- 
tioners. It is. a subject which has 



Digitized by 



Google 



276 



SOCIETY PROCEEDINGS. 



been sadly neglected in the past. 
I tliink it is coming a little more to 
the front now. Every day we meet 
with evidence of past neglect. I 
think it would be just as reasona- 
ble to expect to detect some chest 
disease without examination of the 
thorax as to detect a difficult partuil- 
tion without measuring the pelvis. 
Cased for confinement are constantly 
sent us with a diHgnosis which is 
absurd. We know this on examina- 
tion, but not simply by looking at 
the patient, which is probably all 
that some do. On reducing the 
physician *8 statements down to fig- 
ure's we at once see inaccumcy. 

An illustrative case was admitted 
to the Sloane Hospital today, the 
patient having been sent by a physi- 
cian of good reputation, but who 
evidently was deficient in pelvimetry. 
He evidently had not examined the 
patient or, if he had, it was not done 
properly. 

Examination of the inside of the 
pelvis ought to be insisted upon as 
well as external examination. While 
the latter is important, I think inter- 
nal measurement must be the final 
test, and it should be made under 
light chlorof(»rm ansethesia. I intro- 
duce my hand in cases where external 
measurement has shown departure 
from the normal, and feel over the 
inside of the pelvis thoroughly. 

The question of measuring the 
child is also one of extreme interest, 
and also full of diflBculties. A cer- 
tain amount of information can be 
obtained through the abdominal walls, 
especially where the child is high, 
the head above the brim, the position 
being determined by external manip- 
ulation or by touch through the 
vagina. Of course there is a good 
deal of room for error, but I think 
you can come fairly near estimating 
the size of the child's head; at 
least in a number of cases in which 
I have tried it the result showed not 
more than reasonable variation, say 



half a centimetre. That at least 
gives one some idea. Just grasping 
the head between the hands is a 
fair guide to one who is at all famil- 
iar with the dimensians of the head. 
Again, by vaginal examination, with 
the cervix a little dilated, I have been 
able a number of times to detect by 
touch the degree of ossification of 
the cranial bones by the readiness 
with which they yield under the 
finger. 

Dr. Harris. — The gentlemen 
seem not to have left much for me to 
say in conclusion. *I must apologize 
for the length of my paper, as doubt- 
less it has, in that regard, tested your 
Ktience. I regret that Dr. Marx has 
en compelled to go, as I wi:ih to 
say a word or two in reply to his 
remarks. 

I understand he prefers the instru- 
ment of Dr. Collyer because it out- 
spans my instrument, is the lighter 
and is cheap. I do not wish to make 
a microscopical comparison between 
Dr. Collyer's instrument and my own, 
for such a comparison would be re- 
quired to determine the relative 
capabilities of these two instruments. 
Both span amply, with preference 
probably in favor of my pelvimeter. 
My instrument, as stated in my paper, 
weighs one hundred and ninety-seven 
grams ; Dr. Collyer's two hundred 
and twenty-nine grams. Both, of 
course, are inside-pocket instruments. 
My instrument occupies a rectangu- 
lar space of twenty-six cubic inches ; 
Dr. Col Iyer's torty-one 'cubic inches. 
As to cost, I have been told that my 
instrument may be made as cheaply 
as the Collyer instrument. Steel is 
the metal of which such instruments 
of precision should be made. If my 
instrument is also made in aluminum, 
it is very light, but it should be made 
a little thicker than the aluminum 
one shown tonight. It should weigh 
about one hundred and fifteen or one 
hundred and twenty grams, instead 
of ninety-seven grams, which is the 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



277 



weight of the one you have seen. I 
would not recommend anyone to buy 
the ahiminum instrument until the 
blades have been made heavier, lest 
they should become bent. I discover 
also that the instrument of Dr. CoU- 
yer is made in brass. The one I have 
was loaned and came back to me a 
little bent. The instrument I now 
have in my hand, my own instrument, 
b made of steel, and if properly tem- 
pered, it can be relied upon. It is 
lighter than brass, but of course twice 
as heavy as it would be if made of 
aluminum. 

Aside from measuring the pelvis 
and headland estimating the degree 
of ossification of the latter, one has 
to lake into account the patient's 
previous history, a point well brought 
out in the paper. 

Regarding spanning capabilities of 
Collyer's instrument and my own, 
which are the only ones in the race, 
this chart, which I failed to pass 
around, shows both of them to be 
ample. 

Respecting the pelvic bandage 
which I am now using after symphys- 
eotomy, I did not mean to dwell 
upon it this evening. In fact I did 
not intend to show the photographic 
▼iews of it which you have seen. It 
was an experiment, and I found it 
very convenient and efficient. I do 
not know whether such a one has 
been used before or not. I would 
like to ask Dr. Col Iyer for the width 
of his bandage, for that is an esse- 
tial |K>int. I think he said it passes 
around the crest. 

Dr. CoLLYBK, — It is not a ban- 
dage, really, but a si rap with a 
buckle, which holds the symphysis 
firmly together. It is made of web- 
bing that will not stretch. It is about 
two inches wide, with a buckle at- 
tached to lighten it firmly. Of course 
a muslin bandage dressing may be put 
over it. 

Dr. Habbis. — I want to make my- 
self plain on one point. I do not want 



any person to assume that I regard 
external pelvimetry as conclusive, 
although it may be conclusive in 
certain cases. I only want it known 
that I regard it as presumptive evi- 
dence. And it is very strongly pre- 
sumptive in many instances. It is 
the evidence which we reqiiire to 

frepare us for what may be coming, 
alwaj^s rely finally upon internal 
measurements, as you might well 
suppose. I should only use external 
pelvimetry to discover probable or 
possible internal deformity. The 
trouble is that cases requiring inter- 
ference are not discovered until they 
have been too much tampered with. 
I have practiced obstetrics a good 
deal myself. I presume I have de- 
livered a thousand, possibly fifteen 
hundred women, and I know that I 
have done a great denl of disagreeable 
and possibly bad work in times past, 
and I know that many are doing such 
work now. I know further that they 
will continue to do it unless they 
avail themselves of proper examina- 
tion of their patients. And I fully 
agree with Dr. Tucker, and wish to 
thank him for the emphasis which he 
has placed upon the necessity for pel- 
vic examination. As to the patients 
whom we should examine : I have 
clearly stated that in my paper. And 
as to those whom we see for the first 
time when called to the labor, we 
should proceed to examine them at 
once, if there is any indication of 
delay in the second stage. 

As a matter of fact, I know that 
fifteen to twenty-five children have 
been intentionally mutilated to effect 
delivery in the town where I live, 
in the last fifteen years. I have col- 
lected a considerable number of such 
cases, and I think the total will be 
more than twenty-five. Yet I must 
say that I have been unable to get 
the proper external pelvic measure- 
ment of more than one or two of 
these cases. 



Digitized by 



Google 



278 



REVIEW OF GYNECOLOGY. 



REVIEW OF GYNAECOLOGY. 



Osteomalacia. By Dr. L. Seelig- 

MANN. 

The author reports the case of a 
woman, aged thirty-seven, married 
fifteen years, had had seven children 
at term and five miscarringes. Pre- 
sent trouble dated from eighth gesta- 
tion seven years previously; since 
then has been almost entirely con- 
fined to bed. Conj. diag. eight cm. ; 
pelvic outlet admits only two fingpi"s. 
At term of last gestation Porro's 
operation was performed ; livinfir child 
weighing 2 kil. 410 gram. Primary 
union without temperature; stump 
came away at the end of four weeks. 
To rectify the bony deformity, a 
traction apparatus was applied to the 
lower extremities with counter frac- 
tion from the axillae five days after 
operation. Very successful result at 
the end of eight weeks; eighteen 
centimetres increase in height; the 
pains in the bones and joints; the 
swelling of the extremities had dis- 
appeared. The kyphoscoliosis and 
deformity of the ribs were almost 
entirely reduced. The pelvic outlet 
was larger, conj. diag. nine centi- 
metres. Finally the patient could 
attend to her household duties. Ac- 
cording to the author, removal of the 
ovaries is the proper treatment where 
prophylactic and medical means of 
treating osteomalacia have failed. 
He rejects the proposition of Zweifel 
to leave the ovaries and ligate the 
tubes. (^Berl, kliu. Wochen. No. 44, 
1894 ; review in British Qytuecologi- 
eal Journal^ Nov,^ 1894.) 



Puerperal Insanity. 

Properly speaking, the puerperal 
condition refers only to the junctional 
and organic modifications which take 
place in women during and after 
parturition, before the return of the 



menses, or the physiologyical estab- 
lishment of lactation. But from the 
point of view of puerperal insanity, 
this condition may be divided into 
periods of one gestation ; two, puer- 
peml condiiion proper; three, lacta- 
tion. The following statistics show 
the relative frequency of psychosis in 
each of these periods: gestation, 3.1 
in 100 ; puerperal condition proper 
9.2 in 100; lactation, 3.6 in 100. 
According to Mare^, insanity caused 
by pregnancy generally develops about 
the end of the fourth month, and 
increases progressively. Melancholia 
is the most frequent form. Schmidt 
gives the foUowing proportions: 52.9 
in 100, melancholia; 31.3 in 100, 
mania; 10 3 in 100, chronic systema- 
tized delirium ; 6 8 in 100, general 
paralysis. Maro6 observes that labor 
seldom relieves this form of mental dis- 
ease; on the contraiy, the symptoms 
are generally aggravated, and melan- 
colia often assumes the form of more 
or less violent mania. Abortion, 
sometimes recommended as a curative 
measure, should be strictly forbidden. 
Gestation, with these patients, is 
usually normal, and abortion seldom 
occurs spontaneously. The opinion 
advanced by some author -t that preg- 
nancy exerts a beneficial influence 
upon insanity already established ia 
not sustained by statistics. Esquirol 
believes that marriage and labor 
usually stimulate the disease. When 
psychosis appears at an early period, 
prognosis is more favorable than 
when it occurs toward the end of 
gestation, but it generally persists for 
several months, and relapses may be 
expected in subsequent pregnancies. 

The causes of puerpeial insanity 
proper — that is, insanity — which 
develops during the period following 
labor before the organs of generation 
have resumed their normal functiona. 



Digitized by 



Google 



REVIEW OF GYNECOLOGY. 



il9 



are divided by Campbell — Clark into 
predisposing causes and producing 
causes. In the first category, heredi- 
tary predisposition is the most im- 
portant, as it exists in fifty-six per 
cent, of these cases. The -complicated 
influences affecting a first pregnancy 
are next in order. Nearly half the 
patients suffering from this form of 
psychosis are primiparse. Among 
producing causes, infection occupies 
the first rank — infection of the uterus 
or of other organs. Campbell — Clark 
reports 70, of 100 cases, caused by 
infection ; 66 by infection of the 
uterus, and 4 of the kidneys. More 
than half of these patients were 
under the influence of intense moral 
emotions ; and we realize the impor- 
tance of this influence when we con- 
sider the large number of women who 
suffer from puerperal infection. Dr. 
Idanof gives the proportion of eight 
or nine per cent, and the compara- 
tive rarity of puerperal insanity. The 
disease usually appears about the 
fourth or fifth day. Irritability, 
headache, insomnia, agitation, dimin- 
ished secretion of milk, are premoni- 
tory symptoms. Fever may or may 
not be present, but the head is always 
hot. Sometimes the disease assumes 
a fatal form ; when the tongue be- 
comes dry and furred, the secretions 
cease abruptly and the patient falls 
into a comatose state, which soon 
ends in death. Puerperal insanity 
proper assumes the most diverse 
forms: mania in 47.8 percent.; mel- 
ancholia in 87.9 ; systematized deliri- 
um in 5.8 ; acute dementia iu 5.5. 
Prognosis is favorable in most cases, 
more favorable in mania than in mel- 
ancholia. Patients suffering from 
insanity after prolonged lactation 
usually present symptoms of extreme 
exhaustion. Prognosis is not unfav- 
orable, but more grave than in puer- 
peral insanity proper. Therapeutic 
inclinations are the same in all kinds 
of puerperal insanity. Treatment 
consists in the removal of all excit- 



ing causes, a tonic rSgime^ mild pur- 
gatives, injections of chloral hydnite 
and other soothing influences. {Le 
Progres Medical^ April 7, 1 894 ; revietff^ 
iu British Gyn<Bcological Joumal^Nov. 
1894.) • 

Sarcoma of the Uterus in a 
Woman, aged Twenty-one. By 
Dks. Laver and Wilkinson. 

The patient had a child three years 
previously, and had menstruated dur- 
ing lactation. Neaily two years after, 
she became pregnant, but miscariied 
at the third month. For five months 
she had a colored discharge, then a 
sfvpie flooding, followed by prqfuse 
menorrhagia. The uterus was cu- 
retted ; small round-celled sarcoma 
was discovered and vaginal hysterec- 
tomy was performed on October 4th, 
She recovered froln the opemtion, 
the chart showing the type of 
pysemia. though there were no meta- 
static abscesses. She however went 
home and died December 15 of the 
recuirent disease in the lungs. 
{Quarterly Medical Journal^ Aprils 
1894: review in British OyncBcological 
Journal^ Nov.^ 1894.) 



The Use of Cocaine in RraiDiTY 

OP THE CekVIX during LaBOB. 

By Dk. Fabbau. 

The author has successfully em 
ployed applications of cocaine in two 
cases of rigidity of the cervix during 
labor. In the first case, which was a 
rather old primipara, ijs rigidity of the 
cervix prevented the progress of labor 
for forty-eight hours, and over which 
chloroform had no control. An incis- 
ion of the cervix was decided on ; the 
writer applied a tampon soaked in 
a 10 per cent, solution of cocaine in 
order to obtain a certain degree of 
local ansesthia. Three minutes after, 
he removed the tampon and was sur- 
prised to find that the cervix had 
dilated considerably during this short 



Digitized by 



Google 



280 



BOOK REVIEWS. 



space of time. The dilatatiion con- 
tinued rapidly and labor ended nor- 
mally. The second case was a 
pvimipara, aged forty; an application 
of a tampon, imbibed with a ten per 
cent, solution of the drug, applied to 
the vaginal portion of the uterus, 
rapidly did away with the existing 
rigidity which had resisted for three 
days all the means employed to 
relieve it. (^London Obstetrical 
Society, Nov, 7, 1891; review in La 
Revue Internationale de Med, et de 
Chirugie Dec. 25, 1894.) 



A CoNTBrnuTiON to the Study op 

PUBliPKBAL GOXTRB. By De. J. 

C. Mangin. 

The author has had the occasion of 
observing a case of sudden death by 
asphyxia in a pregnant woman. As 
to the accidents which may be pix)- 
duced by the thyroid body in preg- 
nant women, they may be classed as 
follows : (1) congestion of the thyroid ; 
(2) simple inflammatory thyroiditis ; 
(8) suppurating thyroiditis; (4) con- 
g^estion of a preexisting goitre; (5) 
simple or suppurating sturmitis of a 
preexisting goitre ; (6) progressive 
hypertrophy, with tendency to asphy- 
xia, in a parenchymatous goitre. 
This is the ** suffocating puerperal 
goitre." An infrequent accident dur- 



ing pregnancy, due to a goitre, \& 
fatal asphyxia. The case of the 
author is consequently most interest- 
ing in this point of view. The prog- 
nosis of puerperal goitre is coq- 
sequently more serious than most 
writers believe. The ti-eatment 
varies according to the variety of the 
classiBcation here given. {Parii 
TheBii ; review in La Itevue^ In'emor 
tionale de MSdical et de Chirugit 
Dec. 25,1894.) 



SVMPHYSBOTOMY WITHOUT SUTURB. 

By Db. Bussemakbr. 

The case was operated on by 
Professor Pagenstecher, of Elberfleld. 
The wound was simply dressed with 
antiseptics and healed in about a 
month. After two months, the ends 
of the symphysis could not be moved. 
It therefore seems proven that an 
efficient bone suture hastens the per- 
fect reunion of the cut symphysis, 
but that this will also take place later 
without it, or a fibrous union results 
answering all purposes. The question 
of bone sutures or none was discussed 
at the meeting of the Wein Geb»irt- 
shilfund GynsBhol. Gesellshaft Jane 
14,1894. (Centralbl. fUr aynoehol 
No. 87, 1894 ; review in Bntish Oynm- 
cological Journal^ Nov,^ 1894. 



BOOK REVIEWS. 



AU Exchanges and Books for Reveiw should be sent to Db. G. G. Cumbton, 826 Beacon St., Boston. 



Transacjtions op the New York 
State Medical Association, 
1893. VoLUiMB X. Containing 
TdB First Decennial Index. 

The contents of this society's vol- 
ume is full of interesting and impor- 
tant matter, both medical and surgi- 



cal, and, although each memoir is of 
merit, we can only mention the most 
important on account of space. Ne- 
phrotomy and nephrectomy by E. D. 
Ferguson, M. D. ; Placenta Praevia 
and Treatment, by Z. J. Lusk, M. 
D. ; Discussion on Lesions of the 
Pleura, by Drs. McCollom, White, 



Digitized by 



Google 



BOOK REVIEWS. 



281 



Traux and Leale ; an important 

Piper on The Surgical Treatment of 
ulmoiiarv Cavities, by M. P. Dand- 
ridge, M. D. Fermentive Dyspepsia, 
by Austin Flint, Al. D.; Bloodless 
Amputation at the Hip Joint, by 
John Wyeth, M. D. ; brief comments 
on the Materia Medica, by E. H. 
Squibb, M. D. ;a number of other 
good papers, complete this most ex- 
cellent volume. 



ing the book still more valuable, if 
such could be the case. 



Obstetrical Nqksing. Third edi- 
tion. I^y Anna M. Fullerton, 
M. D. P. Blakiston, Son & Co., 
Philadelphia, publishers, 1894. 

Nursing in Abdominal Surgery. 
Second edition. By Anna M. 
Fullbkton, M. D. P. Blakiston, 
Son & Co., publishers, Philadelphia, 
1894. 

The two volumes before us, both 
by Dr. Fullerton, are intended for 
the obstetric and surgical nui-se, and 
are well-fitted for their end. To detail 
their respective contents would be too 
long; but it may be said that all they 
do contain is well worth perusal. 
From the fact that they have attained 
respectively the third and second 
edition, indicates that they have 
been appreciated, and as the author's 
style is clear and easy, and the vol- 
umes abounding in practical sug^^es- 
tions, it is probable that another 
edition will soon be called for. 



Sbxual Neurasthenia. By Drs. 
Bkabd and Rockwell. Fourth 
edition. New York, 1895. E. B. 
Tkbat, Publisher. 

A fourth edition of this remarkable 
book is quite sufficient to demon- 
strate the fact that it is appreciated 
by the profession. The iuteresting 
subject of which it treats is one that 
should be carfeully and profoundly 
studied by every physician, who 
should be au courant with it. The 
present edition has been enriched by 
a chapter on Sexual Erethism, render- 



ObstetriC Surgery. By Egbert 
H. Grandin, M.D., Obstetric Sur- 

feon to the New York Maternity 
lospital, Gynsecologist to the 
French Hospital, etc. ; and Georgb 
W. Jarman, M.D., Obstetric Sur- 
geon to the New York Maternity 
Hospital, Gyn»cologitjt to the Can- 
cer Hospital, etc. ; with eighty- 
five (8o) illustrations in tlie text 
and fifteen full-page photographic 
plates. Royal octavo, 220 pages. 
Extra cloth, $2.50, net. The F. 
A. Davis Co., publishers, 1914 and 
1916 Cherry street, Philadelphia. 

As announced in the preface, the 
keynote of this volume is election in 
obstetric surgery. From beginning 
to end the work is clearly written 
and full of practical information. 
Commencing with a sound chapter 
on obstetrical asepsis, the authors 
lead the reader through obstetric 
dystocia, artificial abortion and pre- 
mature labor, the use of the forceps, 
version, symphysiotomy. Cesarean 
section, embryotomy, surgery of the 
puerperium, and ectopic gestation. 
Theoretically and practically the 
work is excellent, and we say with- 
out hesitation that we have noit 
seen a better one on the subject, all 
things considered. It is illustrated 
by many figures, and fine plates 
make it still more clear and its 
large type and good paper and bind- 
ing does credit to its publishers. 



We are informed that the F. A. 
Davis Co. have in active preparation, 
a work which is to be a companion to 
Kraift — Ebing's famous Psychopa- 
thia Sexualis, by Dr. A. Schrenck — 
Notzig of Munich entitled •^Su^estive 
Thereapeutics in Psychopath ia Sex- 
ualis." Ihis coming work will, no 
doubt, attain the importance that 
Krafift — Ebiug's now has. 



Digitized by 



Google 



ANNALS 



—OF— 



GYN^OLOGY AND PiEDIATRY. 



DEPARTMENT OF PJEDIATRT, 



A Cheap Form of Malt Diastase for Poor Practice. 



E. CHANNING STOWELL, M. D. 

BOSTON. 



Much has been written for and 
against malt diastase as a therapeutic 
agent, but we still find the rank and 
file of the general practitioners pre- 
scribing it and sure also that tbey are 
doing good. Tbere seems to be very- 
good evidence that the diastase of 
malt or pancreatine if administered 
just before a meal, or during the early 
part of a meal or if added to the food 
a short time before it is taken, does 
act in the stomach on the starches 
for a considerable time. We know 
that diastase will act in a slightly 
acid medium as well as in alkaline 
or natural solution. Heat overlTO® F., 
and the stronger acid fluids, like the 
gastric juice during the latter part of 
a meaU destroy its energy. In many 
cases, besides the aiding of the diges- 
tive processes diastase seems to 
have besides a distinct tonic effect. 
Perhaps this is because it is a form 
of vital energy, as many think. 

With the purpose of supplying 
a malt diastase of a cheapness to 



warrant its prescription in out pa- 
tient departments and in poor dis- 
pensary piactice, it was suggested to 
use the formula given by Sir Wm. 
•Roberts in "Coll. Contrib. on Diges- 
tion and Diet" (London, 1891). This, 
in infusion was used by him in his 
experiments and possesed marked 
efSciency and keeping power. 

He takes three ounces or three 
heaping tablespoonfulls of cnished 
malt and mixes it well in sejus with 
half a pint of cold water. This ii 
to stand over night ten to twelve 
hours in the cold. Then decani 
carefully and strain through three 
folds of muslin. If the barley graini 
are squeezed a little through tb< 
muslin, it adds a little to the yaluc 
of the preparation as a food. Thu 
infusion must be used fairly quickly 
If it must be kept some time, in ordei 
to prevent fermentation one must U8< 
as an extracting medium cold watei 
and twelve to twenty per cent, rec 
tified spirit, — the higher percentagi 



Digitized by 



Google 



CONDITION OF HEALTH IN MASSACHUSETTS. 



288 



being inecessary in the warm summer 
weather. 

As to the cost: At wholesale bar- 
ley malt of the best quality can be 
bought for eighty cents a bushel and 
will be retailed therefore at about 
ninety c<?nts to one-dollar. So the ex- 
pense cannot be very great. 

This cold infusion of malt has 
been used during the fall in the chil- 



dren's clinic of Dr. Harold Williams, 
at the Boston Dispensary, and to a 
slight extent in the dispensary dis- 
tricts. So far there is nothing but 
praise to be said for it ; because, firsts 
it is very cheap ; second, it is as effic- 
ient as the higher priced articles; 
third, by reason of the rectified 
spirits it is still further a stimulant 
to digestion. 



EDITORIAL 



Dr. Hartwell and the Condition of Health in Massachusetts. 



Dr. E. M. Hartwell, Director of 
Physical Training, Boston Public 
Schools, in his report to the school 
•committee, School Document No. 8, 
1894, has made a decided and valua- 
ble contribution to medical literature 
*nd sanitary science. It is a report 
which should be read by all who are 
interested in paediatry. After allud- 
ing to this first report, and briefly re- 
Tiewing the progress of physical 
training in New England, Dr. Hart- 
well devotes several pages to statis- 
tics showing the increase in popula- 
tion of great cities. Especially is 
this found to be the case in Massa- 
chusetts, the " Commonwealth of 
Cities." Sixty-nine and nine tenths, 
per cent, of the population of Massa- 
chusetts, live in cities according to 
the census of 1890, and at the present 
rate of increase in ten years, time 
eleven-twelfths of our population will 
be city people. " The well-nigh uni- 
versal belief that the influences and 



concomitants of city life are prejudi- 
cial, on the whole, to continuous 
vigorous health seem to be well 
founded. The death rate of urban 
districts the world over is almost in- 
variably higher than in country dis- 
tricts. This is especially the case as 
regards the mortality of infants and 
children." la Table IV. of the re- 
port, Dr. Hartwell compares the 
death rates per 1000 inhabitants of 
all ages of London, Boston and Ber- 
lin: Berlin, twenty-four and five- 
tenths; Boston, twenty-three and 
three-tenths; London, nineteen and 
one-tenth. In children of the school 
age, from five to fifteen years the 
figures are : Berlin, four and eight- 
tenths; Boston, six and six-tenths; 
London, three and nine tenths. In 
other words nearly twice as many 
children per 1000 of the school age 
die in Boston as in London I Mak- 
ing allowance for superiority of the 
English climate over that of the Mas- 



Digitized by 



Google 



284 



EDITORIAL. 



sachusetts climate as is shown by the 
excess of mortality of Boston over 
Massachusetts as compared with the 
excess of London over England, and 
Dr. Hartwell concludes that among 
children Boston's local death-ra'e ap- 
pears to be fourteen times as great as 
London^ s local death-rate.'*^ The reason 
for these figures is that sanitation is 
less efficient in Boston than in Lon- 
don, and Boston has not kept pace 
with the advances in school hygiene 
and the application of its principles. 
**Among the agencies which are most 
effectual for promoting and conserv- 
ing the health of growing children, 
muscular exercise may be fairly 
placed next to pure air, sunlight and 
a sufficency of nutritious food.*' The 
importance of physical training is 
then insisted upon, in proof of which 
are cited the figures showing the im- 
provement in the Unittfd States army 
by hygienic means. The structure of 
the body, the general effects of mus- 
cular exercise, its special effects, 
and its effect upon the nervous system 
are caiefully considered. In relation 
to this latter effect, there follows an 
elaborate and exhaustive consideration 
of stuttering, the conclusion of 
which Dr. Hartwell says : "I am 
firmly persuaded that the presence of 
five hundred stammerers and stutter- 
ers in our public schools is an unnec- 
essary evil, because it might be pre- 
vented and may be abated by simple, 
well approved, practicable measures." 



In Dr. Hartwell's report is inco^po^ 
ated the report of Dr. C. L. Scudder 
upon the " seating " of school-children 
with the conclusions reached that the 
methods are faulty and productive of 
a tendency to spinal curvature, and 
the " Chauncy Hall Desk is favorably 
mentioned as an example to school 
authorities as what might be accom- 
plished by school seats. Dr. Hartwell 
concludes his repoi-t in the words of 
Superintendent Philbrick of the 
School Committee : " Complete phys- 
ical health and development is es- 
sential to the truest and best intellec- 
tual results of education . ... 
All we have done in the interest of 
school hygiene during the past twelve 
years is far, very far, from being 
what we can safely accept as a satis- 
factory finality. It is in truth only a 
beginning of the vast work yet to be 
accomplished if we mean to make oar 
system of education a complete suc- 
cess." In conclusion, we would say 
that Dr. Hart well's report is the most 
complete and systematic public doc- 
ument on the subject which ha.<» ever 
come to our knowledge, and as a re- 
view of the study of the health in the 
Boston public schools, which are 
equaU if not superior, to any schools 
in the country, it should attract a 
widespread and careful perusal, and 
the suggestions of Dr. Hartwell 
should meet with a ready adoption 
upon the part of school authorities. 



Digitized by 



Google 



FOREIGN BODIES IN THE HEART. 



285 



Foreign Bodies in the Heart 



In a recent number of '*2ie« An- 
nales de la PolicUnique de Bordeaux^ 
Dr. Sengensse relates tbe case of a 
child aged three^ who, after a fall 
remained unconscious for about a 
qnarter of an hour. It was then 
discovered tbat a needle that was 
sticking in her waist was missing 
and it was thought tbat she had 
swallowed it. The following day 
she was restless, complained of 
violent pains when she breathed, and, 
upon careful examination, a lump 
was discovered over tbe fourth inter- 
costal space, wbich increased in size 
at each cardiac contraction. On in- 
cising tbis prominence, tbe head of 
the needle was found ; evidently tbe 
rest was sticking into the beart. 
The needle was easily extracted. 
It measured forty-two millimetres 
in length and had remained plunged 
in tbe heart for thirty- six bours, 
probably in tbe right ventricle. Re- 
covery was rapid and uneventful. 
Needles and pins introduced into 
the heart witbout producing accidents 
have already been put on record. 
Projectiles of small calibre have 
been found encsyted in the walls of 
the heart, hair-pins, needles, pins, 
an ivory tootb-pick (Barbier of Ami- 
ens,) a piece of wood three inches long 
(David,) and even still larger bodies. 
An interesting case is recorded by 
Tillauxin his Ttaite d*Anatomie To- 
pographique. A maniac introduced a 
bar of iron, measuring sixteen centi- 
metres in length, in the region 
of the heart. When Prof. Tillaux 



saw tbe patient, the foreign body had 
disappeared, but tbe fingers could 
feel tbe rising up of tbe skin with 
each contraction of the heart. Other 
than rather rapid beats, there was 
no otber trouble in the circulation. 
Believing that the piece of iron acted 
as a cork, thus preventing hemor- 
rhage, Tillaux at fii-st did not dare to 
remove tbe body ; the next day it 
could liardly be felt, and soon could 
not be felt at all. The patient made 
such a good recovery tbat he tried 
again to commit suicide. He died 
the next year and it was found tbat 
the iron bar had traversed tbe ante- 
rior aspect of tbe left lung, the pos- 
terior wall of tbe ventricles, by pene- 
trating tbe left side, and was at 
time of death engaged in tbe rigbt 
lung. In animals, grains of shot 
are quite often found in the heart, 
and Plater found in a pig's heart 
the end of a small stick wbich had 
been pushed in six montbs previ- 
ously. In certain cases tbe foreign 
body has only been discovered at 
the necropsy, and nothing during 
life bad ever caused suspicion as to 
its being there. 

Sucb cases have been reported 
by Lagier, Barbier (of Amiens), 
Peabody and others. Peabody found 
in tbe beart of a woman, who died 
at thirty-nine years of age of a 
mitral stenosis, a pin whose origin 
could not be discovered, and wbich 
had probably been for a long time 
in the organ. Tbe pin was planted 
in one of tbe papillary muscles at- 



Digitized by 



Google 



^86 



EDITORIAL. 



tached to the anterior segment of 
the mitral valve, traversed this 
muscle and penetrated obliquely 
three centimetres deep in the wall 
of the ventricle. The question as to 
searching for and extracting foreign 
bodies in the heart has been dis- 
<)U8sed, when, as in the case men- 
tioned, the thing is possible. Dr. 
Sengensse believes as Peyrot that, 
^^ allowing long and narrow foreign 
bodies to remain is at least as danger- 



ous as to extract them, and that in this 
case abstention is not an absolute rule 
by which to be guided," and he con- 
cludes with Broca and Hartmann, 
that foreign bodies when lost should 
not be searched for, but that those, as 
in the case reported, which project ex- 
teriorly or under the skin, should be 
extracted. As to pointed instruments, 
success b not infrequent, as is 
shown by quite a number of cases. 



The Relation between Tuberculosis and Diphtheria. 



In the Oct., 1894, number of the 
Revue de la TuberculoBe^ Prof. L^on 
Revilliod, of Geneva, published an 
article, in which he studies the re- 
lations which may unite these dis- 
eases, and which, according to the 
author, have a tendency to evolution 
in the same subjects. A soil that is 
good for diphtheria is also favorable 
for the development of tuberculosis. 
There is, in a word, a family tempera- 
ment favorable to the receptivity of 
both these affections. Prof. Revilliod 
recalls in the first place the fact that 
he has already endeavored to demon- 
strate that diphtheria belongs to the 
fiarae family as tuberculosis, and 
bases this conclusion on the fre- 
<juency of family epidemics, in which 
it was impossible to attribute the 
•contagion, either on account of the 
long lapse of time separating the at- 
tacks in different members of a 
family, or on account of the distance 
of the places from each other in which 
the attacks appeared. Since his first 



writings, comprising fourteen families, 
in which several cases of diphtheria 
developed, in different countries or 
houses, and at times sufficiently long 
apart, so that all idea of contagion 
could ba excluded, Revilliod men- 
tions twenty-one new facts of the 
same kind, upholding this disposition 
of certain families to diphtheria. It 
should also be noted that Prof. 
Revilliod is far from admitting the 
great power of contagion that is gen- 
erally attributed to diphtheria, and 
that he explains the isolated cases, 
spontaneous in appearance, by the 
latent microbism which may exist in 
Loeffler's organism, as in the pneu- 
mococcus, bacterium coli, and even in 
Koch's bacillus (Straus). Remaining 
in the latent state in predisposed fam- 
ilies, it puts its activity into play 
under the influence of external or 
atmospheric causes, which give rise 
to malignant or benignant, localized 
or generalized forms of the disease, 
according to the receptivity of tlie 



Digitized by 



Google 



NEW YORK ACADEMY OF MEDICINE. 



287 



subject. The specificity of the " diph- 
theiisable" soil being established, it 
now remains to demonstrate how this 
bears itself regarding tuberculosis. 
Now, from a large number of facts 
observed by Uevilliod, it is shown 
that diphtheria and tuberculosis co- 
exist Avith a particular frequency in 
the same given family. Several 
writers have already shown the fre- 
quency of scrofula and tuberculosis 
in patients suffering from diphtheria. 
Sann^ says that tuberculosis and the 
cachexisB hold an important place 
among the diseases which prepare the 
road for diphtheria. A fact that has 
been demonstrated is that patients 
on whom tracheotomy has been per- 
formed hardly ever live over the age 
of twenty-five or thirty years ; this 
may be because they oficn become 
tuberculous. Now, Prof. Uevilliod 
has met with a goodly number of 
cases in which diphtheria was ac- 
companied by tuberculosis, either in 
the subject himself attacked, or in his 
ascendants and his collatemls. This 
is what happened in forty-two cases 
out of the least two hundred cases of 
diphtheria observed by Prof. Rev- 
illiod; that is to say, that twenty- 
one per cent, of the diphtheiitics in 
this statistic count in their respective 
families several cases of pronounced 



tuberculosis. The author conse- 
quently concludes that not only does 
diphtheria favor the development of 
tuberculosis and vice versj^ hut that 
the same soil is favorable to both dis- 
eases. This is more than an ordinary 
coincidence, for if one considers scar- 
let fever, for example, it is at once 
seen that it is never combined with 
tuberculosis, although it grafts read- 
ily on a diphtheritic soil and vice 
versa. The facts observt-d by our 
former teacher. Prof. Revilliod, pre- 
sent great interest and will surely be 
the cause of other work in this di- 
rection. But as is stated in the Jour- 
nal de. Medicine et de Chirurgie Prac- 
iiques^ issue of Dec. 10, 1894, the 
great objection that will be made 
until a large number of cases of thb 
kind have been observed, is that 
tuberculosis is a disease so frequent 
that it is very possible that of the 
two hundred patients, tuberculosis 
might be found forty-two times in 
the families under consideration. 
And the same journal suggests that 
it would be interesting in this stand- 
point to compare diphtheria with 
some other disease of similar fre- 
quency, as, for example, typhoid 
fever, and investigate the number 
of cases of this latter disease coincid- 
ing with family tuberculosis. 



Meeting of New York Academy of Medicine. Section in PaBdiatrics, 

December 13, 1894. 



Dr. Joseph E. Winters, chair- 
man. 

Dr. Mary Putnam Jacobi pre- 
sented a case of 



CONGENITAL PTOSIS. 

One eye alone was affected. At 
birth the eye was completely closed. 



Digitized by 



Google 



288 



NEW YORK ACADEMY OF MEDICINE. 



and 80 remained for two weeks. The 
cliild was, at the end of two montli8, 
able to open tbe eye about half. The 
lid seemed smaller and softer than 
that of the other side, and the whole 
eye seemed smaller. Ihe case was 
peculiar. The lesions in such cases 
generally extend to all the external 
muscles of the eye. Numerous other 
eases were reported from literature, 
all without exception being bi-lateral. 
No cause could be detected, the 
child and parents being in perfect 
health. 

Dr. North rup said that the size 
of the eyeball was often deceptive 
when the eye could not be completely 
opened. If the child recovered, the 
ball would probably be found to be 
of normal size. 

The subject for discussion was 

TYPHOID TEVER IN IKFANT8 AND 
CHILDREN. 

The first paper was read by Dr. 
William P. Northrup, on 

PATHOLOGY AND OCCURRENCE. 

The characteristic lesions of typhoid 
fever are changes in the lymph nod- 
ules of the intestine, the lymph nodes 
of the mesentery, and in the spleen. 
These changes are constantly associ- 
ated with the presence of a special 
micro-organism — the typhoid bacil- 
lus. This germ is usually found in 
early cases in the contents of the 
intestines, in the lymph nodules and 
the mesenteric nodes, in the spleen 
and rarely elsewhere. The symptoms 
are believed to be due to a systemic 
poison developed by these bacteria. 
There is frequently a concurrent or 
mixed infection, giving rise to phe- 
nomena which are not peculiar to the 
disease. 

In a paper read in 1892, the author 
made the following statements: **'Jy- 
phoid fever in children under two 
years has never been observed in the 
New York Foundling Asylum as far 



as the record shows." *' The swollen 
Peyer's plaques, enlarged mesenteric 
nodes and spleen in children can not 
safely be interpreted like the same 
lesions in adults." Since that paper 
was written no case has appeared at 
the Foundling Asylum. Elsewhere 
the author has, however, seen an 
undoubted case of typhoid fever in a 
child just two years old, which he 
reported in detail. It was his wish 
to encourage a healthy skepticism as 
to all diagnoses of typhoid in chil- 
dren of two years and younger. He 
showed also a specimen illustrating 
the fact that the post-mortem findings 
of swollen follicles, swollen Fever's 
plaques, and enlarged spleen might 
easily be misinterpreted. In the 
cases reported, the diagnosis rested 
upon these points: previous history 
of typhoid in the family; continu- 
ous lever with drowsiness or stupor; 
typical rose colored spots ; enlarged 
spleen ; constipation ; moist, coated 
tongue ; gradual return to normal 
condition during third week of ill- 
ness. 

The author's conclusions are stated 
as follows: (1) Typhoid fever is not 
a disease of infancy, t. €., under two 

! rears, there b«'ing apparently much 
ess susceptibility than in adults; (2) 
diagnosis rests upon the same points 
as with adults; (3) the spleen in 
infants must be felt below the border 
of the ribs to be pronounced enlai'ged ; 
(4) enlarged mesenteric nodes, swollen 
Peyer's plaques, solitary follicles, and 
spleen in infants are not uncommon 
in oases where the clinical history 
excli|des typhoid fever. 

Dr. William L. Stowkll read a 
paper entitled : 

ENTERIC FEVER IN INFANTS AND 
CHILDREN, A CLINICAL STUDY. 

The object of this paper was two- 
fold — First, to ascertain whether the 
clinical aspect of this fever differed 
essentially from the same disease in 
adults. 



Digitized by 



Google 



NEW YORK ACADEMY OF MEDICINE. 



289 



Second, to asoertain, in part from 
litemture, if this fever attacked in- 
fants, and if so were the lesions char- 
acteristic in them. 

For many years typhoid fever in 
children was described as infantile or 
intermittent fever. In 1847, Dr. 
Wood suggested the term enteric 
fever, which is now commonly used. 
Thiityfour cases were reported by 
the author, collected from large dis- 
pensary and private practice. These 
cases lead him to believe that the 
disease was not common in young 
children in New York. New York's 
annual mortality from typhoid was 
two and two-tenths per thousand in- 
habitants. 

The shortest duration was ten 
days, the longest fifty -two, and the 
average twenty-three and eight-tenths 
da\s. The adult mean is twenty- 
eight and one-tenth (Osier) ; eight and 
eight-tenths p»*r cent, relapsed or were 
reinfected. Tympanites was nearly 
always present to a slight degree. 
Diarrhcea was marked in twenty-nine 
and five-tenths per cent, of the cases. 
A few were markedly constipated, 
but loose stools usually occurred a 
few times before recovery. Diarrhoea 
occurred in thiiiiy-three per cent, of 
Osier's adult cases. Rose spots ap- 
peared in sixty-six per cent, of the 
cases. As to season, seventy-three 
per cent, occurred during the last 
four months of the year. 

The endemic nature was illustrated 
by thirty cases appearing in six 
groups. The two youngest were 
twelve months and seventeen months 
respectively. The mean age was 
eight years. Fifty-nine per cent, 
were males. Epistaxis occurred in 
twenty and five-tenths per cent. 
The tongue was usually moist and 
coated except in those who had high 
temperature. The composite chart 
for temperatures of all the cases did 
not show as high a range as typical 
cases were supposed to nave. Head- 
ache was present as a rule, though 



comparatively mild in many cases. 
Violent delirium occurred twice and 
great stupor twice. Pneumonia oc- 
curred in ten per cent., but was not 
severe. Bronchitis was common. 
Alopecia occurred in convalescence 
as in results. Infants were not ex- 
posed to the poison of typhoid, but 
when they come in direct contact 
with the germs they were susceptible 
to them. 

From these cases the following con- 
cludions may be drawn : — First, the 
disease is not common in childhood; 
second, the types and varieties do not 
dififer materially from those of 
adults ; third, the term is shorter 
than in adults; fourth* the progno- 
sis is better in children than in 
adults, there being fewer complica- 
tions; fifth, in infants the mortality 
is high because the extremes of life 
are feeble. 

Hbnby D. Chapin read a paper 
on 

TREATMENT AND MANAGEMENT. 

The treatment of typhoid fever, 
must be based entirely on the type of 
fever present. When the fever is 
low and the symptoms mild, as they 
commonly are in children, veiy little 
medicine is required. Walking 
typhoid is especially common in chil- 
dren, hence relapses are especially 
common. Rest in bed should be in- 
sisted upon. It is often difficult to 
enforce this rule, but it will do much 
to insure a short course. The diet 
should be fluid, milk being preferred. 
One or two quarts may oe given 
daily. Kumyss, matzoon, and butter- 
milk may all be used. Stimulants 
are rarely needed, but when indicated 
should be given as to adults. When 
the temperature is high cold to the 
head in the form of an ice poultice 
should be offered to the occiput and 
vertex. The child should be sponged 
with a mixture of water and alcohol 
at a temperature of sixty degrees. 
Constipation is the rule in children. 



Digitized by 



Google 



290 



NEW YORK ACADEMY OP MEDICINE. 



Dry masses are inclined to collect low 
in the bowels and are best removed 
by enemas. If diarrboea appears 
bismuth is indicated. For indiges- 
tion, pepsin should be used. Aro- 
matic sulphuric acid is an excellent 
remedy when the bowels are loose 
and the digestion impaired. Chlor- 
ide of lime is one of the best and 
cheapest disinfectants, but carbolic 
acid, one in twenty, or bichloride 
solution, one in five hundred, may be 
employed. All soiled clothing should 
be thoroughly boiled. In some cases 
the bronchial mucous membrane 
seems to bear the brunt of the attack, 
when codeine in small doses proves 
of value. 

Dr. R. C. Newton, of Montclair, 
who has had large experience in an 
epidemic, said that he believed that 
many cases of supposed tvplioid in 
children were actually malaria. He 
believtd that a close diagnosis was 
often difficult. In most cases seen in 
the recent epidemic a remissson in 
the second week was very common in 
children. This was often misleading, 
and children who were allowed to 
^t up were much more ill afterwards. 
The eruption varied greatly. In 
some cases but very few spots ap- 
peared. In others they were pro- 
fuse, there being in one case liiT 
spots. The disease as it appears in 
children reminded him very strongly 
of '^mountain fever" whicn he had 
seen in the West. He was inclined 
to think that typhoid fever could be 
sometimes aborted in the early stage 
by free doses of calomel, which would ~ 
sweep the germs out of the canal. 
The last twelve of his cases had been 
treated with chlorine water and had 
done unusally well. 

Dr. W. B. NuVES said that one 
evidence of the rarity of the disease 
in voung children was the fact that 
in over two thousand autopsies which 
had recently been reuorted but six 
were under two years. It was, how- 
ever, in his opinion more common 



than was generally believed, for most 
of the cases recovered. The pro- 
dromal symptoms in children are not 
marked or distinctive. A numl)er of 
cases were reported by the speaker. 

Dr. A. Seibkkt said that the use 
of the term •^enteric fever" should be 
discarded, as it means simply an in- 
testinal 'fever. There are many 
forms of intestinal fever. Typhoid 
fever is due to the typhoid bacillus, 
and should receive that name. He 
believed neither children nor adults 
should be allowed to take raw milk. 
If the childi-en in Montclair had 
received boiled or sterilized milk, 
they would not have taken typhoid 
fever. Systematic irrigation of the 
rectum, not of the colon, once or twice 
a day was an important matter of 
treatment. The disease was due to 
absorption of the poisonous products 
of the germs. Absorption from the 
rectum was rapid and the disease 
could be materially modified if it was 
kept clear. It was well known 
that the severity of the disease was 
in proportion to the number of bac- 
teria present. He said that he gave 
no milk to typhoid fever cases and 
found these patients did much better. 
He fed his patients on soup, broth 
and stimulants and sometimes tea 
and coffee. He gave no antipyretics 
and no quinine, but always gave cal- 
omel in the early stages. 

Dr. 11. KoPLiK paid theim|K)rtance 
of making the differential diagnosis 
between typlioid and malaria by 
examination of the blood was great. 
Outside of epidemics, he believed 
that typhoid was extremely rare 
under two years. 

Dr. A. JACoBr did not believe that 
typhoid was uncommon in young chil- 
dren. Many reported autopbies were 
from hospitals which did not receive 
children. Children readily escaped 
typhoid because they took little 
water, and what they did take wag 
usually boiled. Their bowels were 
loose, as a rule, and the germs fra- 



Digitized by 



Google 



REVIEW OF PiEDIATRY. 



291 



qnently passed without infecting the 
patient. Children bear typhoid tern- 
pei-atiires remarkably well. It whs 
not uncommon to find a child with 
high temperature in this disease 
desirous of getting out of bed. 

Dr. C. (y. Kkklkv, for three 
years resident physician of the New 
York InfHnt Asylum, said that he 
had never seen a case of typhoid 
under two years, and had not seen the 
lesions of the disease in four huudi'ed 
and fifty autopsies. 

The (Chairman said that he should 
be sorry to have the section believe 
that typhoid fever was so extremely 
rare under two years. He had seen 
the disease at that age. 

Dr. W. P. North i:uP said that he 
should be sorry to have the section 
so away with the idea that typhoid 
fever is common in infants. The 
New York Foun^lling Asylum cares 
for over eighteen hundred patients 
every year. Eleven hundred are cared 



for by nurses outside of the insti- 
tution, and are circulating about the 
city in every locality. When they 
are ill they come back at once to the 
asylum. Why do they never come 
back with typhoid? Not a case 
under two years has returned with 
typhoid fever in twelve years of his 
expeiitnce, and twice that of Dr. 
O'Dwyre's. In over two thousand 
autopsies made by the speaker on 
these young children, not a solitary 
case has been found. He did not 
mean to say that an infant could not 
have typhoid fever; but he did mean 
to say that it was not common, and 
that it seldom occurred sporadically* 
In overwhelming; epidemics, such as 
that in Montclair, and such as Earle 
reported from Chicago, the facts must 
be accepted, while still maintaining 
that it is not a disease of infancy, 
and not common under two years of 
life. 



REVIEW OF PiCDIATRY. 



Dr. Andrew MacPhail, Professor of 
Patholojry and Diseases of Children, 
in the University of Bishop College, 
Montreal, gives an interesting ac- 
count of an epidemic of paralysis in 
children, with a report of one hundred 
and twenty-five cases. These cases, 
which might be classed as cases of 
** polio myelitis anterior acuta," oc- 
curred in the State of Vermont in an 
area of fifteen by twelve miles, of 
which the city of Rutland is the 
centre. The epidemic began in June, 
increased in July and culminated in 
August, and, though cases ocoasifmally 
occur, yet the mnlady has now almost 
abated. Of the cases reported, 
thirteen were fatal, twenty -five re- 
covered, thirty improved and thirty- 



two unmarried unimproved. The 
general characteristics of the attacks 
seem to have been fever and head- 
ache, fr 41 owed by paralysis of one or 
more of the extremities* This paraly- 
sis, which in every case was motor, 
has persisted in about one-fourth of 
the cases and in many has been 
followed by autophy. No cause could 
be discovered for the cases, and in no 
case could an autopsy be procured. 
(^Medical News, Dec. 8, 1894.) 



An excellent article appears "On 
the care of the ear during the course 
of the exanthemata" by Walter 
Downie, M. B. in an analysis of 
five hundred and one cases of tym- 
panic disease 



Digitized by 



Google 



292 



REVIEW OF PiEDIATRY. 



26.1 per cent originated daring an attack 
of measles. 

12.6 per cent, originated during an attack 
of scarlatina. 

8. per cent, originated daring an attack of 
whooping cough. 

.6 per cent, originated daring an attack of 
mumps. 

29.4 per cent, were catarrhal In origin. 

20 per cent, originated during eruption of 
teeth. 

1.6 per cent, were syphilitic in nature. 

The writer considers these cases 
for the most part due to occlusion, 
of the eustachian tubes, caused by 
the secretion of catarrhal products ana 
causing retained secretions in the 
middle ear. He accounts for the 
prevalence of middle ear symptoms 
m the exanthemata to the fact that 
the child is kept in bed and for the 



most part lies in a dorsal position 
which favors a retention of secretions 
within the hollow of the nazo-phar- 
nyx. "From the very beginning of 
the illness/' he goes on to say^ **wneii 
there are any catarrhal symptoms, the 

fatient should be directed to use the 
andkerchief frequently and strongly 
and the nurse in attendance should 
see this carried out.** If the child is 
too young he advises Politzer's inflsr 
tion bag. He regards the dangler of 
rupture of the tympanic membrane in 
cases of intense inflammation as less 
than the danger to be feared from the 
retained secretions. {British Medioal 
Journal, Nov. 24, 1894.) 



Digitized by 



Google 



ANNALS 



—OF— 



GYNECOLOGY AND PEDIATRY. 



Vol VIII 



KKBRUARY, 1895. 



No. 5. 



Ectopic Pregnancy— Extra Tubal. 



C. LESTER HALL, M. D., 

KA1C8A8, CITY, MO. 



A fair discussion of any one of the 
pathological conditions known and 
called ectopic gestation demands 
more than a passing notice of them 
all. The generic term is a synonym 
for the abnormal, a deviation from 
nature, and a tendency to evil re- 
sults. To a perfect organism it is 
deemed impossible, and yet it has 
happened in cases -where it is im- 
possible to trace an exciting, pre- 
disposing cause. In these, the auto- 
genetic cannot be excluded. 

To the materialist, he who must 
trace an inward effect from an out- 
ward cause, this statement will be 
challenged as heterodox, but to the 
broader and more comprehensive 
view, it has a place in an etiology. 
Along with constitutional immunity, 
must be recognized auto-infection, 
waywardness of nature and the unex- 
pected. A perfect tenement of the 
soul would bid defiance to all causes 

1. Read before the meeting of the Western 
Association of Obstetricians ana Gynsecologiats, at 
Omaba, Deo. 27, 1894. 



of its destruction from without or 
within, and .decadence would be im- 
possible and we would live on for- 
ever. Such evidently was not de- 
signed in our architecture, and the 
structure of our bodies has been left 
weak in places and imperfect in form. 
This inherent vulnerability ever 
makes us a prey to the destroyer, and 
natural processes are perverted. 

It must be admitted at the outset 
that nature's design is that the ovum 
should be fecundated and find lodge- 
ment within the uterine body, where 
the anatomical arrangements and 
physiological processes will best sub- 
serve the interests and well being of 
both mother and offspring. Review- 
ing the construction of the female 
generative organs, how the graafian 
follicle, breaking away from, its moor- 
ings, starts on its migratory jour- 
ney to meet its affinity, depending 
upon the fimbriae and ciliated epithe- 
lium for its safe arrival at its destina- 
tion, it is not surprising that it is 



Digitized by 



Google 



294 



C. LESTER HALL. 



more frequently lost to its natural 
-course, and is it unreasonable to sup- 
pose that its fecundating mate, weary 
At its long delay, starts in search for 
that upon^which depends its future 
existence ? Failing to see the object 
of its mission in the avenue of its 
natural^travel, " nothing daunted," it 
presses onward to greater depths 
until it overtakes the maternal germ. 
Granting that " the normal function 
of the ciliated epithelium is to carry 
all ^thej tube contents toward the 
uterus," it must be granted that it 
often fails of its mission in cases 
where no trace of destruction of the 
■cilia is discoverable, where there exists 
no histoiy of preexisting tubal dis- 
ease — in the primiparous woman — 
ip the healthy woman, with previous 
pregnancies normal. No class or 
station in life is exempt from this 
accident. 

The experiments of Dode, in which 
he injected an emulsion of charcoal 
into the abdomen of a rabbit and 
after several hours found the tubes 
filled with particles of charcoal, and 
his further experiment of injecting 
the ova ascaris lumhricoides suis into 
the abdominal cavity, after which in 
twelve hours he found large numbers 
of these ova in the tubes, does not es- 
tablish the theory of Tait as to ectopic 
pregnancy being the result of former 
tubal trouble with the destruction of 
the ciliated epithelium. They only 
prove nature's way, which is not con- 
:8tant or invariable. If these experi- 
ments of Dode were conclusive, there 
would be no such thing as ovarian, 
tubo-ovarian, tubal and abdominal 
pregnancy, or tubal abortion in 
women with healthy reproductive 



organs. Dode claims that an ovum 
which had escaped into the abdominal 
cavity would be taken up by the tube 
and carried into the uterus. 

Whatever may be the consensus of 
professional opinion in reference to 
Tait's theory as to the etiology of 
ectopic pregnancy, it must be con- 
ceded that the majority of these cases 
are primarily tubal and become intra- 
ligamentous and abdominal by rup- 
ture secondarily. 

Accepting Tait's theory, it is dif- 
ficult to reconcile the apparent incon- 
sistency that many cases which are 
claimed as primarily abdominal, are 
in reality the result of tubal abor- 
tion, for it should, in a spirit of fair- 
ness, be admitted that a condition of 
the tube which would permit the 
escape of the fecundated ovum would 
also favor the escape primarily of the 
fecundating material. 

The escaping fecundating mater- 
al may be brought in contact 
with the mother germ, just as it 
emerges from the tubal ostium, and 
constitute what may be called fim- 
briated pregnancy, and not necessa- 
rily tubo-ovarian, and yet it may 
never break away from its attach- 
ments, — but form additional attach- 
ments to the abdominal parieties, 
^nd be walled off from the general 
abdominal cavity. 

The skepticism expressed by Lusk, 
Beale and others as to the existence of 
primary abdominal and extra-tubal 
pregnancy, where the tubes are in- 
tact, and not in communication with 
the sac, make this question a debata- 
ble one. 

The varied symptomatology of 
ectoptic gestation makes a diagnosiB 



Digitized by 



Google 



ECTOPIC PREGNANCY. 



296 



difficult and frequently impossible. 
It can be truthfully said that there 
are no pathognomonic signs of ec- 
topic pregnancy. 

The differential diagnosis between 
ectopic pregnancy and oophoritis is 
often perplexing. Both conditions 
cause pain — both are accompanied 
with heemorrhage of uncertain dura- 
tion and irregular return. A differ- 
ential diagnostic sign has been 
pointed out by Vertsinski, Thomas 
and Lebedoff, which they claim as 
characteristic, viz. : the varying size 
of the tumor in inflammatory condi- 
tions of the tubes and ovaries — "the 
tumor sometimes is as large as an 
orange, and in only a few days it 
can hardly be defined/' and this peri- 
odical variation in size is closely 
connected with menstruation and 
ovulation. The same condition has 
been observed in a case of ectopic 
pregnancy. 

While the expulsion of the deci- 
dual membrane is considered a valu- 
able symptom, Lusk says that it is 
not a constant occurrence. 

The American text book of gynss- 
cology divides the diagnosis of 
ectopic gestation into two periods. 

First. — Prior to tubal rupture or 
abortion. 

Second. — Subsequent to tubal rup- 
ture or abortion — but claims that 
" mistakes in diagnosing ectopic ges- 
tation are bound to occur, even with 
the most careful, from the fact that 
the condition is sometimes found at 
operation, when not a period has 
been missed, and not a symptom of 
pregnancy has been presented." 

Irvine S. Haynes, in a recent article 
on the diagnosis and treatment of 



tubal pregnancy, says : *' All writers 
are unanimous in stating that the 
diagnosis is comparatively easy after 
rupture has occurred, and they are 
just as fully agreed that the diagno- 
sis is difficult and uncertain previous 
to this undesired event." He asks 
the question, " Can tubal pregnancy 
be diagnosed previous to rupture? 
If it can, what are the pathognomo- 
nic signs?" 

In tubal or tubo-ovarian pregnancy, 
rupture occurs between the third or 
twelfth week, and more frequently 
near the eighth week, at which time 
the tubal ostium is closed by the 
resulting congestion. 

Dr. Andrew F. Currier says : "The 
mere presence of a tubal tumor, even 
if it contains blood, is not, in my 
opinion, evidence of gestation." 

Smith says : "A positive diagnosis 
cannot be made within the first eight 
weeks without an exploratory inci- 
sion." 

Haynes says: "Absolute demon- 
stration is possible only by an explor- 
atory coeliotomy." 

As to the treatment of these cases, 
two methods have been adopted^ viz., 
electricity in the earlier months of 
gestation, and surgical treatment. It 
has been advocated by those who 
favor the electrical plan, to resort to 
the treatment before the fourth 
month. The success attained by 
McGinnis, Brothers and many others, 
demands recognition and considera- 
tion. Brothers reports 78 cases with 
one death. But surgical interference 
certainly offers the best hope for the 
patient. 

When we remember that in ectopic 
pregnancy rupture may take place 



Digitized by 



Google 



296 



C. LESTER HALL. 



prior to three weeks (and if it be 
tubal, always before the eigth week), 
the arguments of those who advocate 
the use of electricity fall to. the 
ground. Added to this is the state- 
ment by competent observers, that 
"it IS often impossible to make a 
correct diagnosis," except by explora- 
tory incision. It must be evident 
that anything short of surgical inter- 
ference must be tentative and uncer- 
tain. 

Werth says; "'that ectopic preg- 
nancy is always to be regarded as a 
malignant growth and should be 
treated as such." 

The foregoing has been considered 
by the writer as a necessary prelimin- 
ary to the report of a case herewith 
presented. History furnished by her 
husband. 

Mrs. H., wife of a worthy and 
reputable physician of Kansas City 
gave birth to her first child in 1888. 
Sub-involution with hsemorrhage in 
the third week, and anaemic neuralgia 
— complete recovery, after which 
menstruation was regular and health 
good. Had a miscarriage in 1890 
with considerable hsemorrhage — re- 
covery — subsequent menstruation reg- 
ular, except a few days variation at 
each period. From January to May, 
1894, suffered with uterine prolapse. 
Had painful menstruation about May 
3d. Next period in June was pain- 
ful and she had to go to bed. Uterus 
swollen and soft, with leucorrhoeal 
discharges and slightly stained with 
blood. June 6th, Dr. M'. curetted the 
uterus and brought away some fun- 
goid granulations, which were not 
submitted to microscopic examina- 
tion. Uterine cavity 4i inches deep. 



Considerable tenderness over the 
region of the uterus -followed, with 
pains simulating uterine contractions. 
Also pain and sensitiveness over 
region of left ovary. Temperature 
99° to 10 1% constipation, vomiting 
from June 1st till August first. At 
this time I was call^ to take charge 
of the case in the absence of Dr. M., 
who did the curetting, consequently 
an imperfect history was obtained. 

I found the uterus 4i inches deep, 
somewhat fixed, induration around the 
uterus, but no well-defined mass. 
Under local treatment, rest and nutri- 
tive and sustaining treatment, patient 
made decided and progi-essive im- 
provement, and in ten days the uter- 
ine cavity measured three inches. 

I should have said, that there had 
not been at any time mammary en- 
largement, shock or other symptom 
of rupture. The question of extra- 
uterine pregnancy was discussed and 
laid aside. August 10th, had an at- 
tack of apparent pelvic peritonitis 
with gaseous distension of the abdo- 
men, which subsided in twenty-four 
hours. 

In my absence from the city, Dr. 
Robert T. Sloan attended the patient 
for two weeks, in which time she did 
badly. On my return a consulta- 
tion of the following physicians was 
called: Drs. Sloan, Massie, Halley 
and myself. We found the patient 
in a deplorable condition. Uterus 
was fixed, enlarged and retroverted, 
with a mass in front of and to either 
side of the uterine body. Temper- 
ature ranging from 99° to 102% pulse 
90 to 100, bowels constipated as a 
result of the inflammatory exudation 
in the pelvis and immediately in 



Digitized by 



Google 



ECTOPIC PREGNANCY, 



297 



front of the sigmoid flexure of colon 
and rectum. 

The question of the possibility of 
an ectopic gestation wi^is again dis- 
cussed and its existence agreed upon^ 
and operative interference advised as 
soon as the patient's condition would 
permit, she being very anaemic. 

From this time, August 23, there 
was such progressive improvement 
that Dr. Sloan and myself recanted 
in our opinion as to extra-uterine 
pregnancy. The masses gradually 
disappeared, fever subsided, pulse 
became normal and appetite restored, 
patient cheerful, and we had begun 
to felicitate ourselves upon the pro- 
spective early recovery of our patient ; 
but about September 30, she had a 
sharp attack of pelvic inflammation 
with marked increase of mass to left 
and behind the uterus. On October 
2, Dr. Crowell was called in con- 
sultation, and agreed with Dr. Sloan 
and myself as to the advisability of 
surgical interference, and on Octo- 
ber 4, with the assistance of Drs. 
Sloan, Massie and Crowell, we pro- 
ceeded with every anti and aseptic 
precaution, by first puncturing the 
abscess in Douglass' cul-de-sac, and 
emptying about two ounces of fetid 
pus. As this did not affect in the 
slightest degree the mass to left of 
the uterus, Dr. Crowell, at my 
request, made an incision into it, supe- 
rior to and parallel with Poupart's 
ligament, and rapidly removed the 
contents of gestation sac, consist- 
ing of bones, placenta, disintegrated 
tissue and offensive material. This 
sac was attached to the abdominal 
wall in the inguinal region, and was 
practically extra-peritoneal. 



The patient rallied well from the 
operation — a fecal fistula was devel-. 
oped, but gave no special trouble and 
was soon practically healed with only 
a narrow sinus remaining. Indica- 
tions pointed to the recovery of the 
patient, when, on October 11, septic 
pneumonia developed and she died 
on the 14th. 

Some perplexities arose in the 
diagnosis and treatment of this case, 
which were insurmountable and are 
to be regretted. 

1st. Owing to the fact that the 
product of the curettage was not 
examined microscopically, whereby 
decidual membrane might have been 
detected and a diagnos is made. 

2d. The varying size of the 
masses which occurred several times 
during the progress of the case y*^ 
misleading. 

3d. This marked reduction of 
size and tension of these masses took 
place at a time when she had uterine 
hsemorrhagic discharges, which is so 
characteristic of inflammatory tubal 
diseases. 

The final extreme condition which 
demanded surgical interference, re- 
sulted evidently in infection of the 
posterior mass from the rectum, and 
while no communication could be dis- 
covered between this pus cavity and 
the gestation sac, yet the proximity 
of these two cavities was such, that 
infection must have occurred from 
the one to the other. 

Despite the extreme prostration of 
our patient, we were justified in the 
hope that she would recover, until 
the septic pneumonia supervened. 
Wounds never did better, or cavities 
granulate and contract more rapidly. 



Digitized by 



Google 



298 



CHARLES GREENE CUMSTON. 



Autopsy showed that the gestation 
sac was attached to the fimbriated 
extremity of the tube simply, and 
not tubo-ovarian, with no evidence of 
tubal rupture. In the absence of 



signs of distortion of the tubal ostium, 
we were forced to conclude that this 
case was one of primary extra-tubal 
pregnancy. 



Parietal Fibro-Myomata of the Uterus, and Professor VuUiet's Operation 

for their Extraction. 



CHARLES OBEEKE CUMSTON, B. M. 8., M. D., 
BOSTON, BIAS8. 

Instructor of Clinical Oyncecology^ Faculty of Medicine^ Tuft%* College, 



CONTINUED FROM JANUARY NUMBER. 



III. REPORT OF CASES. 

I SHALL divide our cases into four 
categories — 1, the cases where there 
was incision followed by spontaneous 
enucleation ; 2, those where incision 
was followed by partially spontaneous 
and partially forced enucleation ; 3, 
operations in which the incision was 
followed by neither spontaneous nor 
forced enucleation ; 4, cases ^f dila- 
tation without incision. 

The first series is composed of four 
cases which are reported as follows 
by Prof. VuUiet: — 

Case I.—** In 1882 I made my first 
operative attempt, and under these 
circumstances: Treating a lady for 
grave hsemorrhages that were not 
arrested by any of the usual methods, 
I made a digital exploration of the 
uterine cavity. After the procedure 
already indicated I discovered in the 
superior part of the posterior wall a 
discoid tumor, having the diameter 
of a half-dollar. It had the con- 



sistence usually presented in fibro- 
myoma; consequently it was dis- 
tinct from the consistence of nor- 
mal uterine tissue. This tumor gave 
me the impression of being nearer the 
mucous than the serous membrane. 
I knew that sacrification of the 
mucous membrane covering a fibro- 
myoma is an excellent means of pro- 
ducing hsemostasis. My patient was 
in danger. I then decided to profit 
by the dilatation for incising the 
mucous membrane of the uterus. I 
made an incision longer than the 
diameter of the tumor, and deep 
enough to reach the new growth. 
No accident occurred. The hsem- 
orrhages stopped; the periods came 
back at their time in usual quantity. 
I intended to follow this case, when 
I learned that my patient had left 
Geneva without informing me. Six 
months afterward I saw her again ; she 
was in perfect health. By bi -manual 
explorktion I found the uterus was 
normal in shape and size." 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



29» 



Case IL— "In June, 1882, I per- 
formed a similar operation for a 
fibroma, having the diameter of a 
dollar. It protruded slightly into 
the uterine cavity. The layer of 
tissue covering it was extremely thin. 
This, then, was not a typical intra- 
peritoneal fibro-myoma. Neverthe- 
less, the greater part of the mass was 
encased in the wall, and it had the 
greatest resemblance to an interstitial 
fibroma. The incision did not give 
rise to any accident. The neoplasm 
began to come out of the cervix at 
the end of a week. I made fre- 
quent antiseptic injections, and atten- 
tively watched the descent of the 
flaps, and as by degrees they reached 
the vulva I resected them, after which 
the vagina was dressed with iodoform 
gauze. The elimination was com- 
pleted at the end of three weeks. No 
fever existed." 

" These two cases were in private 
patients; I mention them because they 
prove the harmlessness of the incision, 
and also because they explain how I 
was led to deliberately attack small 
fibro-mj'omata entirely intra-parietal 
— that is to say, at equal distance from 
the mucous and serous membranes." 

Case III. — '^In the month of Feb- 
ruary, 1883, while replacing Professor 
Vaucher at the Maternity, I had the 
opportunity of performing a third 
operation. Ida W., servant, unmar- 
ried, aged forty-four; had one child 
twenty years ago. The child, she 
said, was very large ; she was three 
months getting well. About the age 
of thirty-seven her monthly periods^ 
which had been up to that time nor- 
mal, became more frequent and abun- 
dant. In her thirty-eight year she 



had during eight months, and in her 
forty-first year during six months, a- 
complete suspension of her terms ;. 
but except on these two occasion* 
the menstruation took place every 
twenty-one, and even every fifteen^ 
days. In spite of her approach to 
the menopause, her periods increased 
in frequency and abundance. In 
December, 1883, and January, and 
February, 1884, she bled without 
interruption, even when lying down* 
It was this that made her come into 
the Maternity. When we saw her in 
February, 1884, she was very thin, 
pale, and decidedly 'cachectic. The 
uterus is double the normal size, and 
not painful. Unable to work, she 
demanded treatment at any price- 
In the first clinical lecture I set forth 
the reasons which, under reserve of 
any results from the intra-uterine 
examination, led me to diagnosticate 
the tumor as a fibro-myoma. 

The following day the patient was 
anaesthetized, and we examined the 
uterine cavity by direct digital exam- 
ination. The night before a sponge- 
tent was introduced into the cervix. 
When the patient was anaesthetized 
I brought the cervix into view with 
a speculum, and seized one of its lips 
with a pair of my forceps. The tent 
being withdrawn, I introduced the 
index finger as high as possible into 
the uterus ; then by a gentle but con- 
tinued traction I lowered the organ 
until my finger touched the fundus. 
Then confiding the forceps to an 
assistant, keeping the uterus down, I 
found, by utero-abdominal bi-manual 
exploration, a spherical, flattened 
mass in the anterior wall, well defined 
and hard, of a consistence analagoua 



Digitized by 



Google 



800 



CHARLES GREENE CUMSTON. 



to ilmi of fibro-myomata. * The uter- 
ine cavity showed no difformity of its 
walls^ no projection ; only the exterior 
eurfiice of the anterior wall, instead 
of presenting its normal curve for- 
wards, 8<-emed, on the contrary, con- 
Tex and globular. I asked Dr. 
Fontanel to make an intra-uterine 
exatniimtion, and let him note all 
these particulars. My diagnosis was 
then confirmed: I had to do with a 
fi bra- myoma of the typical intra- 
parielal variety. It seemed disposed 
to dt'vt lop rather more into the ab- 
dominal than into the uterine cavity. 
I had a very clear idea of the thick- 
ness of tlie tissue covering the neo- 
plasm. Encouraged by my previous 
experiments, and convinced of the 
harmlessness of an incision of the 
uterine wall, I decided to try to 
change the direction of the migration 
of the nt-tjplasm by giving it an easy 
issue into the uterine cavity. An 
incision was also justified as a means 
of hannostasis. 

I tiijule an incision with a but- 
ton eoil bistoury, about a centi- 
inetie dfep, beginning at the fundus 
ut**ri, and ending a centimetre 
above the external orifice. The haem- 
orrhage was insignificant. The uter- 
us was irrigated with a ^^^ subli- 
mate solution, and was tamponed as 
well as the vagina with iodoform 
gaiiif-e. Two days after Professor 
Aaneht'j transferred the patient to 
his Ward, and I did not see her again. 
I heard that a parametritis developed, 
from which she recovered perfectly. 
At ihiy time the Maternity was 
infected, so that this complication is 
not to I ft} wondered at. We took 
all posisil>le measures, but without 



success. Infectious complications con- 
tinued to appear after energetic meas- 
ures were taken by Professor Vaucher. 
Four months and eight days past 
without news from this patient, when 
she came to the consultation at the 
Policlinic. She said that she lost no 
blood during the week following the 
operation ; but at the end of the week 
the haemorrhages, although not so 
profuse as before, appeared two or 
three times a month. They dimin- 
ished afterwards, and during the week 
preceding her first visit to the Poli- 
clinic no blood was lost. She only 
mentioned abundant whites flowing, 
without smell, during this last period. 
When I placed the patient in the 
examination chair I was in no way 
satisfied with the result of my opera- 
tion — parametritis and return of the 
haemorrhages ; but the minute my 
finger touched the cervix my ideas 
changed. I felt, crowded between 
the lips, the inferior segment of a 
polypus, free on all its periphery, 
except in front, where it adhered to 
the cervical wall, exactly at the point 
where my incision ended. By pene- 
trating into the uterus I found the 
same state as high up as my finger 
could reach. The polypus was free 
everywhere, excepting at its anterior 
part, from which the pedicle started, 
inserting itself on the entire length 
of the anterior wall, precisely where 
I made my incision in the month of 
February. This pedicle was the 
same length as my incision. I can- 
not complete my description better 
than by comparing this pedicle to the 
mesenteric attachment of the intes- 
tine. I insist on this particular dis- 
position of the attachment of the 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



301 



polypus, because it proves that there 
was only a simple coincidence be- 
tween my operation in February and 
the presence of a uterine polypus in 
June. J^er speculum the polypus was 
well seen, as well as its inferior im- 
plantation on the anterior lip. I 
c^uld have immediately performed 
ablation of the polypus ; nevertheless, 
I explained to the students the rea- 
sons which caused me to defer it. 
There was no lygency for operating, 
for the patient had lost no blood, and 
no signs of inflammation or infection 
were present. On the other hand, 
there were the following disadvan- 
tages : the equator of the polypus had 
passed the internal orifice, so that the 
uterine contractions could, in the 
future, act with more energy, on the 
bulk of the neoplasm. These con- 
tractions could, in lengthening, trans- 
form the membranous pedicle into a 
funicular pedicle, and accomplish the 
passage of the neoplasm out of the 
wall in the first place, and out of the 
uterine cavity afterwards. Once the 
tumor is completely isolated from the 
wall, the opieration WQuld be simpler 
and the chance of infection less. 
Ergotin was prescribed internally, 
and tampons of tannin and injections 
of sulphate of copper locally. In 
July, Ida W. entered the Maternity, 
and I removed the polypus. The ex- 
tirpation was very simple; the mass 
weighed about ten grammes. I saw 
the patient often. She has since 
gone back to her work as a servant, 
with health considerably better. The 
menstruation is very irregular and 
far from abundant. The uterus is 
very small in volume, as if it had 
undergone a certain decree of atrophy. 



JEn rSsumSj the ciise was one of a 
small fibro-myoma, which, interstitial 
in February, became intra-uterine in 
June4 this transformation was due to 
the incision. This incision weakened 
the resistance of the muscular layer 
existing between the neoplasm and 
the uterine cavity, and had given a 
preponderance to the layer between 
the neoplasm and the peritoneal cav- 
ity. Nevertheless, the migration of 
the neoplasm was not of sufficient 
rapidity to hinder the intra-uterine 
mucous membrane from cicatrising, 
otherwise the fibro-myoma would 
have immediately been expelled, and 
no polypus would have formed." 

Case IV.— Mrs. M. G., from St. 
Girod, aged thirty-seven ; married at 
nineteen; had had neither child nor 
abortion. At the beginning of 1880 
she noticed that her abdomen swelled. 
Since this she experienced difficulties 
in passing water, which became 
gradually more pronounced, and suf- 
fered continually with pains in the 
kidney. In June, 1887, had abun- 
dant metrorrhcea, and the *'flowers" 
commenced. Dr. Rosset found a ut- 
erine tumor, and ordered a subcu- 
taneous injections of ergotin.* She 
came to Professor Vulliet in August, 
and he found a fibroid tumor of the 
uterus, and told the patient to go 
home and continue the injections of 
ergotin, and advised, in addition, 
daily seances of electricity (fifteen 
minutes). She returned a month 
later. The situation, instead of being 
better, was sensibly worse. The 
patient suffered from sharp pains in 
the abdomen, obstinate constipation, 
and great difiiculties in making 
water; she could not attend to her 



Digitized by 



Google 



802 



CHARLES GREENE CUMSTON. 



work. She entered the private clinic 
of Professor Vulliet. 

General state good ; abdomen pro- 
jecting. Local condition — volumi- 
nous fibroid tumor obstructing the 
pelvis, pressing on the rectum and 
bladder, and reaching above the um- 
bilicus. Cervix could not be found ; 
the finger could not be insinuated 
behind the symphysis to search for 
the cervix. Retroversion of the 
uterus very pronounced ; reduction 
was tried in vain, the body would not 
tilt above the promontory. Vulliet 
tried, at three different times, to re- 
duce the organ. The fourth day all 
was prepared for a laparotomy : 
nevertheless, when the patient was 
profoundly anaesthetized, the profes- 
sor made a last effort in taxis. Push- 
ing above brought about no displace- 
ment. Pressing in the other direction 
was tried; he felt the uterus slip 
lower down. He then made alterna- 
tive pressures on the abdomen and 
per vaginam. The uterus gradually 
became more movable in both direc- 
tions, and suddenly it passed the 
promontory and took its normal 
position. 

The tumor was then more prom- 
inent ; it extended about three fingers' 
breadth higher than before the re- 
duction ; it seemed, in the first place, 
as if there existed a tumor on both 
horns of the uterus. The cavity 
measured twelve centimetres, and had 
a curved direction, with concavity 
forwards. Dilatation was practised, 
introducing first Hegar's small bou- 
gies, then with strips of laminaria cut 
in form of urethral sounds. These 
were with drawn the next day, and 
replaced by nine large iodoform tam- 



pons. At the end of eight days the 
cavity was well open. Vulliet found, 
by intra-uterine touch, combined with 
abdominal palpation, an interstitial 
fibroid of the posterior wall, and gen- 
eral hypertrophy of the walls. An 
incision was made in the tissues cover- 
ing the part where the fibroid was 
found; then the uterus was tamponed. 

The prominences felt at the right 
and left on the fundus diminished in 
size during the following days; the 
left horn remained more developed. 
These projections were attributed to 
a median furrow due to a long pres- 
sure of the promontory on the middle 
of the extremity of the uterus. 

The tampons were changed once 
every two days. At the third dress- 
ing, the woman having felt the pre- 
ceding day some expulsive pains, 
about fifteen grammes of pieces of 
fibro-muscular tissue came away; and 
after this, each time the dressing was 
changed, debris of the ' same nature 
was found. The uterus still remained 
voluminous, but the tume faction of 
the left horn formed the essential part 
of the abnormal development. Vulliet 
decided to make a second incision 
over this local enlargement. Hardly 
had the knife penetrated into this part 
when a flood of blackish, slimy blood 
escaped. The appearance of this blood 
clearly indicated that it was a pro- 
duct of retention. It was very prob- 
ably a local hsematometria, produced 
by the closing of the uterine walls 
unexpectedly on account of the com- 
pression which was produced when 
the tumor was imprisioned behind 
the promontory. Vulliet introduced 
his fingers and enlarged the opening- 
The return of this diverticulum to 



Digitized by 



Google 



PARIETAL FIBRO-.MYOMATA OF THE UTERUS. 



80S 



the cavity of the uterus caused a 
depth of fifteen centimetres of same. 

Tampons were placed up to this 
diverticulum, and daily intrauterine 
dressings were made for a week (irri- 
gations, tamponing, &c). Faradiza- 
tion and ergotin were ordered, and 
two weeks after the operation the' 
uterus had undergone such an involu- 
tion that it reached only two fingers' 
breadth above the symphysis. The 
patient then returned to her home. I 
learnt that when there she was in bed 
for two weeks for a phlegmasia alba 
dolens. 

It is evident that a series of ma- 
noeuvres cannot be performed in the 
uterus, such as had been accom- 
plished, without exposing the patient 
to some of the slight complications 
of labor. The fact of having found 
a local haematometria in the living is 
rare. Professor Zahn, to whom I 
mentioned the fact, said that he had 
sometimes found the phenomenon at 
the autopsy. The case is doubly in- 
teresting — first, the patient demon* 
strated that retroflezio uteri fibroBi is 
a complication which, so far as sur- 
gical interference is concerned, 
renders the operations more difficult, 
the more so if the retroflexion of 
the gravid uterus compromises ges- 
tation and labor. The reduction of 
the uterus , is the first indication to 
fulfil, and it may certainly often be 
accomplished by a persevering and 
well-combined taxis. On the other 
hand we were placed face to face with 
a case which is such as not to admit 
of a laparotomy — the indication was 
urgent to intervene. Now, a laparo- 
tomy performed under the circum- 
stances was of a nature to change the 



statistics of operations for fibro-myo- 
mata in a favorable direction. 

Second series: Cases where incision 
was followed by enucleation, partly 
forced, partly spontaneous. 

Casb V. — Miss Sophie P., aged 
forty-three, unmarried, virgin ; has 
suffered between twenty to thirty 
years from chloro anaemia, and had 
small-pox in 1871. Since the c(»m- 
mencement of 1884 her menstrua- 
tions have been painful and abundant. 
Two years later intermenstrual loss 
of blood and a discharge of yellowish- 
white secretion commenced. Since 
April, 1886, Miss P. has had fearful 
pains between the umbilicus and the 
pubes, extending towards the kid- 
neys, and particularly towards the 
right hip. Dr. Rolland, of Divonne, 
found a uterine tumor, and put hi& 
patient under a palliative treatment, 
consisting of sitz baths and astringent 
injections. He sent her to Professor 
Vulliet o^ September 17, 1886. 

General condition — thin, face 
pinched, abdomen perfectly round, as 
in a six months' gestation. Local con- 
dition — cervix dilated to the size of a 
sixpence; inferior segment of uterus 
globular. The finger introduced into 
the uterus feels a hard and elastic 
tumor ; the organ reached two. fin- 
gers' breadth above the umbilicus. 
Dilatation — intra-uterine examina- 
tion reveals a fibromyoma, a conical 
portion of which projects into the 
cavity ; and another, much more con- 
siderable, is found in the superior 
part of the posterior walls of the 
organ. In other words, then, the 
bulk of the tumor is incased in 
the uterine muscle, and its point pro- 
jects into the uterus. 



Digitized by 



Google 



304 



CHARLES GREENE CUMSTON. 



The patient was etherized for the 
exploration. Profiting by the circum- 
stances, Professor Vulliet washed out 
the cavity with a solution of corrosive 
sublimate at -^j^ per cent., and secur- 
ing the cervix by claw-forceps he 
split it by two lateral incisions ; then 
sliding a pair of long, curved scissors 
along two fingers introduced into the 
uterus he commenced a resection of 
the tumor at the base of the project- 
ing part ; then seizing the top of the 
new growth by a tenaculum it was 
drawn down, and the resection was 
continued until it became circular. 
By traction the neoplasm came down. 
The incision was stopped when it was 
found dangerous to cut higher. Vul- 
liet thought that he could remove 
about a quarter of the tumor as it was ; 
the rest remained imprisoned in the 
wall. Instead of trying enucleation, 
which was diflBcult and dangerous on 
account of the situation of the tumor, 
it was decided to leave th^ further 
elimination to spontaneous enuclea- 
tion. The cavity was washed out 
with sublimate and stuffed with 
iodoform tampons; the dressings 
were changed every two days. A 
discharge was established, resembling 
such as is seen after a normal 
labor, with this difference, that in 
it were found pieces of fibrous tissue. 

The patient having felt, at differ- 
ent times, expulsive pains, a second 
examination was made at the end 
of the month. The greater part of 
the tumor had entered the uterine 
cavity. It was drawn outside by 
forceps, and the attachments which 
held it back were cut through with 
scissors, and, after an operation of 
about half an hour, it was entirely 



removed. In this case we had to 
do with a fibro-myoma, partly sub- 
mucous, partly intra-parietal. The 
circular incision made around the pro- 
jecting part of the tumor and the 
ablation x)f this part may be consid- 
ered as a resection. The intra- 
parietal part, under the influence 
of expulsive pains, was afterwards 
pushed into the uterine cavity. It ia 
evident that immediate efforts to 
enucleate would have failed. By the 
permanent dilatation, uterine action 
was produced by the tampons remain- 
ing in the organ, which provoked and 
facilitated the expulsion, at the same 
time the iodoform cotton assured 
asepsis and drainage. The patient 
was seen in December, 1887, and was 
in perfect health. 

Case VI. — February 24, 1887 
Professor Vulliet was called, in con 
sultation, to see Mrs. G., aged thirty 
six, married fourteen years, and i 
multipara. For twelve years th< 
patient has suffered from her uterus 
her abdomen gradually increasing ii 
size. Having consulted many sur 
geons, she is made aware that she has i 
fibroma of the uterus. Since August 
1886, the menstruation — up to tha 
time regular and normal — has com 
pletely stopped, and the abdomen ha 
become more swollen. She said tha 
the doctors she had consulted were i 
doubt as to gestation. During th 
week before my consultation she ha 
had, at several times, symptoms lik 
those of the commencement of labo 
It was under these circumstances ths 
she summoned Dr. W., who calle 
Professor Vulliet into consultatioi 
After a most careful examinatioi 
Vulliet made a diagnosis of a gest 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



806 



tation, the foetus dead, and could not 
be expelled on account of a tumor. 
The following day a new labor com- 
menced, and a foot was presented at 
the external orifice. The extraction 
offered no difficulty, and a foetus of 
about five months, dead for some 
weeks, was found. To effect delivery 
the introduction of a hand into the 
uterine cavity was required. Profit- 
ing by the circumstance, Vulliet pal- 
pated the tumor between his hands, 
and thus determined its size, con- 
sistence, and, above all, its relations 
with the walls of the uterus. It was 
a typical interstitial fibroma of the 
anterior wall. It extended above to 
the fundus uteri, and below up to the 
internal orifice; the cervix, strictly 
speaking, was normal ; the convexity 
of the tumor faced the serous mem- 
brane; in the mucous membrane 
there was no marked projection ; the 
neoplasm was hard and resistant, and 
not elastic, being the size of a large 
orange. Upon this ground the pa- 
tient declared that she had decided, 
for some time past, to undergo a radi- 
cal operation, and decided to have it 
performed as soon as she recovered 
from the abortion. 

The size and abdominal develop- 
ment of the tumor showed that an 
attempt to perform a total extir- 
pation could be obtained only by 
laparo-hysterectomy ; but Professor 
Vulliet, profiting by the physiologi- 
cal dilatation caused by the gesta- 
tion, thought his method might 
be employed after artificial dilata- 
tion had been practised. He ex- 
plained his plan to Dr. W. and 
myself. It consisted in observing 
the patient for two days, so as to 



eliminate all pre-existing infection ; 
then to tampon the uterus to see how 
tijis organ would behave in regard to 
a " tamponnement k demeure " post- 
partum; and lastly, if no fever or 
intolerance appeared, to perform a 
resection of the tumor. Without put- 
ting aside the accidents which might 
ensue. Professor Vulliet thought that 
the dangers would not be greater 
than those accompanying laparo- 
hysterectomy. No pyrexia having 
been found, and the tamponing being 
perfectly well supported, the opera- 
tion was performed five days after 
the abortion. The hand was easily 
introduced into the uterus, freed from 
the tampons, and washed out with a 
solution- of sublimate (i^jVir). Seiz- 
ing, with the other hand, a button- 
pointed bistoury , with a hidden blade, 
it was slipped along the fingers of 
the other hand into the cavity of the 
uterus ; a long and deiep incision 
could then be easily made. The 
haemorrhage was of no importance; 
in consequence the cavity was again 
plugged at once, and the tampons 
were changed every second day. 

The sixth day after the incision 
Vulliet was again suddenly called 
to see the patient, who was again in 
labor. By touch, he discovered a 
round, flat disc in the vagina, which 
had been spontaneously expelled from 
the uterus ; he then felt the remain- 
ing tumor projecting into the cavity 
through the gaping of the incision. 
I administered the ether, and Vulliet 
proceeded to the extirpation of the 
intra-uterine portion of the tumor. 
The cavity was again washed out with 
sublimate, and completely plugged 
with iodoform tampons. At three 



Digitized by 



Google 



306 



CHARLES GREENE CUMSTON. 



different times, at intervals of six and 
five days, the patient had expulsive 
pains, and, with each, pieces were 
expelled from the incision ; they were 
immediately removed by traction and 
by section. March 23, the patient 
was completely delivered of this 
tnmor, which she had carried for 
twelve years. The uterus was large 
•on account of the modifications in 
its structure, caused by the tumor as 
well as by gestation. Two months 
later the patient possessed a normal 
•uterus, fit for conception and gesta« 
tion. We have often seen her since, 
and she was never better in her 
life.^ 

Case VII.— Mrs. S. B., aged forty- 
six, married, a confinement in 1871, 
has had menstruation three times at 
the commencement of gestation, an 
abortion at six weeks in 1881. She 
dates her trouble from 1879. At this 
time she experienced a malaise in the 
■entire uterus, and had vomiting as if 
pregnant. Menstruation was before 
this irregular, became, during the last 
fieven years, so abundant that it stops 
only for a few days ; constant dys- 
ipenorrhoea, severe pains in the kid- 
neys and abdomen, troubles in micturi- 
tion, yellowish-white discharge. In 
1884 Mrs. B. came to Geneva to con- 
sult Dr. D. Professor Vulliet, who 
was by chance at this gentleman's 
house, removed a polypus, as large as a 
small mandarin orange, from below the 
inferior segment of the uterus and 
lodged in the vagina. This operation 
relieved the patient, but soon after 
.bloody discbarges appeared again. 
She was then advised to leave off her 
occupations, and was put under treat- 
ment by ergotin. During the winter 



thB discharge was considerably dimin- 
ished and the suffering less, bat all 
commenced again in the spring, when 
Mrs. B. began once more to work 
She was sent to Professor Vulliet, ir 
January, 1887. 

The uterus was as large as a 
a four month's gestation, but per 
fectly regular in form. Four sSance 
of dilatation by tampons were sufiB 
cient to enable us to see five o 
six centimetres deep into the cavitj 
aided by an intra-uterine speculun: 
Nothing was seen except an intens 
inflammation of the mucous men 
brane. By examination with tw 
fingers and by lowering the organ, 
tumor was distinctly felt, having th 
dimensions of an orange. It formed 
slight vault in the cavity, but coi 
sideraby more so in the abdomen, i 
the region of the right horn. Incisic 
two and one-half centimetres deep 
abundant hsemorrhage, but lasting 
short time. The finger, inserted ii 
mediately into the incision, felt 
tissue which could deceive nobody ; 
was the fibroma itself that bad be< 
cut. Irrigation with corrosive su 
limate ; tamponing ; ergotin ; electi 
city. After the second day lab 
pains ailnounced the expulsion ; tl 
third day intra-uterine examinati 
having shown fibrous masses in i 
uterus, the patient was put und 
ether. These masses were seized a: 
excised with scissors ; about forty 
fifty grammes of tissue were removi 
Some debris existed in the gap of t 
opening. Continuation of tamponi 
and treatment. 

Labor again began in three da 
The patient is etherised. By 1 
touch, the remains are found £oi 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



807 



ing a hard tumor very intimately 
united with the uterine wall. Vul- 
liet, with a pair of strong forceps, 
armed on the inside of their blades 
with sharp points, seized the fibrous 
masses and by a movement of rotation 
was able easily to enucleate them ; he 
removed this time fifty to sixty 
grammes of fibrous tissue. Intra- 
uterine touch, combined with abdo- 
minal palpation, showed that the 
uterus was completely freed of all 
new growth. This patient was a 
woman who had already had a fibroma 
removed ; it was consequently just to 
suppose that there still might exist 
others, but the uterine walls were of 
normal consistence and everywhere 
homogeneous, so that nothing ap- 
peared suspicious. It is probable that, 
when several fibrous nuclei exist, the 
great development of one prevents 
development of the others ; but if 
spontaneous elimination or an abla- 
tion takes place, thus removing the 
tumor, the others may grow and pro- 
duce the same train of symptoms. 
VuUiet considered this fibro-myoma 
as intra-parietal, having two poles — 
one sub-mucous, the other sub-serous. 
The muscular tissue must have been 
very thin, but had not lost its con- 
tractility ; spontaneous elimination 
was a proof of this fact. January 23, 
we saw the patient, who was exceed- 
ingly well ; menstruation was normal, 
a fact which, the patient said, had 
never before occurred in her previous 
•life. 

Case VII L— Mrs. L. M., aged 
fifty, married ; six normal deliveries, 
•ne abortion with good termination. 
Very abundant menstruation, regular 
until November 8, 1887. Very little 



whites. For about three years has 
had pains in the kidneys, feeling of 
weight in abdomen, troubles of the 
bladder and rectum. November 8, 
1887, patient was suddenly taken with 
haemorrhage when getting up. Since 
then, has had bloody discharge, which 
stops only for a short time ; the com- 
mencement of each haemorrhage is 
announced by pains in the abdomen. 
Dr. B., having recognized the presence 
of a uterine tumor, called Pi*ofessor 
Vulliet in consultation on April 5. 
An operation was decided on, and the 
patient entered Professor Vulliet's 
private clinic on April 8. General 
condition — tall, well built, thin, with 
with marked anaemia ; patient states 
that she weighed ninety-seven kilos, 
in October, 1837 ; she has sensi- 
bly diminished in weight. April 9, 
Vulliet had the first sSance of dilata- 
tion by tampons, a second was made 
the 10th, a third the llth. On the 
next day, the uterus was open enough 
to allow of the introduction of four 
fingers into the cavity of the organ. 
Local condition — by abdominal 
palpation a fibrous tumor is felt, en- 
cased in the anterior wall ; it projects 
into both abdominal and uterine 
cavities, especially at its inferior part ; 
the posterior wall of the uterus is 
thin. Diagnosis — ^fibrous tumor of 
the uterus. 

The operation took place April 
12. Vulliet commenced by with- 
drawing about thirty tampons from 
the uterine cavity; an irrigation 
of five litres of corrosive sublimate 
dlfinr) ^*® ^^^^ made ; the vulva 
was held apart, and the uterus was 
drawn down ; a " boutonnidre " was 
then made with scissors in the uterine 



Digitized by 



Google 



308 



CHARLES GREENE CUMSTON. 



mucous membrane ; it was then 
opened up six to seven centimetres, 
and the neoplasm was thus brought 
into view. The finger was then in- 
troduced so as to perform enucleation, 
which was remarkably easy on the 
entire periphery. As the uterus 
was hard to draw down, the finger 
could not reach the upper limits of 
the tumor to accomplish the enuclea- 
tion, so it was decided to amputate 
with scissors as high up as possible, 
when the cavity, resulting from this 
operation, could be stuffed with tam- 
pons. This amputation was difficult, 
and brought away the lower part of 
the tumor weighing about two hun- 
dred grammes. The two following 
days the tampons were renewed after 
irrigation. On the third day there 
was a slight rise in the temperature, 
and it was feared that the remaining 
portion had been infected, so Vulliet 
removed from the surface about fifty- 
grammes of tissue which presented 
no signs of decomposition. On the 
eighth day after the operation, having 
noticed that the tumor had consider- 
ably descended, Vulliet decided to 
end the extirpation, which, thanks to 
the spontaneous enucleation produced 
since the last sSance^ was very easy, 
for the finger reached the superior 
limits. This portion weighed two 
hundred and seventy grammes. Mrs. 
M. was well at the end of eight days 
without accidents. 

We have here another example of 
a tumor for which, on account of its 
size and situation, laparotomy was 
indicated, and which was extirpated 
by the natural passages without muti- 
lating the uterus. 

Third series : Cases of resection 



followed by neither enucleation nor 
forced enucleation. 

Case IX. — In August, 1884, 
Vulliet operated at the Maternity on 
a fourth case. Mrs. G., aged fifty- 
three, complained for ten years of 
abundant loss of blood every two 
weeks. Has always had anaemia, is 
feeble, and the gravity of her condi- 
tion justified energetic intervention. 
He examined by intra-uterine touch 
and discovered an interstitial fibroma 
situated in the posterior wall; the 
maximum of development was a little 
to the right of the median line. He 
made an incision the entire length of 
the uterine wall about a centimetre 
deep; on complication. The patient 
remained in bed two weeks and then 
left for the country. Two weeks 
later she returned to the Maternity. 
Vulliet did not see her, and it was Dr. 
Fontanel, the assistant of the Bervice^ 
that received her. It was learned 
from him that no haemorrhage ap- 
peared, and that the patient felt and 
appeared better. Since that she has 
not come to the Maternity, feeling 
probably too well to come for her own 
interest. In February, 1887, we 
looked her up. Mrs. G. was perfectly 
well ; she attends to her occupations 
as schoolmistress. Her uterus is 
double the normal size.. Vulliet 
believes that there exists another 
fibrous tumor which keeps it thus 
enlarged ; but this tumor is probably 
sub-serous, and gives rise to no symp- 
toms. 

Case X. — Mrs. M. D., aged forty- 
six ; three confinements, one abortion, 
which kept her in bed six months; 
she catinot tell what the complication 
was; no heredity in the family; 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



309 



domestic troubles. Menstruation 
regular until 18S3. Since this date, 
discbarge more frequent and very 
abundant, every two or three weeks 
lasting eight to ten days. Subjective 
symptoms : feeling of weight and dis- 
comfort in abdomen and kidneys; 
pains sometimes sharp. In 1884 the 
discharges of blood became more 
abundant ; to the metrorrhagia are 
added white and yellow discharges; 
micturition frequent ; enlargement of 
abdomen. She underwent different 
treatments, principally cauterization 
of the cervix. Professor Vulliet was 
consulted on August 24, 1886. 

General condition : Uterine facies, 
thin, projecting abdomen, • digestive 
trouble, anaemia. Local condition; 
Abdominal tumor situated in the mid- 
dle, as large as a six months' and a 
half uterus, hard and resisting; enor- 
mous cervix, its entire left lateral 
segment is considerable. The exter- 
nal orifice assumes a semi-circular 
shape, and is pushed to the left, on 
account of the projecting tumor ; it 
admits two fingers, which penetrate 
easily to a distance of two or three 
centimetres. All movements given 
to the cervix are reproduced by the 
tumor. The cavity measures eight- 
een centimetres. By the introduc- 
tion of large sounds, drawing the 
organ down and bimanual exploration, 
the tumor is found to be interstitial, 
situated in the right lateral wall. 
Vulliet was struck by one peculiarity ; 
this was the softness of the tumor. 
He commenced at once the dilatation 
of the cavity with iodoform tampons, 
^fter three or four stances, ten centi- 
metres into the cavity could be seen 
by means of an intra-uterine speculum. 



Intra-nterine touch gave the exact 
relation of the new growth to the 
walls. It was a large tumor, entirely 
abdominal. The uterus had kept its 
shape, notwithstanding that the right 
horn was evidently more developed 
than the left. . As high up as could 
be felt, the left wall was thinned. 
There was no projection into the 
cavity. Vulliet made a longitudinal 
incision, in order to loosen the inter- 
nal layer, at three different ^ times, 
allowing a repose of two weeks be- 
tween each stance. At the same 
time, he ordered faradization and 
ergotin, so as to push the neoplasm to 
the side weakened by the incision. 
The last incision was made about the 
middle of October. A watery run- 
ning was produced. Some weeks 
after, the fibroma had gradually 
diminished. The difference in volume 
was more marked in the bilateral and 
antero-posterior diameters. The dis- 
charges stopped, the patient became 
gay, strong, and active. The abdo- 
men had its normal dimensions. The 
incisions had not been followed by 
spontaneous enucleation, but they 
had caused, with the aid of electricity, 
an absorption and a remarkable 
haemostatic effect. 

This continued for three months, 
when suddenly, about the beginning 
of January, without any known cause, 
during the absence of Professor Vul- 
liet, the patient was taken by a 
series of malaises. The abdomen 
became large and painful on pressure ; 
no vomiting, cephalalgia, or fever. 
Upon his return, Vulliet found the 
symptoms very different from those 
in August ; the abdomen had become 
greatly swollen. The tumor reached 



Digitized by 



Google 



310 



CHARLES GREENE CUMSTON. 



above the umbilicus. By abdominal 
palp.ation, fluctuation was felt in cer- 
tain parts of the neoplasm. Little by 
little the inflammatory symptoms sub- 
sided, but the tumefaction lemained 
The diagnosis was undecided. Was 
it an oedema of the fibroma and the 
formation of a cyst? Finding a spot 
where the fluctuation appeared pro- 
nounced, an exploratory puncture 
was made ; this gave no result. But 
the fluctuation becoming more evident 
and more extensive, a second puncture 
was made fifteen days later ; it gave 
issue to four litres of non-sticky, 
grayish-yellow pus. Following this 
second puncture the patient had a 
few days of relief and repose, but the 
liquid soon reappeared. Towards the 
end of February the fluctuation was 
again evident in the entire tumor, 
and signs of absorption showed them- 
selves in a slight pneumonia, probably 
septic. In presence of these alarming 
symptoms the urgency of an interven- 
tion was felt. But what interven- 
tion? Laparotomy with total hyste- 
rectomy could not be thought of, for. 
on one hand, the patient was very 
feeble, and could not stand the shock ; 
on the other hand, the tumor was too 
large, too diffused, and its adhesions 
were probably too numerous for one 
to count on a radical operation with 
any chance of success. Professor 
Vulliet decided to make an explo- 
ratory incision, and, on account of the 
circumstances, to fix the walls of the 
cyst to the lips of the abdominal 
wound ; to empty and scrape the 
cavities after having destroyed the 
partitions dividing them, and so try 
to procure a fixation of the fluid 
tumor by a consecutive drainage. 



The patient was etherized on Feb. 
28, 1887. Having made an incision 
through all the abdominal tissue, ten 
centimetres in length, Vulliet reached 
the uterus, fastened it by sutures to 
the lips of the abdominal wound; 
then an incision was made in the 
uterine wall, from which twelve litres 
of nasty pus was withdrawn. The 
cavity was washed with a solution of 
corrosive sublimate (yoVo)' *"^ ^ 
drainage-tube, of one and a half cen- 
timetres in diameter and fifteen cen- 
timetres in length, was introduced. 
Every day the cavity was washed 
with an antiseptic solution. As the 
cavity diminished in size a smaller 
and shorter drainage-tube was in- 
serted and a lArger one removed. 
The patient got well with astonishing 
rapidity. After the month of May 
she resumed her occupation. At this 
time she experienced no discomfort, 
and all physiological functions were 
normal. The abdominal portion of 
the tumor is only noticed in the part 
where it is fixed to the wall ; the 
cervical portion is considerably atro- 
phied. Mrs. D. may be considered 
as cured ; she is forty-seven ; the 
menopause will soon render a new 
growth of fibromata improbable. The 
history may thus be summed up: — 
Ist. A fibroma, probably oederaatoas 
from the commencement. 2nd. 
(Edema is reduced under the influ- 
ence of the incisions, ergotin, and 
electricity. 3rd. Reappearance ol 
oedema when the incisions were cica 
trised. 4tb. Formation of a cyst in 
the tumor. 5th. Puncture leading to 
suppuration of the cyst. 

I have quoted this case, even 
though the intervention did not cause 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



311 



expulsion of the tumor by the natural 
passages. I think it proves that 
oedema and cystic degenerescence 
tend to produce conditions in which 
one cannot count on spontaneous ex- 
pulsive efforts, which are absolutely 
necessary after incision. But, I 
believe that, even in a similar case, 
Vulliet's operation by the natural 
passages and by the interior of the 
dilated cavity, may prove of great 
service. This patient was relieved of 
a tumor to the same extent as if a 
sub-vaginal amputation of the uterus 
with fixation of the stump in the 
wound had been performed. It mat- 
ters little whether the uterus be fixed 
by the edges of an incision made into 
the wall, or by the surface of amputa- 
tion, if the remaining uterine mass 
cause neither trouble nor pain and 
its volume is insignificant; besides, 
the dangers were not as considerable 
as if laparo-hysterectomy had been 
performed. It may be advanced that 
we produced infection by the incisions 
and by punctures. In reply I would 
say that the uterus was already the 
seat of an ichorrhcea and that the 
infection could have been produced 
as well by the traumatism of lapar- 
otomy as by the operations we per- 
formed. 

Fourth series, where there was 
only dilatation without incision. 

Case XI. — Mrs. L. R., aged forty- 
six, married ; three normal deliveries, 
one abortion ; menstruation regular 
until 1885, when the c'ischarges 
became so abundant that there was 
an interval of only two or three days 
between them ; dysmenorrhoea in- 
tense ; hsemorrbagia commenced ordi- 
narily by vomiting. 



» February 17, 1887. — Professor Vul- 
liet was called into consultation by 
Dr. U. Mrs. R. was in a very grave 
condition. During the day she had 
had an attack of ursemia, as well as 
the vomiting characteristic of intes- 
tinal obstruction ; much albumen in 
the urine. Upon examination Vulliet 
confirmed Dr. R.'s diagnosis. These 
troubles were due to compression by 
a tumor completely obstructing the 
pelvis, pressing the rectum and blad- 
der against the bones. The fingers 
could not be introduced behind the 
symphysis to find the cervix, which 
was pushed high upwards. Tympan- 
ites did not permit of abdominal 
palpation, so that, in short, it was a 
case where an exploration could not 
be obtained, and which demanded an 
urgent intervention. The uselessness 
of the efforts at reduction led to the 
conclusion that the mass was fixed by 
adhesions. Nevertheless, it was de- 
cided to try vaginal and rectal irriga- 
tions and cold applications to the 
abdomen. 

When the patient was better she 
entered Professor Vulliet's private 
clinic. The tumefaction had not 
diminished miich, and to save the 
life of the patient an operation was 
necessary, which presented itself 
under very bad conditions. The 
patient was etherized, Vulliet not 
wishing to operate without trying 
reduction. He was about to give up, 
when it seemed to him as if the 
tumor was slightly displaced. He 
commenced again, and suddenly the 
fundus uteri swung above the prom- 
ontory, and at the same time the 
cervix came into place. The tumor 
reduced reached to the umbilicus. 



Digitized by 



Google 



312 



CHARLES GREENE CUMSTON. 



This reduction changed the physiog- 
nomy of the case. Extirpation by 
laparatomy roight have been tried, 
which presented no special difficulties, 
but Vulliet preferred to have recourse 
to dilatation. When the uterus was 
largely dilated he could find nowhere 
a circumscribed tumor. The entire 
organ was hypertrophied ; the walls 
were uniformly thick. It was prob- 
ably the kind of new growth de- 
scribed by Virchow as general hyper- 
plasia of the uterine fibro-muscular 
tissue. A Hodge's pessary was intro- 
duced to prevent another retrover- 
sion. This woman is at present well. 
The uterus has considerably dimin- 
ished in volume. 

In this case if reduction had not 
been a'ccomplished, it would have 
been necessary to perform sub-vaginal 
amputation of the uterus, while, when 
once reduction was accomplished, the 
case became entirely different; the 
urgency of operating disappeared, 
and tamponing availed to bring about 
a considerable diminution of the 
hyperplasia and its symptoms. Dila- 
tation in a like case replaces an 
operation which gives many chances 
for a fatal ending. 

Case XII. — Mrs. A. H., aged 
thirty-three, married, multipara, anae- 
mia for several years. In 1882 she 
received bad treatment from her hus- 
band — kicks, etc. Since then she 
experiences continual contractions in 
the abdomen, constipation, frequent 
nausea. Menstruation always regular. 
Since 1883 she has had watery dis- 
charges and whites. She came to the 
Policlinic in September, 1887. She 
had not consulted a doctor. General 
condition: Well built; ansemic; ab- 



dominal facies. Local condition: 
Projecting abdomen ; voluminous 
uterus, extending four fingers' breadth 
above the umbilicus, situated rather 
to the left; cervix normal, closed; 
anterior cul-desac relatively free. In 
the posterior cul-de-sac is felt a round 
body, with an even surface, smooth 
and voluminous. Sound enters fifteen 
centimetres deep. Dilatation with 
laminaria and prepared sponges, com- 
bined with iodoform tampons ; these 
were well supported. In six days two 
fingers could be introduced into the 
uterus just above the internal orifice. 
At this point the anterior wall ap- 
peared quite free. In the posterior 
wall is felt a convex tumor, hard and 
fibrous, commencing just above the 
internal orifice. As I was alone I 
could not bring down the organ ; and 
as the cavity was very deep (fifteen 
centimetres) for exploring with only 
two fingers, I continued the dilatation 
by introducing eleven iodoform tam- 
pons, each as large as a walnut. Vul- 
liet being obliged lo leave for a certain 
time, and not wishing to undertake 
the case, I stopped the dilatation for 
the time being. The patient re- 
turned in November. At the exam- 
inatign I was astonished at the 
diminution of the tumor — the uterus 
had fallen three fingers breadth below 
the umbilicus. Thinking that this 
happy result might be due to the 
intra-uterine iodoform tamponing, I 
recommenced the dilatation. 

November 9. — Laminaria. 

November 10. — 10 iodoform tam- 
pons in the cavity, and prepared 
sponge. 

November 11. — 15 iodoform tam- 
pons and large prepared sponge. 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



313 



November 12. — 19 large iodoform 
tampons without sponge. 

November 13. — 3 laminaria, sepa- 
rated by tampons. 

Before each stance of tamponing, 
intra-uterine irrigation with corrosive 
sublimate solution. At the end of 
five days the dilatation was at the 
same point as when I left off the first 
time. Having kept this degree of 
, dilatation for four weeks I left the 
patient at rest, and commenced again 
about the I5th January. At each 
dilatation the uterus was notably re- 
duced in size. It augments, it is true, 
in volurtie at the time of menstruation, 
but afterwards it comes back to the 
proportions it had before. In spite of 
these relapses a regular reduction in 
volume was obtained, and the greater 
part of the discomforts as well. Mrs. 
H. can continue her daily occupa- 
tions. 

I have mentioned this case although 
there was no surgical intervention to 
extirpate the new growth; it supports 
certain setiological considerations as 
to fibro-myomata that I mentioned in 
the commencement of this memoir. 
This is not the only one ; in the 
greater number of cases that under- 
went tamponing, the volume of the 
new growths diminished very much. 
The fibromatous tumor seems to be a 
kind of goitre of the uterus on which 
idoform appears to act in the same 
way as in cervical goitre. 

Case XIII. — Mrs. P., aged forty- 
two, pluripara, consulted Professor 
Vulliet in July, 1885, for a large 
fibroma which had reached the level 
of the umbilicus some time previously. 
She lost blood in abundance during 
and between her periods. The pro- 



fessor performed dilatation ; the haem- 
orrhages stopped. In August and 
September the menstruations were 
normal. In October the haemorrhages 
appeared again, and in December she 
came and begged to be operated upon; 
being poor; she could not be detained 
at home by her sickness. 

Vulliet reports its further progress 
as follows: ''Having already per- 
formed dilatation, I had been able 
to forsee that it would be very easy 
to obtain, in a short time, a large 
dilatation of the uterus. This con- 
sideration, as well as the splendid 
results that enucleation had given me, 
encouraged me to have recourse to 
this method. I regretted, as will be 
seen later on, having changed the 
rules which had guided me before — 
rules, in accordance with which, I 
had applied my operation only in the 
case of small or medium -sized myo- 
mata. In this case 1 tried to operate 
in a space measuring 18 centimetres, 
and on a uterus reaching to the um- 
bilicus. 

On November 8th I commenced 
dilatation ; on the 12th it was so 
complete that I could introduce four 
fingers into the uterus. By biman- 
ual palpation I could distinctly feel 
a fibroma as large as a child's head, 
situated at the fundus of the 
uterus in the superior and posterior 
walls. Being absolutely interstitial, 
it caused no projection in either the 
interior or exterior of the organ. I 
cut down on it, making a long inci- 
sion into the capsule; this incision 
was not deep ; no complication. Two 
days later the patient entered into 
labor which lasted two hours and 
then stopped. The next day I intro- 



Digitized by 



Google 



814 



CHARLES GREENE CUMSTON. 



duced my finger into the uterus I felt 
a little mass of fibro-myomata form- 
ing a hernia into the half-opened in- 
ferior part of the incision. I intro- 
duced new tampons, hoping to 
produce a spontaneous delivery. La- 
bor commenced again during the day, 
but was feeble. On the next day 
things were the same. The woman 
having lost blood during two years 
was very weak. On the evening of 
the 16th of November there was a 
slight elevation of the temperature. 
On the morning of the 17th, the fever 
having increased, and the patient's 
expression presenting a certain de- 
gree of alteration, I foresaw the dan- 
ger. Introducing the entire hand 
into the uterus, I made fruitless 
efforts to seize the new growth, and 
succeeded in drawing down only 
insignificant fragments. Placing the 
patient in the genu pectoral position, 
with the aid of my intra-uterine spec- 
* ulum I could see that part of the new 
growth which formed the hernia in 
the incision, but could get no further. 
My inability to extract or enucleate 
the growth resulted from the fact 
that the field of operation was situ- 
ated too high up. 1 could not reach 
it^ either by downward traction or by 
pressure from above. I was certain 
that I could easily operate on the en- 
tire neoplasm if it were only three or 
four centimetres lower down, for I 
had every facility lor manoeuvres in 
the breadth of the cavity. 1 proposed 
abdominal hysterectomy, but the pa- 
tient having had shooting pains, abso- 
lutely refused to submit to the opera- 
tion, hoping that the affair might 
terminate by delivery. She died in 
the night of the 17th. 



I will not argue the point that 
hysterectomy would not have prob- 
ably given another result, for the 
patient, bloodless and worn out, pre- 
sented the most unfavorable condi- 
tions for a laparotomy. I restrict my- 
self to the statement that the only 
fatal case occurring after the applica- 
tion of my method is just this one, 
where I transgressed the limits that I 
had proposed before my first publica- 
tion, and I draw from this case this 
conclusion — that enucleation must not 
be attempted when the fibroma is situ- 
ated too high for one to force its 
extraction at the first sign of infec- 
tion." 

Case XIV. — Miss R., of Lyons, 
aged sixty-five, virgin, menstruated at 
' twelve years ; health excellent up to 
the age of forty-five. She then 
noticed that she was getting stout ; 
she performed palpation on herself, 
and felt some hard and movable 
masses in her abdomen which pro- 
truded on each side of the linea alba, 
and reached, she said at this time a 
hand's breadth above the pubes. Hav- 
ing no pain, she did not consult a 
doctor. At the age of fifty -two she was 
suddenly and without any appreciable 
reason attacked with peritonitis,which 
appears to have been severe. She 
was already convalescing from this 
peritonitis when she was attacked by 
an acute affection of the chest, which 
put her life in danger. This compli- 
cation is important. I take note of 
this pleurisy or pneumonia, for it 
seems to have given rise to embolism, 
as will be seen later on. Miss R. 
was in bed 63 days ; she never re- 
covered her former health ; her men- 
struation, which had been normal 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



316 



until the peritonitis, never once ap- 
peared again. As she suffered from 
her abdomen, she was sent by her 
doctor to Lyons. The specialist con- 
sulted, diagnosticated a fibroid tu- 
mor and advised subcutaneous injec- 
tions of ergotin. This treatment 
produced no improvement, but the 
patient, although gradually becoming 
more feeble, did not try any other. 
She came to Geneva, August 6, 1888, 
to consult Professor Vulliet. 

The examination showed the follow- 
ing : a pale, nervous woman, with 
cachetic aspect ; she walked with dif- 
ficulty on account of pains and abdom- 
inal weight ; she lost a clear, transpar- 
ent, yellow liquid in great quantity. 
Abdominal palpation aud vaginal 
touch revealed a median tumor, em- 
bossod, of irregular consistence, feeling 
in certain parts as hard as stone and, 
wherever the finger pressed, arterial 
pulsation could be felt; it reached 
the umbilicus, the fundus uteri 
formed a ball as large as an orange 
and extended on both sides in the 
form of horns; the horns came within 
about three centimetres of the supe- 
rior anterior iliac spines, and both 
ended in a swelling as hard as bone; 
the tumor was slightly movable, 
causing the posterior cul-de-sac to 
move with it. It was impossible to 
introduce a small whalebone sound 
more than two centimetres ; this 
caused a severe haemorrhage. 

The patient entered Professor Vul- 
liet's clinic, and dilatation was prac- 
tised. This was extremly diflBcult and 
aborlious, and was performed very 
slowly. In the first phase (six days) 
only a progressive catheterisra with 
soft sounds was performed. In the 



second phase sticks of laminaria were 
twice introduced. In the third phase 
dilatation was produced only by tam- 
pons. At the end of fifteen days the 
cavity was widely open and admitted 
a finger and blunt curettes, as well as 
irrigation cannulas of large dimen- 
sions. There was no fever and the 
patient felt better, as if the dilatation 
alone had produced relief. Exami- 
nation by intra-uterine touch : The 
patient having been anaesthetized, the 
professor introduced his finger into 
the uterus ; it entered with ease, but, 
as the tumor did not descend either 
by pressure from above or by trac- 
tion by forceps, there was no means 
of penetrating more than five or six 
centimetres into the cavity, which 
measured twelve centimetres in 
depth ; as far as the internal orifice 
the consistence of the uterine walls 
was normal and supple, but from this 
point the finger felt as if it pene- 
trated into a box of bone or stone, 
so great was the rigidity of the walls; 
the organ could not be bent or moved 
in any direction — it was perfectly 
rigid ; in front and in the back 
only was there a certain suppleness. 
The dilatation was obtained only by 
means of these two zones ; the rest 
did not seem susceptible of expansion. 
The entire anterior face of the walls 
of the parts accessible to the finger 
were covered by voluminous buds. 
A curette being introduced brought 
out about 100 grammes of buds, 
mixed with friable pieces, which ap- 
peared like degenerated fibroid tissue. 
Vulliet was about to stop the scrap- 
ing, which did not bring anything 
else away, when he felt the instru- 
ment touch a hard' surface, which 



Digitized by 



Google 



316 



CHARLES GREENE CUMSTON. 



gave the same sensation as a vesical 
calculus might give when touched by 
a metallic sound. It was impossible 
to withdraw the smallest piece capa- 
ble of showing the nature of this 
hard body. The uterus was well 
irrigated, and then tampons were 
introduced. Forty-eight hours after, 
attempts were again made, which 
withdrew a small quantity of a 
crushed and shapeless calculus. A 
microscopical examination was made, 
and it was found that there was a 
new growth, composed .of fibroid 
tissue, having undergone calculous 
degeneration, and complicated with 
an endometritis. 

It is useless to describe in detail 
the numerous remedial measures 
adopted to combat this disease. 
During six weeks this patient was 
placed on the operating table every 
second day, and, by means of the 
curette and forceps serving as 
lithotrites, we extracted more than 
250 grammes of real stone. Some- 
times this was only dSbris^ in the 
form of grit; sometimes irregular 
pieces, of which the largest was as 
big as an almond, were extracted. 
Some seemed to have been broken by 
the operation, while others produced 
the impression of an independent 
nucleus, offering the shape of little 
shells, and retaining on their surface 
certain imprints ^- due probably to 
the moulding in some recesses of 
the shell ; several must have been 
encased in the wall. As these, for- 
eign bodies were removed the uterus 
became smaller ; at the end of a month 
it did not reach above the sym- 
physis. The region of the horns was 
then attacked. Their extraction was 



executed in the same manner as for 
a calculus in a canal. The first ex- 
tracted were from one to two centi- 
metres in diameter; the others, as 
they approached the more external 
parts of the horns, were smaller. I 
collected all the dSbris^ and gave it 
to Professor Zahn. At the end of 
six weeks' treatment the uterus was 
in its normal condition ; the consist- 
ence everywhere the same. Neither 
the sound nor bimanual examination 
revealed the existence of a foreign 
body. In spite of this long series of 
operations the patient gained her 
strength and flesh, and these multiple 
extractions had caused only slight 
sufferings compared with those oc- 
casioned by any uterine dressing, 
even in a most tolerant uterus. 

If we take into consideration the 
facts established by this case, we 
find — 1st, general augumentation 
in the volume of the uterus; 2nd^ an 
infiltration or a calculous deposit in 
the interior of the walls of the organ; 
3rd, fibroid tissue in abundance. 
These facts, as well as a microscopical 
examination, lead us to diagnosticate 
multiple interstitial fibroma or fibroid 
infiltration, having, undergone calcu- 
lous degeneration. Scraping opens 
the capsule, and by the opening thus 
practised the extraction of the cal- 
culus deposit is mechanical. A wide 
and permanent dilatation by tampons 
can alone permit such an operative 
procedure, otherwise abdominal hys- 
terectomy would have been resorted 
to, and this presented itself in very 
bad conditions. This patient, who 
had recovered her health entirely, 
died six weeks after her recovery in 
a most sudden manner; she pre. 



Digitized by 



Google 



PARIETAL FIBRO-MYOMATA OF THE UTERUS. 



31T 



sented no abdominal symptoms and 
no swelling of the legs. The 
family would not consent to an* 
autopsy, so that nothing could be 
learned as to the nature of the cause 
of death. 

Case XV.— M. T,, from Nice, 
aged forty-four. Menstruated at 
thirteen years, the menses being 
always abundant, regular and with- 
out pain ; duration three days. Had 
her first child in 1869; breech presen- 
tation, with normal post-puerperal 
stage. In 1879, miscarriage at seven 
months, fcBtus dead ; recovered with- 
out any complication. In 1888, miscar- 
riage at three months; recovery un- 
complicated. Infectious troubles of 
the genital organs. For the last three 
years the patient has felt tired, had 
pains in the back, obstinate constipa- 
tion. For two years the menses have 
been very abundant, lasting eight 
days ; between the menstrual periods, 
leucorrhoea is excessive, being some- 
times tinged with blood. Quite se- 
vere and repeated uterine colics occur. 

Examination showed a crest-shaped 
tumor situated on the cervix ; the Na- 
bothian glands are increased in volume. 
The uterus is the size of a three 
month's gestation, in normal position 
and movable ; the adnexa appear to be 
normal. Operation on March 9, 1893. 
Excision with scissors of the small 
tumor on the cervix and another situ- 
ated on the cervical canal, in order to 
determine microscopically their na- 
ture, which proved to be benign. 
March 9, uterus packed with iodoform 
gauze; March 10, a laminaria was intro- 
duced. After dilatation, a fibrous 
polypus was found in the uterine cav- 
ity about the size of a large pigeon egg. 



March 11, etherization ; bilateral 
incision of the external orifice. Two 
fingers were introduced into the 
cavity and about two- thirds of the 
polypus were removed by morcelle- 
ment, as it was found that the 
growth could not be removed entirely 
from its bed. The uterine cavity and 
vagina were packed with iodoform 
gauze. Suture of right incision of 
cervix, which bled freely. Slight 
expulsive pains were noticed by the 
patient. The after results were 
long. A foetid discharge appeared, 
lasting for two weeks, necessitating 
daily intra-uterine irrigations of a 
carbolic acid solution and iodoform 
gauze dressings. Little by little all 
symptoms subsided. The uterus came 
back to its normal size and the pa- 
tient, who was much debilitated, re- 
gained her health and strength, leav- 
ing the clinic in excellent condition. 

En rSsumS, I would say that Prof. 
Vulliet's method is indicated wherever 
there exists a marked disproportion 
between the depth of the uterine 
cavity and the greatest diameters of 
the tumor; by it a radical cure of 
fibromata can be brought about, when 
there is a layer of contractile tissue 
on the peripheral side and when the 
growth is not undergoing degenera- 
tion, alterating its consistence; that 
when conducted under all antiseptic 
precautions it is without danger ; it ia 
conservative surgery, as it does not 
necessitate hysterectomy ; the dilata- 
tion of the uterus exercises a marked 
haemostatic action ; and, lastly, iodo- 
form tampons appear, as local appli- 
cations, to cause a permanent reduc- 
tion in the size of the growth. 

826 Beacon St., Boston. 



Digitized by 



Google 



818 



DR. KAPLAN-LAPINA. 



The Treatment of Catarrhal Salpingitis by Electricity.^ 



DE KAPLAN-LAPINA. 



I DESIRE to relate to this Society 
four cases of uterine disease, accom- 
panied by lesions of the adnexa, in 
which electrotherapeutics sufficed to 
bring about a complete and definitive 
recovery. 

Case I. — Mrs. C, aged 25, works 
on a farm. Menses at the age of 14, 
every month, lasting from three to 
four days, moderate in quantity and 
without pain. Married at nineteen ; 
has had two children, the last one 
five years ago. The present disease 
dates back from her first labor, and 
was made worse by her second. I saw 
the patient for the first time in Sep- 
tember, 1892. Before this, she had 
been to the Charity Hospital, where 
Dr. Walter advised repeated curetting, 
and if this did not succeed to perform 
a laparotomy. She had very sharp 
pains, weight and fullness in the pel- 
vis, especially on the right side. 

Symptoms, — Very abundant leucor- 
rhoea ; the menses are perfectly 
regular, slightly abundant and last 
two or three days. Digestion poor, 
anorexia, coated tongue, impossibility 
to work, walking painful, sometimes 
even impossible, on account of the 
pain. The patient is small, thin and 
very nervous. On examination I 
found an enlarged uterus, hard, thick, 
in anteversion and very painful on 
pressure. The right tube is very 
much hypertrophied, very painful ; 
the corresponding ovary is notably 
increased in size. The left tube is 

•Read before the Soclete Francaise d'Electro- 
ttaerapie at the October Meeting and translated in 
extenso from the Bulletin of the Society. 



less hypertrophied and sensitive, its 
ovary is normal. By the speculum, 
the cervix is found to be hypertro- 
phied, congested, of a blueish color: 
a small erosion exists around the ex- 
ternal orifice. Examination of this 
patient was most easy and allowed of 
a complete idea as to the condition of 
the adnexa. 

Treatment, — I treated the patient 
from Nov. 30, 1892, to March 15, 
1893. Seventeen applications were 
made during the three months and a 
half, consisting of positive chemical 
galvano-caustic of five minutes dura- 
tion, and from twenty to ninety 
milliamperes. The patient rested for 
one hour after each application. 

She was never put on any other 
treatment and never missed a day at 
her work, at least as much as her 
health would allow. In March no ap- 
parent lesions could be made out and 
Dr. Apostoli saw the case at this time 
and saw for himself the integrity of 
the genital organs. I should add that 
the patient became pregnant in 
August, 1893, five months after the 
end of treatment. She was delivered 
six months ago, nursed her child and 
feels well. I saw her again on Octo- 
ber 10, 1894, and found that she still 
continues to feel in excellent health. 

Case II. — Mrs. L., aged 43 ; worku 
on a farm ; eight pregnancies, the 
last one, eight years ago, was very 
difficult ; shoulder presentation ; has 
been sick since this last labor. 

Diagnosis, — Fugous endometritis ; 
complete laceration of the left side of 



Digitized by 



Google 



CATARRHAL SALPINGITIS. 



819 



the cervix, forming a very painful 
cicatrix in the left cul-de-sac, with re- 
traction of tW cuL-de-sac, and a 
doughiness around the cicatrix. Very 
marked right sided salpingitis ; the 
adnex on the left could not be reached 
on account of the cicatrix. 

Symptoms. — Persistent menor- 
rhagia, leucorrhoea, severe pains, even 
when in bed, poor digestion, anorexia, 
sleeplessness, impossibility of work. 

Treatment. — This was commenced 
February 15, 1893, and ended May 
21 of the same year. During the 
three months I made eighteen applica- 
tions, of five minutes duration, with 
the positive chemical galvano caustic, 
of from forty to one hundred milli- 
amperes. The patient became preg- 
nant in November, 1893, ending in the 
birth of a fine child at term. The 
patient has been well since. 

Case III. — Mrs. L. aged 27 ; has 
had four children, the last one four 
years ago ; the patient's trouble dates 
back from the last pregnancy. 

Diagnosis. — Metritis, endometritis 
with double salpingitis, worse on the 
right side. 

Symptoms. — Continual pains in the 
pelvis, especially before the menses, 
leucorrhoea, general weakness, walk- 
ing difficult, working almost impossi- 
ble. Treatment was commenced on 
March 15 and applied for the last 
time on June 14th, as at that time 
all pain had disappeared. There 
were fifteen applications in all, of 
five minutes duration and varying 
from 30 to 60 milliamperes. A close 
examination showed that the genital 
organs were noi-mal. This woman 
has had a child two months ago at 
term and continues to feel well. 



Case IV. — Mrs. S.,aged 89, house- 
wife. Menses at the age of 14, regu- 
lar every month but very painful. 
Married ai twenty^ had her first child 
at twenty-one. This first pregnancy 
was followed by three miscarriages, 
then by two normal pregnancies. 
The patient says, however, that she 
suffered ever since her first confine- 
ment, which ended by the application 
of the forceps, and obliged her to re- 
main four weeks in bed. 

Examination of the patient on De- 
cember 12, 1892, showed a complete 
laceration of the perineum with a 
slight prolapsus of the anterior vagi- 
nal wall ; the uterus is low down, 
increased in size, hard and retroverted. 
The tubes are slightly hypertrophied 
but not very tender. 

Symptoms. — The patient complains 
of dragging pains and especially of 
weight in the pelvis. These local 
symptoms are accompanied by palpi- 
tations, flushes of heat and difiiculty 
in walking. Menses are only slight 
in amount. Treatment consisted in 
the application of chemical galvano- 
caustic, sometimes positive, at others 
negative ; intensity of the positive 
from 40 to 80 milliamperes, the nega- 
tive never over 40 milliamperes. Du- 
ration of treatment four months, from 
January 4tli to May 3, 1893. Total 
number of applications thirteen. 

Results. — The uterus was markedly 
decreased in size ; consistency is nor- 
normal ; mobility is greater ; the tubes 
show nothing abnormal; all the organs 
of generation are devoid of pain. The 
general condition of the patient con- 
firms our examination ; she feels well 
and the menses are much more pro- 
fuse. I saw her in September, 1894, 



Digitized by 



Google 



320 



ALBUMINURIA IN PREGNANCY. 



and she tells me that she is in the 
best of health. 

The treatment of each of the above 
cases might be developed at greater 
length, by giving the details of each 
application and how they supported 
them. But I only wished to expose 
the really important part of the his- 
tory of my patients, that is to say, 
the diagnosis and the condition of the 
organs at the end of the treatment. 



Three out of four of these patients 
became pregnant, and one of them was 
a woman of 43 years. In no one of 
them were the lesions of the adnexa 
in any way doubtful, lesions of long 
standing and well marked. All 
four were not improved, but actually 
cured, since Case IV., which is the 
latest, dates back now sixteen months 
and I have never lost sight of any of 
them since their treatment ended. 



Albuminuria in Pregnancy. 



C. F. SHOLLENBERGER, M. D., DENVER, 

Professor of Pcedeatrics in Gross Medical College; Visiting Physician to 
Gross' Midwifery Dispensary, Denver, 



There is no question in the minds 
of the leading obstetricians of this 
and other countries that albuminuria, 
as a complication of pregnancy, is of 
serious import, both during the time 
of gestation and of delivery. It must, 
however, be admitted that as far as 
its being a factor in the causation of 
many important puerperal diseases, it 
is still imperfectly understood. That 
albuminuria in every pregnant woman 
is necessarily attended with serious 
kidney lesion does not follow, for I 
believe that in at least ten to twenty 
per cent, of cases of pregnancy an 
examination of the urine will show 
albumen in greater or less quantities, 
and in the vast majority of these this 
pathological condition will be un- 
attended with any serious trouble. 

In many of these cases it disap- 



pears entirely after delivery, showing 
that its presence must have been due 
to some tempoi-ary cause, and not as 
indicating any organic lesion of the 
kidneys. 

That albumen is often met with in 
pregnant women was first brought to 
the attention of the medical fraternity 
by Dr. Rayer, whose researches 
proved that this alteration in the 
urinary secretions often affected the 
health of the mother, seriously en- 
dangered the prognosis of delivery, 
and greatly retarded the regular 
development of the foetus. 

We know that the presence of 
albumen in the urine ordinarily indi- 
cates a serious organic lesion, which 
nearly always proves fatal and hence, 
when this symptom occurs daring 
pregnancy, we have every reason to 



Digitized by 



Google 



ALBUMINURIA IN PREGNANCY. 



821 



feel alarmed. The question will nat- 
urally arise, is this* condition due to 
the same causes as those found in 
Bright's disease, or is it simply one of 
the numerous modifications produced 
in the female economy during preg- 
nancy ? 

In the first instance, the trouble is 
of so serious a nature as to solicit our 
most anxious interest ; in the second, 
it is generally produced by temporary 
<;auses, and in a large majority of 
cases, being purely functional in 
origin, will disappear with the causes 
that produced it. Ordinarily, the 
mild albuminuria of pregnancy is not 
accompanied by the many functional 
disturbances of the body and the 
varied symptoms associated with 
grave kidney lesions. 

Dropsy, which is almost a constant 
symptom of Bright's disease, is quite 
often found wanting in the albumi- 
nuria of pregnancy. One eminent 
authority considers that dropsy, as a 
symptom of albuminuria in preg- 
nancy, is found wanting in at least 
forty to fifty per cent, of cases. 

Then, again, in by far the greater 
number of cases, the albuminuria of 
pregnancy disappears in a very short 
time after delivery,- whereas we have 
all had painful professional experi- 
ence of the great obstinacy of albu- 
min us nephritis. In fact, it is difiScult 
to explain the sudden disappearance 
of this otherwise serious alteration 
in the urinary secretions, except on 
the hypothesis that it is functional in 
origin and simply a modification pro- 
duced by gestation. 

However, on the other hand, we 
have all se^n cases of albuminuria 
followed by a fatal attack of convul- 



sions during labor, in which the 
kidneys showed decided structural 
changes, very similar to those found 
in the various stages of albuminous 
nephritis. Healthy urine, as a rule, 
contains no albumen, nor should it be 
found in the urine of a healthy wo- 
man during pregnancy. When we 
find it, it indicates a pathological con- 
dition of which albuminuria is a 
symptom. 

Every functional disorder, whether 
tempomry or ^permanent presupposes 
a temporary change in the organ that 
presides over that function. In look- 
ing for the causes of albuminuria in 
pregnancy, we should not take it for 
granted that the kidneys alone are at 
fault in the production of this symp- 
tom. The kidneys simply eliminate 
the albuminous urine, whereas the 
secretion of urine is both a local and 
a general function. It is general 
because it begins everywhere, and it 
is local because it ends in the kidneys.. 
The function begins in all parts of 
the body, by the admixture of heter- 
ogeneous elements with the blood, 
and is finished in the kidneys, where 
elimination takes place, and the blood 
returns from it in a purified condi- 
tion. If we take this for granted, it 
naturally follows that if we consider 
a pathological condition of the kid- 
neys as the sole cause of the albu- 
minuria, we must overlook very many 
other causes which may have a corre- 
sponding influence. 

It is reasonable to suppose that if 
any structural change in the kidney 
itself can increase or diminish the 
quality and the quantity of the 
urinary excretions, that an alteration 
of the blood itself, such as a diminu- 



Digitized by 



Google 



322 



C. F. SHOLLENBERGER. 



lion or increase of its solid or liquid 
elements, can produce a like change. 

Both clinical observation and post- 
mortem will assist in supporting this 
statement, for although in many cases 
of albuminuria in pregnancy we find 
grave kidney lesions, in a fair per- 
centage of cases such lesions are 
entirely absent. 

Albuminuria is always preceded by 
an excess of albumen in the blood, 
and it is stated that the blood of all 
pregnant women will show an excess 
of albumen as compared to the nor- 
mal. 

Dr. Gubler regards the super albu- 
minosis of the blood of pregnant 
women as the main determining cause 
of albuminuria. He argues that as 
the mother's blood must furnish all 
the nutritive principles for the foetus, 
and that in a soluble and diffusible 
form, it must necessarily follow that 
as albumen is necessary for the proper 
nourishment of the new being, it 
must be found in excess in the 
mother's blood. If this view be cor- 
rect, it would follow that if there is 
more albumen in the blood of the 
mother than is required by the 
mother and foetus, albuminuria re- 
sults. It may also be due to the fact 
that the mother produces too much 
or that the foetus appropriates too 
little, or, as is occasionally the case, 
both of the causes may act conjointly 
and albuminuria results. 

Should the children born of an 
albuminous pregnancy be strong and 
well developed, the causes of the 
albuminuria were, no doubt, due to 
some changes in the maternal econ- 
omy, but if, on the other hand, they 
are weak and puny, it would be 



equally as just to suppose that their 
condition was due to their not appro- 
priating suflBcient albumen, and hence 
its excess in the blood of the mother 
and elimination through the kid- 
neys. 

The experience of many leading 
obstetricians enforces the truth of 
the statement that very often the 
children born of albuminous preg- 
nancies are below the medium in 
weight and development. 

Another matter that is worthy of 
consideration, as far as the etiology 
is concerned, is increased blood 
pressure. Experiments have proven 
that if sufficient water is thrown into 
the vascular system to increase sud- 
denly the mass of the blood, and 
thus produce strong vascular tension, 
albumen will be found in a short 
time in the. urine. 

A still more decisive experiment 
has been made by ligating the emul- 
gent vein. The sudden arrest of the 
venous circulation is followed by a 
progressive stagnation in the capil- 
lary vessels and albuminuria results. 
By gradually tightening the ligature 
so that entire interruption of the 
venous flow is not obtained for sev- 
eral hours, or even days, the same 
has been obtained. From the results 
obtained by these experiments, it 
would almost necessarily follow that 
any tumor causing sufficient pressure 
upon the venal vein, or vena cava 
inferior, to slow up and obstruct the 
returning circulation in the kidneys, 
might be followed by albuminuria. 

One very eminent authority (M. 
Jaccoud) believes that this is the 
most frequent cause of albuminaria 
in pregnancy. In the majority of 



Digitized by 



Google 



ALBUMINURIA IN PREGNANCY. 



823 



cases albuminuria does not manifest 
itself until the latter half of the 
period of gestation, but at this time 
the rapidly increasing size of the 
womb causes pressure not only on 
the venal circulation, but seriously 
retards the venous circulation of the 
liver and spleen, and the great pres- 
sure thus produced on the malpighian 
bodies results in the passage of al- 
bumen in the urine. 

Thus far we have not paid any 
special attention to the kidneys as to 
the influence they may have in the 
etiology of this disease. Under no 
circumstances should they be over- 
looked, but, on the other hand, 
neither should we consider them the 
only factor in the causation of al- 
buminuria. The kidneys must un- 
dergo some change, for, if they did 
not, the albumen would remain im- 
prisoned in the blood vessels. In the 
majority of cases the kidneys become 
affected with more or less passive 
congestion, and certain changes in 
their parenchyma ensue, these changes 
being necessary to allow the proteine 
matters to pass through it, and in 
most cases are transient in character. 
We can well understand how co- 
operative influences, such as an injury 
or the impression produced by cold or 
some concurrent disease, might in- 
crease the congestion into a mild 
inflammation, and a so called sec- 
ondary albuminous nephritis result. 
On the other hand, there may have 
been an existing kidney lesion, ante- 
dating the time of conception or 
occurring during gestation, and thus 
the kidneys themselves may be the 
seat of the initial symptoms of the 
disease. 



Under these conditions, the para- 
mount influence at work in the eti- 
ology of the disease would be a 
primary albuminous nephritis. Quite 
a number of other theories have been 
advanced in the etiology of the dis- 
ease, but I think those just mentioned 
are now most generally accepted 
by our leading authorities as the 
prime factor in the causation of the 
albuminuria of pregnancy. Let me 
again repeat them : 

First: A changed condition of the 
blood accompanying gestation, result- 
ing in supalbuminoresis. 

Second : The growing uterine tu- 
mor, producing over-distension of the 
blood vessels of the kidneys. 

Third: An organic lesion of the 
kidnej^'i?, which may be either primary 
or secondary, resulting in albuminous 
nephritis. 

At this time the question might 
naturally arise, why do we have such 
a large number of cases of albuminuria 
in primiparse? This, I think, can be 
satisfactorily explained by the rigid 
condition of the abdominal walls in 
first pregnancies, and the greatly in- 
creased pressure to which the womb 
would subject all the viscera back of 
it. This would also prove a satisfac- 
tory explanation of why the albumen 
disappears so rapidly from the urine 
after delivery is accomplished, i. ^., 
after the abnormal pressure is re- 
moved. 

Another subject which needs more 
attention than can be given to it in 
this paper, is that in nearly all cases 
the presence of albumen in the urine 
is accomplished by a decrease in the 
normal amount of urea, and in many 
cases the greater amount of urine 



Digitized by 



Google 



324 



C. P. SHOLLENBERGER. 



voided, the less, proportionately, is 
the amount of urea. In this condition 
of affairs the kidneys are mostly at 
fault, elimination being imperfectly 
performed, the urea accumulates in 
the blood. 

Whether the various nervous dis- 
orders commonly attending albuminu- 
ria in pregnancy are due to uraemia, 
or uranemia, as it is called by Gubler, 
will not allow of discussion in this 
paper, but I think the majority of 
authorities agree that the urea found 
in the blood is sufficient to account for 
all these symptoms. It is almost im- 
possible to state at what time the 
albuminuria commences, as there are 
so few cases of pregnancy in which 
we are consulted about the disorder 
until some of the more pronounced 
symptoms manifest themselves. If it 
were possible to examine daily, or at 
least several times a week, the urine of 
all pregnant women in our care, we 
might arrive at an accurate conclusion 
as to its time of appearance, but at 
present our statistics on the subject 
are rather meagre and not to be relied 
upon. 

The usually accepted opinion is that 
it does not appear until the latter half 
of pregnancy, although Bach states 
that he has seen it at six weeks in a 
very nervous patient^and Cazeauxhas 
seen it a number of times at three or 
four months. 

In my own experience, out of sev- 
enteen cases of albuminuria in preg- 
nancy of which I have kept a record, 
fourteen appeared after the end of 
the six months, one just two 
weeks before the end of gesta- 
tion, and in two the albumen 
was present at my first examination 



' of the urine, at three and four months 
respectively. The two cases just 
mentioned were, I think, cases of 
primary albuminous nephritis, ulti- 
mately proving fatal, one at the time 
of delivery in a severe attack of 
eclampsia, and the other from the 
primary disease eight months after 
delivery. Of the other cases, two 
had attacks of eclampsia, of which 
one proved fatal. The other cases 
recovered without any serious results, 
with one exception, this patient dying 
of chronic Bright's disease two years 
aft^r delivery. 

As to the effects of albuminuria on 
the foetus, four of the children were 
still-born — however, not necessarily 
due to the albuminuria — and three 
of them were very puny and of feeble 
development ; but this may simply 
have been a coincidence. I wish to 
add that in only three of the cases 
did I have an opportunity of examin- 
ing the urine prior to the sixth month 
of gestation, and hence it is reason- 
able to suppose that in at least a fair 
percentage .of the cases the presence 
of silbumen in the urine might have 
been detected some weeks earlier. 

At times it appears only at the 
moment of delivery, as the excessive 
efforts, necessary in parturition, are 
well calculated to produce congestion 
of the kidneys. Other cases are 
reported in which it was first discov- 
ered a few days or a week after the 
termination of labor, in these latter 
cases the albumen disappearing in a 
few days. 

Various figures are given, but in 
the majority of cases the albumen 
disappears with the termination of 
labor. In others, however, it contin- 



Digitized by 



Google 



ALBUMINURIA IN PREGNANCY. 



826 



ues and gradaally passes into chronic 
and well differentiated Bright*s dis- 
ease. What is the percentage of 
pregnant women afflicted with albu- 
minuria? Here authorities differ 
widely. Myer found albumen in the 
five and four-tenths per cent, of preg- 
nancies. Nineteen and seven-tenths 
per cent, of all pregnant women 
had piemature labor, but this was 
increased to twenty-seven and seven- 
tenths per cent, of those who had 
albuminuria, and of those having 
albumen with casts to forty-one and 
two-tenths per cent. Of 1,138 women 
whose urine was examined during 
labor, twenty-five per cent, had albu- 
men, and in nearly one-half of these 
th^re were casts. 

Dumas considers that from fourteen 
per cent, to sixteen per cent, of preg- 
nant women are albuminous, while 
Penard states that of 800 pregnant 
women in good health who were 
under his care, the urine was exam- 
ined in all of them systematically 
every fifteen days during the last 
three months of pregnancy, three only 
had gravidic albuminuria, and all of 
these were in primipara. 

As to the percentage of cases of 
albuminuria that will be followed by 
eclampsia, there are very few reliable 
statistics from which to quote. One 
authority gives sixteen per cent., 
another fifty-five per cent., another 
thirty-three per cent., so, taking any 
of these figures, it shows a high per- 
centage, especially in those cases of 
the disease that are well advanced. It 
is also well to remember that not 
every attack of eclampsia is preceded 
by albuminuria, as a few cases have 
been reported in which repeated ex- 



amination of the urine did not show 
any traces of albumen, and yet 
eclampsia resulted. 

Among the symptoms indicative of 
albuminuria are anasarca, amaurosis, 
obstinate headache and vomiting, 
lumbar pains, pleurodynia, vertigo, 
paralysis, insomnia, irritability of tem- 
per, convulsions, and other ill-defined 
morbid conditions which are now be- 
lieved to be due to this disease. 

General infiltration is, however, not 
so uniform an accompaniment of 
albuminuria a9 was formerly supposed. 
If the urine of all pregnant women 
could be examined, it would be found 
that many are albuminous without the 
least evidence of anasarca. Of course 
this must not be confounded with 
dropsy of the lower extremities, which 
is usually produced by mechanical ob- 
struction of the venous circulation. 
The slightest degree of puffiness or in- 
filtration about the face should at once 
arouse our suspicion, and a careful ex- 
amination of the urine should be made. 
The one thing especially to be dread- 
ed, and, if possible, prevented, is 



There is no question that albumi- 
nuria is a strong and a leading predis- 
posing cause of eclamptic convulsions, 
for, as stated before, the cases are 
extremely rare in which the convul 
sive attacks have not been preceded 
by a well-marked albuminuria. The 
time allowed for this paper, however, 
will not allow my entering into 
details as to the theories advanced 
concerning the etiology of the greatly 
feared and very fatal complication of 
pregnancy and labor. 

As to the prognosis, the risks at- 
tending the albumuria of pregnancy 



Digitized by 



Google 



826 



C. F. SHOLLENBERG. 



are by no means slight. One great 
source of danger which we should 
constantly bear in mind is that this 
abnormal condition of the kidneys 
may becotkie permanent and chronic 
Bright's disease follow pregnancy. 

Goubeyre estimated that forty-five 
per cent, of primipara who have 
albuminuria, and who escape the 
dangers that may result during con- 
finement, will eventually die from 
some morbid condition directly trace- 
able to the albuminuria. I think 
this estimate is too great, but we all 
know the danger is not a trifling one, 
and, knowing this, to be forewarned is 
to be forearmed. 

The prognosis, as far as the foetus 
is concerned, is also rather unfavor- 
able. In the milder cases, the prog- 
nosis is good, except that the child 
when born may be rather feebly 
developed, but in the severer cases, in 
which the albuminuria manifests it- 
self early and there is considerable 
anasarca, it is a frequent cause of- 
abortion, of premature labor and of 
the death of the foetus. 

Treatment, — As to the treatment, 
much could be said, but time will not 
allow. Hurdly advises diuretics, 
hydragogue cathartics and tincture 
ferri chloride as a tonic and diuretic. 
If there be no improvement, the pa- 
tient getting worse, labor should be 
induced. 

Tyson strongly advocates the in- 
duction of premature labor in all 
cases where a previous pregnancy has 
been accompanied by albuminuria, 
vnth grave symptoms, and in all 
primipara in whom there is any mani- 
festation of Bright's disease previous 



to pregnancy. Among other means 
suggested are vapor baths, dry cup- 
ping over region of kidneys, a strict 
anti-nephritic diet, ammonia carbonas, 
acetate of potassium, Basham's mis- 
tura ferri. The patient should be 
specially warned against exposure to 
cold or damp weather, as the trouble, 
however mild in its nature, may, by a 
partial stoppage of any of the func- 
tions of the body, be fanned into a 
flame that will ultimately prove 
fatal. 

As to the induction of premature 
labor, I believe it is justified in all 
cases where the disease, in spite of all 
treatment, is going from bad to worse, 
and where, without it, death would 
be sure to ensue either during gesta 
tion or at time of delivery. 

The lessons to be learned from s 
careful study of the disease, aided b> 
every individual experience, is thai 
the existence of albuminuria in preg 
nancy must constantly be a source o 
much anxiety to every careful physi 
cian, and must induce him to look foi 
ward with considerable apprehensioi 
to the termination of the case. 

Again, I believe the urine of even 
pregnant woman should be examines 
at frequent intervals, both during th 
earlier and later stages of gestatioi 
and, if such examination shows an; 
danger, we should at once dideavc 
to correct the evil, for at this, th 
most important epoch in a woman' 
life, no conscientious physician i 
entirely fulfilling his mission or doin 
his whole duty to his patient wh 
does not throw every safeguard in h 
power around • the mothers of tl 
generation yet unborn. 



Digitized by 



Google 



EDITORIAL. 



327 



EDITORIAL. 



The Antiseptic Action of Iodoform. 



A MOST interesting memoir on the 
manner of interpretating the anti- 
septic acton of iodoform, has been 
recently published in les Archives de 
MSdecine UxpMmentale by Dr. 
Stchegoleff. 

It is well known that this substance, 
which gives us such splendid results 
in practice, has shown itself quite in- 
ferior in experimental work. In 1887, 
Heyn and Roosing demonstrated that 
the presence of iodoform on gelatin 
plates did not prevent the develop- 
ment of the various kinds of micro- 
organism (staphylococcus pyogenus 
aureus, pneumococcus, etc.). These 
writers also observed that a tampon 
of iodoform gauze, when introduced 
in the vagina of a healthy woman, 
was, when removed, penetrated by 
micro-organisms. . Their experiments 
were verified by others. There was 
^consequently an unexplainable con- 
tradiction between the experiences of 
surgeons and experimental workers, 
the former admitting, the latter deny- 
ing the antiseptic proprieties of iodo- 
form. 

Dr. Stchegoleff, in order to throw 
some light on the matter, undertook 
some experiments in Prof. Strauss' 
laboratory, with the result of explain- 
ing the mode of action of the drug. 
He found that meat-pepton-gelatin 
bouillon, which is an excellent culture 
media for the bacillus of tuberculosis, 
did not favor the development of this 
organism when iodoform was present 
in the quantity of five per cent. The 



bacilli inoculated in this iodoform 
bouillon died in forty-eight hours. 
An emulsion of a virulent culture in 
a ten per cent, iodoform solution, 
when injected in guinea pigs, showed 
that the animals lived longer than the 
animals which were inoculated with 
a pure culture. In short, iodoform 
kills the bacilli of tuberculosis in cul- 
tures and only attenuates their virul- 
ence when injected simultaneously 
into the organism. 

The action of iodoform on the 
staphylococcus aureus is quite the 
reverse. Thus this organism grows 
as well in a medium containing iodo- 
form as in a normal one, but, on the 
contrary, the inoculation of this organ- 
ism submitted to the action of iodo- 
form proves it to be quite inoffensive. 
Cultures grown in a medium in pres- 
ence of iodoform can be injected at 
doses of one cubic centimetre to 
two cubic centimetres without pro- 
ducing any symptoms other than a 
slight local reaction, while the control 
animals inoculated with streptococci 
grown in media without iodoform, pre- 
sented the formation of abscess or died 
in a few days from septicaemia accord- 
ing to the degree of virulence of the 
culture. If the iodoform is mixed with 
the culture of staphylococci at the 
time of inoculation, a small local ab- 
scess is the only result ; the accidents 
are consequently not entirely sup- 
pressed — they are only attenuated. 
Thus, iodoform does not alter the vi- 
tality of the staphylococcus in the cul- 



Digitized by 



Google 



828 



ANTISEPTIC ACTION OP IODOFORM. 



ture media and still it modifies its 
pathological proprieties. How can this 
apparent contradiction be explained. 

Dr. Stchegoleff questioned as to 
whether iodoform did not act on the 
toxines secreted by the staphylococ- 
cus without acting on the organism 
itself. He made two series of cul- 
tures ; the first were normal, the sec- 
ond contained iodoform in the quan- 
tity of 10 p. c. At the expiration of 
one week he filtered them, in order 
to eliminate all the organisms, and 
then injected rabbits with the filtered 
liquid. The culture liquid which 
contained no iodoform killed the 
animals in several hours, while the 
animals inoculated with the liquid 
containing the drug presented no 
accidents whatever. Dr. Stchegoleff 
believes that, under the influence of 
iodoform, the toxines of the staphy- 
lococcus are transformed into non- 
toxic iodine combinations. It is 
readily understood from this fact 
how iodoform, when applied to a 
wound, prevents suppuration and 
infection, without killing the pyogen- 
ous organisms. The Klebs-Loeffler 
bacillus acts nearly in the same way 
as the staphylococcus in the presence 
of iodoform. It grows well on a 
medium containing iodoform, but its 
virulence is weakened. The toxines 
of diphtheria are attenuated and even 
annihilated by iodoform, provided that 
the dose is sufficient and can act long 
enough. This anti-toxic action of 
iodoform is most remarkable and ex- 
plains its good effects against organ- 
isms which it is incapable of destroy- 
ing. 



The number of Dec. 20, 1894, of 
r Union MSdicale^ from which the 
above report is taken, also mentions 
an article which appeared in the 
Journal of Itussian Military Medidm^ 
by Dr. Saltikoff, entitled " The In- 
fluence of Iodoform on Patholc^cal 
Microbes." According to this writer, 
iodoform acts in general on the Tir- 
ulence and proliferation of micro- 
organisms, but its action differs 
with the different kinds of bacteria. 
Thus this influence is only produced 
in an evident way at the commence- 
ment of a growth of the fetid opcdeh 
cent bacillus; later, this organism 
grows as well on media containiDg 
iodoform as on one without the drug, 
and nevertheless its virulence on 
white mice is completely lost. 

The streptococcus is only slightly 
influenced by iodoform. Cultures of 
charbon bacillus are lessened in 
growth and its virulence diminished 
by the drug. The action of iodoform 
on the staphylococcus aureus is 
marked, but the virulence of this 
organism is only slightly decreased. 
On the various kinds of vibrions, 
iodoform acts in a varying manner. 
It prevents the growth of the comma 
bacillus and Finkler-Prior organism, 
but acts only slightly on Deneke's 
bacillus. 

It may be said, in a general way, 
that besides the ordinary proprieties 
of iodoform, such as diminishing the 
secretion of wounds, lessening pain, 
etc., this drug diminishes the pro* 
liferation of several kinds of patho- 
logical organisms and lessens their 
virulence. 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



829 



SOCIETY PROCEEDINGS. 



Suffolk District Medical Society, Boston — Section for Obstetrics and 

Diseases of Women. 



JAS. M. JACKSON, M. D., SECRETARY. 



Regular meeting, Wednesday, 
November 28, 1894, Dr. G. H. Wash- 
burn presiding. 

correspondence between dr. e. w. 
cushing and dr. tait.* 

Mr, Predident : At a meeting of this 
Society in 1894* I read a paper on 
the ** Operative Treatment of Uterine 
Fibroids," which was published in the 
Boston Medical and Surgical Jour- 
nal, Vol. 130, Number 13. On page 
303 of that number occurs the follow- 
ing expression: **In the light of 
facts recently placed in evidence con- 
cerning Tait, his statistics have far 
less weight with the surgical world 
than was the case a year or two ago." 

This expression was needlessly of- 
fensive to the feelings and reputation 
of Mr. Tait, as all that ray argument 
required, and what was really upper- 
most in my mind, was to bring out the 
fact that since many cases had been 
reported where after removal of the 
appendages the myoma had continued 
to grow, so that hysterectomy had to be 
subsequently performed, the statistics 
of Mr. Tait showing recovery from 
the operation of removal of the ap- 
pendages and arrest of the growth of 
the tumors for a variable, but rather 
limited period, had far less weight 
with the surgical world than formerly, 
because surgeons could not be sure 



•The whole oorretpondence between Dr. Gushing 
*nd Dr. Tait has lately been published in full in the 
Jfew York Sun of February 6, 1895. Only two copies 
of this correspondence were In existence, one of 
which was In the possession of Mr. Tait and the 
other in the hands of the solicitor of Mr. Ernest 
Hart, who is now in India. One or the other of 
Aese parties must be responsible for the publication 
ol^this matter in a lay Journal. 



that many of these cases might not at 
some future time require hysterec- 
tomy. I therefore desire to amend 
my paper by striking out the words 
" concerning Tait," and to express my 
regret that I should have used this 
offensive expression. 

In order to justify myself before 
this society, however, for the use of 
such words, I am compelled to add 
that at the time of using them I fully 
believed that they were warranted, 
having received, not in confidence or 
under any reserve, reports concerning 
Mr. Tait, which, if true, would have 
fully justified me in using them, and 
from a source which I had every rea- 
son to believe to be credible and 
authoritative. As, in the course of 
correspondence with Mr. Tait, he has 
given me prima facie evidence that 
some of these reports were either un- 
true or not founded on facts *' placed, 
in evidence " in the manner in which I 
was informed that they had been 
placed, I have referred Mr. Tait to 
the person who was responsible for the 
reports to me. He is an Englishman, 
occupying a prominent and responsible 
position in the profession, and is 
abundantly able to present his side of 
the question should it be necessary. 
As personally I have no evidence 
whatever of any facts derogatory to 
Mr. Tait, and as I have no desire 
whatever to do him or anyone else 
any wrong, I feel that if I have been 
misinformed concerning him, and on 
^ch misinformation I have based re- 
mstvlqs offensive and injurious to him, 
I owe h]m an apology, which I hereby 
tender in the presence of this society. 
E. W. Gushing. 



Digitized by 



Google 



830 



SOCIETY PROCEEDINGS. 



REMOTE RESULTS OF THE REMOVAL 
OF THE UTERUS AND OVARIES. 

Discussion. 

Dr. E. W. Gushing.— In the first 
place, in regard to the removal of the 
uterus, which usually carries with it 
the appendages, it is a very important 
question. It is a thing which it is 
well to consider, because it is one of 
the later developments of surgery 
which promise a great deal, and it is 
living down opposition to it. When 
in 1887 Martin came over and per- 
formed the first vaginal hysterectomies 
for cancer there was intense opposi- 
tion. Jackson denounced the whole 
thing in Washington, and there was 
an opposition that it was a terrible 
and dangerous operation, and should 
not be tolerated for cancer even. 
Certainly that has passed now. When 
more surgeons began to do it, it was 
found that it was not dangerous. 
Martin did the first three cases here in 
1887. Soon after 1 published twenty- 
one cases with nineteen recoveries, 
and I have done a largo number of 
vaginal hysterectomies since then for 
cancer, and two of them died, one of 
sepsis 11 days after, and one of heart 
failure and shock within a few hours. 
Anybody will admit that the re- 
mote results of the removal of the 
uterusare good if it can save a woman 
from cancer, and about one-half the 
cases are saved for three or four years, 
and something less than that saved 
permanently, yet I know it rather 
made me shiver when in 1885 Martin 
proclaimed that a uterus with any 
cancer should be removed entirely. 

Then came the question of removal 
of the uterus for fibroids,and that again 
worked its way against opposition. 
Where the mortality used to be sixty 
per cent, it is now less than ten 
per cent., so that the removal of 
the uterus for myoma is now as well 
established as removal of the ovaries 
for ovarian tumor. The increased 
safety of it and the advantage to 



suffering women is forcing surgeons 
continually to operate in cases where 
they would not have done it a few 
years ago, that is, the increasing 
knowledge of the bad eflfects of leav- 
ing myomas, complications which fin- 
ally ensue from pressure on the 
ureters, or on the intestine, from de- 
generation of one kind or another, 
from long-continued haemorrhage, 
from salpingitis, has brought it about 
that surgeons are much more ready 
to remove the uterus now than a few 
years ago. And some are going so 
far as to say — although it makes 
the conservatives rather hesitate — 
that they will remove a fibroid the 
size of the fist to guard against 
future growth and accidents. 

Now, however, by the development 
of surgery, it is found that by va- 
ginal hysterectomy a small fibroid can 
be removed with ease and with prac- 
tically complete safety. If we can 
with practically complete safety 
remove the little fibroids, presently 
there will not be any big fibroids, 
just as there ought not to be any 
big ovarian tumora in civilized com- 
munities. Here is a fibroid I re- 
moved the other day. There was a 
prolapse and fibroid. The fibroid 
could not be delivered whole, but by 
pulling it down and splitting it the 
entire mass was easily removed. 
The woman is cured of the prolapse. 
She does not realize that anything 
has been done to her. The entire 
absence of shock is one of the marvels 
of surgery. 

If vaginal hysterectomy is safe 
enough for removal of myomas, then 
comes the question of removal of the 
uterus for prolapse. You know the 
difficulties of recurrence of the 
trouble, the operation for prolapse, 
and all the different things tried. 
Finally Martin propounded removal 
of the uterus for prolapse. Now 
it is done by many and laid down 
as a proper thing to do. If a woman 
has prolapse and is past child-bearing 



Digitized by 



Google 



SOCIETY PROCEEDINGS. 



881 



slip the uterus out; it is the easiest 
thing in the world. When we can 
remove the uterus by the vagina so 
readily I cannot see the need of doing 
it from above for prolapse. Polk in 
New York does this. 

What are the remote bad results 
of removal of the uterus and append- 
ages. What has been charged 
against it is, in the first place, pro- 
duction of insanity ; and, in the 
second place, the production of 
obesity ; and, in the third place, loss 
of sexual desire, by which I suppose 
is meant sexual feeling. Now, in 
regard to the production of insanity. 
It is a fact that various gynaecologi- 
cal operations are followed sometimes 
by insanity. I remember out of 
perhaps some 800 cases in the Mur- 
dock Hospital there were some three 
cases of insanity, all of which recov- 
ered. I had one case at the Charity 
Club Hospital where, after removal 
of a large fibroid, the woman became 
violently insane in a few days, but 
she recovered. I have one case of a 
fibroid removed two years ago, where 
the lady, although apparently sane, 
confesses that she has occasionally 
suicidal tendencies. She wants to 
commit suicide, but knows it is 
wrong and does not do it. How far 
that is insanity some of the alienist 
experts will tell. 

1 repor