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PACIFIC MEDICAL JOURNAL.

Vol. XXXVII.

APRIL, 1894.

No. 4.

Original Articles.

REMARKS BASED ON THE GYNECOLOGICAL OPERATIONS PERFORMED AT THE GERMAN HOSPITAL IN 1893.

By HENRY KREUTZMANN, M. D.,

Gynecologist to the German Hospital and to the San Francisco Polyclinic. (Read before the San Francisco County Medical Society.)

In 1893, at the gynecological department of the German Hospital 73 operations were performed upon 60 patients, the total number of patients treated being 83. The seeming disproportion between patients and operations is accounted for by the fact that most of the patients enter the hospital with the intention of having an operation performed, besides, in many instances, two or more operations were done upon the same patient either at once or at different times. For instance, at the same seance curettement of the uterus, trachelorrhaphy, removal of an ovary and ventrofixation of the retroflexed uterus was done; in another case a kystoma ovarii was removed (Dr. Rethers) and ten weeks afterwards the whole uterus was extirpated for cancer.

I shall give a short synopsis of the operations and then proceed to make a few remarks of a more general character, as seems appropriate before a meeting not of specialists but of general practitioners. It was done:

NO. OF TIMES.

Extirpation of suppurated vulvo-vaginal glands....
Perineorrhaphy for partial laceration.

Perineorrhaphy for total laceration.

Kolporrhaphy..

Partial excision of cervix (wedge-shaped)..

Trachelorrhaphy..

Curettement of the uterus..

Vaginofixation of uterus (Mackenrodt).

VOL. XXXVII-13.

5

1

3

7

7

15

3

High amputation of cervix..

Vaginal extirpation of uterus..

Explorative incision of abdominal cavity.

1

3

4

Incision and drainage of intra-abdominal abscess.. 1

Incision and drainage of extra-peritoneal abscess... 1

Salpyngotomy....

Removal of ovarian kystoma (1 dermoid).

Ventrofixation of uterus

Abdominal total extirpation of uterus.

Vagino-abdominal total extirpation of uterus....
Incision upon fistulous ducts in abdominal walls..
Nephrectomy (abdominal)...

1

10

5

1

2

2

1

The plastic operations upon the perineum were performed after the flap spliting fashion. So much has been written about this operation that I justly presume that everybody is familiar with the procedure. I have personally tried a great many different methods of perineorrhaphy, and have arrived at the conclusion that for total laceration of the perineum the Tait operation is unsurpassed. It is simple in execution and safe in result. Even if union should not take place entirely, the result is always an improvement upon the former condition, and with some further plastic operation a perfect result will be obtained. Equally satisfactory results are had by the same method in cases of ordinary incomplete laceration of the perineum; but when relaxation of the vagina is in existence (rectocele, kystocele), one of the denuding operations is preferable.

In the cases of partial excision of the cervix there was always present a thick patulous cervix and lacerations of the cervix; the operation was done in the typical way, an incision was made on both sides of the portion, splitting the cervix more or less, removing a wedge-shaped piece from posterior and anterior lip and uniting vaginal and cervical mucous membranes and the edges of the side-cuts with a number of sutures. We are at liberty to cut off as much as we see fit in every case. I must confess that I think highly of this operation; the thickened cervix and uterus undergo involution, the discharge ceases. Certainly the os externum uteri will be more or less patulent and cannot be compared with the pinhole-opening, resulting from Emmet's operation, which resulting pinhole-opening seems to many the alpha and omega of modern gynecology. Certainly I have done trachelorrhaphy in seven cases, in one-tenth of the opera

tions performed, but in a number of patients I did this operation incidentally with some other operation, especially since it was the desire of those women, "that the womb be stitched, which had been torn," as Dr. —. had told. In such cases I always tried to find some real disorder by carefully searching the abdomen, and in most cases I succeeded in locating the cause of the patient's complaints in some disease of the uterus, its appendages or the pelvic peritoneum. In no case has the operation been performed with the idea that the disorder of the patient's nerves, hysteria, neurasthenia can be cured by so simple a procedure; but it must not be forgotten that from the moment a woman has been told that her womb is torn, this very idea of having a torn womb haunts her day and night, and forms a link of the endless chain of misery, and the knowledge that the womb has been stitched gives a certain relief to the patient's mind. Not to every woman can it be explained that the laceration is of no importance, that it is her nervous system which is sick; like Shylock on his pound of flesh, she insists upon having put a few stitches into her womb. A great many, if they come to you, know exactly how many stitches are required. I do not want to go too much into detail, since I will make the indiscriminate performance of Emmet's operation the subject of some special paper. But a constant mistake is made by so many in overlooking grave diseases of the genital (or other) organs, when there is a socalled laceration of the cervix in existence, and in attributing symptoms to a harmless tear of the uterus. Trachelorrhaphy is a useful operation, but only in cases of extensive laceration, or compressing scarformations, and in such cases, when the cervix is small and not infiltrated and the wedge-shaped excision not feasible.

nervous

Nobody will doubt that the moral effect and the suggestive power of an operation is a great factor in curing and improving patients, especially those where the functions of the nervous system are not correct. Of this I had a very good illustration last year. A young lady with hysteria had been under treatment at different times, had been in the hospital and much improved under a rest-cure. Then she returned and complained of unbearable pains during her flow, and that she could not hold her urine longer than one to two hours; she wanted her ovaries removed. Upon careful examination, under ether, perfectly normal pelvic organs were found; but one day all preparations

for the removal of the ovaries were made; under ether the skin in the linea alba was incised a few inches long; patient was kept in bed for three weeks; sometime afterwards she left for the country. She was told that she must expect to flow again. Weeks afterwards I received a letter from her stating that she never felt better in her life, that she had come around without knowing it. She had no bladder trouble. I have seen her since, and saw her lately; she complains very little about pain with her menstruation. She is able to do light work and feels so good that she intends to enter into matrimony.

The same splendid results have been obtained and published in many cases of castration a few years ago; but since, in most of these cases, the "cure" was only temporary, and since on the other side the same or in fact more satisfactory results are had by non-operative treatment, removal of both healthy ovaries, castration kat exogen, for nervous and psychical disorders is at the present time abandoned entirely, and rightly are these cases given to the neurologist, to whom they properly belong.

The modern gynecologist has turned his eyes and hands from the ovaries towards the uterus; especially the retroflected uterus, and its surgical treatment has lately grown more and more in importance. It has been surgically attacked directly and indirectly, from below and above, from behind and in front. Three distinct methods have been developed to the exclusion of almost all others: Vaginofixation, ventrofixation, shortening of the round ligaments. The names are self-explanatory.

Dr. Schuecking, of Pyrmont, Germany, first fastened the anterior surface of the uterus to the peritoneum of the plica-vesico-uterina by means of a needle, specially devised for this purpose. This needle is pierced from the uterine cavity into the vagina, the bladder being pushed aside with a catheter, and a silk thread is introduced and tied.

Professor Zweifel improved upon this method by separating the bladder from the uterus, making a transverse incision through the anterior vaginal vault above the portion, as is done in case of vaginal total extirpation of the uterus. Drs. Mackenrodt and Duehrssen, both of Berlin, further improved the technique, introducing the ligatures from the vagina. Mackenrodt dissects the bladder from the vagina, then the bladder from the uterus and carries threads from the mucous membrane of the vagina through the uterus, emerging on the other side into the

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