-FOR

Bright's Disease, Gout, Rheumatism.

Dr. Wm. A. Hammond, of Washington, D. C., Surgeon-General United States Army (retired), late Professor of Diseases of the Mind and Nervous System, University of New York:

"I have for some time made use of the Buffalo Lithia Water in cases of affections of the Nervous System, complicated with Bright's Disease of the Kidneys or with a Gouty Diathesis. The results have been eminently satisfactory. Lithia has for many years been a favorite remedy with me in like cases, but the Buffalo Water certainly acts better than any extemporaneous solution of the Lithia Salts, and is, moreover, better borne by the Stomach."

Hunter McGuire, M. D., LL. D., late Professor of Surgery, Medical College of Virginia, Richmond: "Buffalo Lithia Water, Spring No. 2, as an Alkaline Diuretic, is invaluable. In Uric Acid Gravel, and, indeed, in diseases generally dependent upon a Uric Acid Diathesis, it is a remedy of extraordinary potency. I have prescribed it in cases of Rheumatic Gout, which had resisted the ordinary remedies, with wonderful good results. I have used it also in my own case, being a great sufferer from this malady, and have derived more benefit from it than from any other remedy.'

Dr. Wm, B. Towles, Professor of Anatomy and Materia Medica in the Medical Department of the University of Virginia:

"I feel no hesitancy whatever in saying that in Gout, Rheumatic Gout, Rheumatism, Stone in the Bladder, and in all diseases of Uric Acid Diathesis, I know of no remedy at all comparable to Buffalo Lithia Water, Spring No. 2." urine. In a single case of Bright's Disease of the Kidneys I witnessed decided beneficial results from its "Its effects are marked in causing a disappearance of Albumen from the use, and from its action in this case I should have great confidence in it as a remedy in certain stages of this disease. In Dyspepsia, especially that form of it in which there is an excessive production of acid during the process of nutrition, I have found it highly efficacious."

Water in cases of one dozen half-gallon bottles, $5 per case at the Springs.

THOMAS F. GOODE, Proprietor,

BUFFALO LITHIA SPRINGS, VA.

KANSAS CITY MEDICAL INDEX.

EDITED AND PUBLISHED BY

EMORY LANPHEAR, M. D.

A WESTERN JOURNAL, BY WESTERN WRITERS, FOR WESTERN PHYSICIANS.

VOL. XII. '

MAY, 1890.

ORIGINAL ARTICLES.

No. 125.

REMOVAL OF THE UTERINE APPENDAGES.-REPORT OF THE CASE.

BY J. C. M'CLINTOCK, M. D., TOPEKA, KAS.

The case to be reported is one familiar to the medical world, from having been treated by leading men in foreign countries, as well as at home. The lady, Miss L, aged forty-seven, a native of France, began menstruating at the age of fourteen, and with each menstrual period suffered severe pain both before and during the flow, the pain before menstruating suggesting some early ovarian disease. At the age of fifteen a severe coxalgia developed, lasting two years, and which has returned, at different intervals, from that time to the present.

She was first treated by Sir James Simpson, of Edinburgh, and Dr. Cruveillier, of Paris; then by Bischof, who performed Sim's operation on the cervix, for the relief of dysmenorrhoea. The operation was repeated the following year, the cervix at different times being divided posteriorly, laterally, and, in fact, in all directions; seven different incisions extending through the cervix at different times having been made. Later, she had an attack of abdominal typhus, and for that was treated by the celebrated Leibermeister with his method of cold baths. The patient says that as a result of this treatment she was left a physical wreck, owing to the great shock produced on the nervous system. Next she was treated by Veit, of the University of Bonne.

The fame of American gynecologists having reached her ears, she came to St. Louis, where she was treated by the elder Engelmann, and was for some years under the charge of Dr. G. J. Englemann, who proposed the removal of her ovaries, and offerred to have Dr. Battey, of Rome, Georgia, present, he being the originator of the operation.

Dr. Engelmann was the first to correctly diagnose ovarian trouble, and to propose the radical remedy, viz.: removal of the diseased ovaries. Not consenting to this operation, she next appeared at New York, where she was treated by Lusk and Thomas, remaining in the Woman's Hospital, under the care of Thomas, for some time.

In Chicago she was treated by Drs. Jenks and Ludlam. In St. Paul by Dr. Stone. Doctors Engelmann, Ludlam and Stone were the only ones who suggested ovarian disease; all the others, including Barrett and Hodgen, treated the case for metritis and displacement of the womb, retroversions and anteversions, pelvic peritonitis and pelvic cellulitis, and for disease of the urethra and rectum. She has worn all kinds of pessaries; has been cut, cauterized, bandaged and blistered until no more blisters would rise. She has been fired with hot irons, and undergone all manner of treatment; when there was not enough cervical tissue left to be further subdivided, it was amputated. Following this operation of amputation of the cervix was a severe pelvic cellulitis, as it was called; a large swelling occurred in the left side, extending into the pelvis, which proved to be an abscess discharging through the uterus and bladder. After a time the sinus opening in the bladder closed spontaneously, but pus has at intervals been discharged from the uterus ever since.

Recurrences of peritonitis were continual, following one after another, sometimes four or five in one year; the slightest cause, such as getting the feet wet, or over-exertion, being sufficient to light up a new attack at any time. In most of these attacks peritonitis was very severe, and great danger to life was always present.

She came under my care the first of October, 1888, and had until January of this year, five or six attacks of peritonitis.

On examination I found the uterus anteflexed, with hyperæsthesia of the internal os; the uterus very large and firmly fixed in the pelvis in its abnormal position. Periodical discharges of pus from the uterus started frequent troublesome vaginitis and vulvitis. After a time, finding the swellings in the pelvis were only reduced after a discharge of pus through the uterus, I diagnosed suppuration of the Fallopian tubes. In order to be certain that this discharge did not come from the uterus itself, I had first dilated the uterine canal and then mopped it out until it was perfectly dry, and, by pressure over the swelling on the left side, I could press out into and through the uterus quite a quantity of pus. I supposed the left ovary could be felt in the Douglas cul-de-sac, either through the vagina or rectum.

This was shown during the operation to have been an error, as the ovary could not have been reached in a pelvic examination; in reality, it was the convoluted tube studded with tubercles which had been mistaken for a mis-placed ovary. The patient had been treated for the last two years for malarial fever with a pulse of 90, but which I attributed to the absorption of pus, since quinine and other antiperiodics had no effect on the course of the fever.

Ovariotomy-McClintock.

155

During last year I insisted on the removal of the tubes and ovaries, having become satisfied that the tubes were, one or both of them, distended with pus. To this proposal I did not gain consent until this year, when I was told that the operation might be performed, if the consent of specialists in some other city be given, and my diagnosis confirmed by them. I therefore consulted, at Kansas City, Drs. Todd, Halley and Crowell. They confirmed the diagnosis, saying that there was disease of either tubes or ovaries or both, and that the operation for the removal would be the only method of treatment. Accordingly, on the 28th of January I proceeded, with the assistance of Drs. Lindsay, Stewart and Crowell, to the removal of the appendages. The strictest antiseptic precautions were observed, and the patient was prepared by a restricted diet, baths, and saline cathartics, for a week or two previous to the operation. The operation was done about ten days subsequent to the menstrual period; extreme care being taken to have the premises and surroundings. in perfect hygienic condition; nothing but that which was new was allowed in the house or about the patient.

A minute description of all the antiseptic details will not be given, as many of you know my methods in such matters. The water used in the operation was pure water, distilled and boiled; and pure water alone should be used in the abdominal cavity; the antiseptic solutions should not enter therein.

THE OPERATION.

A small incision, about two inches in length, having been made in the linea alba, the sub-peritoneal fat was exposed, caught up and divided between two pairs of forceps, and in like manner the peritoneum. The omentum was found adherent, but was readily turned to one side; the fundus of the uterus was sought and easily found, it being anteverted; one finger was passed on each side of the broad ligament, and it used for a guide for the fingers in their downward and outward passage in search of the ovary; this led me to a dilated and convoluted tube, bound down with very strong adhesive bands; the ovary being found coiled in the tube; both fingers were then passed down, back of and below the tube, the adhesions torn loose and the distended tube and ovary delivered, the tube being nearly one inch in diameter and about four or five inches in length.

An aneurism needle was thrust through the pedicle, armed with strong silk ligature, which was cut, crossed and tied, one on each side. The tube and ovary were then removed, and in the stump of the oviduct was found a drop of pus, which was removed; the cavity scraped and cauterized to prevent any subsequent infection. The stump was watched a moment to see that no hæmorrhage would follow; and it was dropped back into the abdomen or peritoneal cavity.

Next an examination revealed a distended tube on the other side, a

few bands only holding it down. These were severed, and the tube and ovary removed, and no serum or blood being found in the cul-de-sac, a drainage-tube was not thought necessary; consequently, the abdomen was closed with three rows of superimposed catgut and silk sutures; the first including the peritoneum, the second the fascia, and the third including the fascia and integument. These latter were removed on the fifth day, when firm union was found to have taken place. The buried sutures have never given any sign of their presence. The patient's bowels were moved on the next day after the operation, by sulphate of magnesia; no liquids were allowed, not even water or ice, for the first twenty-four hours; after that, a small quantity of carbonated water was taken, and before forty-eight hours a small amount of beef-juice was given regularly. The diet was then gradually increased. There was no shock following the operation, and the patient did well for two or three weeks, got up and walked about the room, sat in an easy-chair, and was wheeled about through the house, but at about the beginning of the fourth week an inflammation of the femoral artery developed, with great pain, requiring the use of morphine each night.

At first I supposed it to be a phlebitis, and, when I so announced, the patient said she had suffered from phlebitis following an operation some years ago, and that she was confined to her room for four months. A more careful examination showed me that it was not the vein, but the artery that was inflamed; and the inflammation in the artery could be traced to its terminations, and some of the branches of the artery were occluded. The inflammation involved both femoral arteries, but the pain was more severe in the left. This put the patient back to her bed, where she will probably remain for some weeks.

I am satisfied that her former attack of phlebitis, of which she spoke, was an arteritis and not a phlebitis. A diagnosis was only made at that time after sending half across the continent for Dr. Pallen, of New York.

The tubes which I have exhibited here show, the one a pus-cavity or a pyosalpingitis with an abscess of the corresponding left ovary communicating through the fimbriated extremity with the oviduct. The right tube was distended with water (hydrosalpingitis), and the ovary apparently normal.

This case I hesitated to operate upon, owing to the age of the patient (forty-seven years), thinking that the menopause would perhaps soon come and bring relief; but after consulting Gil Wylie of New York city, he said that in these cases the menopause is frequently postponed until after the age of fifty, and that my patient was in very much greater danger from the recurring attacks of peritonitis than she would be from abdominal section. Moreover, as the tubes were found distended and hanging down in such a condition that they never could drain, after the menopause no improvement could have been hoped for, and so the opera