fixing and keeping the child in a certain position in the uterus, in performing version, in pressing out the placenta, in insuring complete contraction of the uterus after labor, in fixing and steadying the uterus during the performance of perforation or ovariotomy, in forceps cases, and in breech cases, by keeping the uterus well contracted on the after-coming head, etc. I will conclude by saying that in every case of labor if internal examination were combined with external abdominal palpation and auscultation a mistake in diagnosis could not be made. HEALING OF CHRONIC ULCERS. BY F. A. VOTEY, M. D., DETROIT, MICHIGAN. In the subject presented this evening, I wish to speak more especially of weak indolent ulcers of the legs, and their treatment by grafting with chicken skin. Who originated the idea I am unable to say, but I have had such success with the plan that a rehearsal of a few cases may be of interest. In each case the surface of the ulcer and that of the surrounding skin was rendered as aseptic as possible. Any excessive inflammation was reduced by antiseptic compresses, and flabby granulations cut down with nitrate of silver. When the granulations presented a sufficiently healthy appearance, a spring chicken was procured, and the skin underneath the wing carefully cleaned. As soon as it was killed a piece of skin was taken from the wing and put into a one four-thousandth bichloride solution. This was then cut into pieces one-tenth to one-fourth inch square and laid upon the granulating surface near the circumference. Over this was placed a layer of lint spread with iodoform ointment, then covered with bichloride cotton and bandaged. The patient was instructed to remain in bed. Case I.-Catherine R., aged about fifty-five years; very corpulent. Has an indolent ulcer upon the outside of the left leg just above the ankle, about five by three inches. Surrounding skin tense and circulation poor. Ulcer has not been healed for ten or twelve years. Patient was prepared for grafting, and on June 2 twenty grafts of chicken skin were applied. Redressed on the 9th, and nineteen grafts remained adherent. June 30 the ulcer was reduced to three and onefourth by one and one-half inches. Seventeen grafts were applied and sixteen remained on July 6. On August 6 ulcer was two and one-half inches long by seven-eighth of an inch wide. Twelve grafts were applied of which only seven have taken. August 27 ulcer was one and one-fourth inches long by five-eighths of an inch wide. Patient then left the city, and whether the ulcer eventually healed I could not ascertain. Case II.-Daniel C., laborer; aged sixty-six years. Has had an ulcer of the leg for several years, which would heal but quickly break down again. Has not been closed for one year. Ulcer is circular, two inches in diameter upon the external surface of middle of right leg. Edges are everted with a large zone of inflammation surrounding the ulcer. Granulations congested. Edges were incised and ulcer poulticed, after which it was grafted with chicken skin on June 30. The bandage was disturbed by patient, causing only two grafts to remain. These grew rapidly and on July 15 ulcer was entirely closed. Patient was seen about six months afterward and cicatrix found to be firm. * Read at a stated meeting of the DETROIT MEDICAL AND LIBRARY ASSOCIATION, and published exclusively in The Physician and Surgeon. Case III.-Thomas B., laborer; aged forty years. Has had an ulcer on left leg above ankle for several years. Leg is much swollen and tissue around the ulcer inflamed. Will close up, but breaks down again readily. Is two and onehalf inches in diameter. Leg was poulticed, and on July 7 ulcer grafted with chicken skin. Dressed antiseptically until September 3, when it was entirely healed. Cicatrix strong and remained so when last seen, four months afterward. Case IV. Miss D., domestic; aged forty-five years. Has an ulcer on the lower third of the left leg, five by five and one-half inches, which has not been healed for ten years. Leg is much swollen. Veins varicosed and edges of ulcer raised one-half inch. Edges were incised and strapped until reduced to a level with granulations. On August 6 sixteen small and three large grafts applied. August 17 all of the grafts have taken, and ulcer reduced to three and one-fourth by one and one-half inches. Ulcer was strapped occasionally until October 3, when outer edge of cicatrix began to break down. This was dusted with bismuth and on the 14th again grafted. The ulcer was reduced to about one inch when last seen. This was an especially difficult case on which many remedies had been tried with but little effect. Case V.-A. L., boy of twelve years. An ulcer of the arm. Two years previous had received an injury in which a large amount of flesh was torn from posterior surface of left arm, with some injury to the elbow-joint. The wound healed but cicatrix has broken down frequently since. At present ulceration extends over olecranon process and is three or four inches long. Granulations are pale and flabby. Ulcer was prepared for grafting, and on June 30 nine grafts were applied. On July 6 five of the grafts had taken. August 2 ulcer was entirely closed with a strong cicatrix. With the exception of the last these were unpromising cases, in which other means had been tried with poor results. Chicken skin furnishes a graft easily procured, and in sufficient quantity. It is easily applied, and produces a cicatrix much smaller, and not so contractile as by strapping or other methods. Whether or not it is durable would remain to be answered by further investigation, but so long as seen these cases showed no tendency to break down again. LECTURES. INFLAMMATION OF THE UTERINE APPENDAGES. BY CHARLES P. NOBLE, M. D., PHILADELPHIA, PENNSYLVANIA. GENTLEMEN: The patient upon whom I shall operate to-day has well-marked inflammation of the uterine appendages, and there is every reason for us to expect to find on the left side a pyosalpinx, which I believe is of gonorrheal origin. Our patient has been married nine years, is twenty-eight years old, has had two miscarriages, but no children; the last miscarriage was eight years ago. She has always suffered from dysmenorrhœa, which has grown steadily worse since her marriage. Leucorrhœa has always been present, and on several occa sions has been quite irritating in character. Eight years ago she began to have groin pains and to suffer on exertion. Dyspareunia also became marked. Six years ago she had a labial abscess, and she has since had three others. She has never been confined to bed until September last (1891), when all her symptoms became aggravated. From September to Christmas she was in bed most of the time, and from Christmas until January 30, 1892, constantly. For the last three weeks she has been under my care, having all the symptoms of acute pelvic peritonitis, with chills, fever and sweats, indicating the formation of pus. The symptoms of pus formation were present when I first saw her, but she improved in every way under the medical treatment instituted. Operation was advised after recovery from immediate attack. This I believe to be the wisest course. Pelvic peritonitis is almost always caused by salpingitis, and many recurrences are necessary, as a rule, to cause a fatal termination. Hence, unless there is evidence of the continuous formation of pus, with septic symptoms, or of a tendency of the peritonitis to become general, operation should be postponed until the patient has recuperated her strength, when she will be less liable to suffer from profound shock. The principles governing the management of inflammation of the uterine appendages are pretty well settled, nor does there seem much prospect of change without the discovery of new facts in therapeutics. When the inflammatory process has advanced to the formation of pus, either as pyosalpinx, abscess of the ovary, or suppurative peritonitis, operation and removal of the diseased appendages is demanded to save life. Spontaneous recovery is scarcely possible, save by the discharge of the pus through the skin, vagina, bowel or bladderalternative to exsection which is not to be entertained. The time for operation must be determined by the conditions present in each case. The management of the appendages on the opposite side, when the inflammatory disease is unilateral, is still under discussion. Where the disease is of gonorrhœal origin, experience has shown that it is best to remove both appendages; because a gonorrhœal endometritis is left, which later infects the healthy tube and entails a second abdominal section for its removal. When gonorrhœa can be excluded with reasonable certainty, especially in young women without children, I would not remove the healthy tube and ovary, unless there be some particular reason for it. Our patient has had the usual preparations for an abdominal section. For some days she has been on soft diet, has had daily baths, and has had the bowels well moved. This morning she had only a cup of coffee. The abdomen has been washed with soap and water, with water, with alcohol, and with bichloride solution. She has also had a bichloride douche. The woodwork of her room has been thoroughly cleaned and washed with bichloride solution, one to one thousand; and the room itself has been thoroughly aired. All the apparatus used about the operation has been similarly treated. This secures asepsis in our appliances. The instruments are heated to 290° Fahrenheit for two hours. They are then put in trays and covered with boiling water. The gauze and sponges have been made aseptic after the formula used in this hospital. Before use they are freed from chemical antiseptics by washing in boiled distilled water. All the water used about the operation has been recently boiled, and has been either distilled or filtered before boiling. The hands and arms of the operator and of the assistants have been thoroughly cleaned with soap and water and with a nail brush, then soaked in a saturated solution of permanganate of potash; and this has been removed by soaking in a saturated solution of oxalic acid. Finally they are washed in bichloride solution, one to one thousand. The patient being now on the table we will again wash the abdomen with soap and water, and shave the region of the incision and the pubes. This adds greatly to the cleanliness of the field of operation and prevents detritus from becoming adherent to the pubic hair. The soapy water is now rinsed off, the field of operation is douched with bichloride solution and this again is washed off with boiled water. This gives an aseptic field and aseptic appliances, with an entire absence of chemical solutions. From this time nothing but boiled water will be used for washing or douching, so that our patient will derive every benefit from antiseptic surgery and be in no danger of poisoning from chemical germicides. As presumably the operation will be more than usually difficult the incision will be made relatively long-two and a half inches. The method used is to cut quickly down to the sheath of the recti muscles, which is likewise incised. (The slight hæmorrhage can be disregarded as a rule. It usually ceases spontaneously, and besides it is better to dispense with pressure forceps as much as possible, as bruising the tissues does not favor primary union). If the middle line is not apparent it is found by picking up the sheath of the rectus lightly and perhaps dissecting it to one side or the other. The posterior layer of fascia is now divided, and the præperitoneal layer of fat exposed. Up to this time the tissues have been divided in situ. As we approach the peritoneum it is best to pinch up the layer of fat and elevate it before cutting. In this way there is no necessity for the use of the grooved director. The peritoneum is incised in the same way. Before opening the peritoneal cavity bleeding from the incision should be controlled. On passing my fingers into the pelvis I find a large inflammatory mass on the left side and a dilated and adherent tube on the right side. The tube is freed by pressing the adhesions off with the pulp of the index finger, until it can be drawn up, when the remaining adhesions are rapidly stripped off and the tube and ovary are well delivered, to be tied off in the usual way. On the left side the mass is made up of tube, ovary, broad ligament and bowel. Separating adhesions along the broad ligament an intra-peritoneal abscess is opened, containing about half a pint of pus. The tube can be plainly made out and freed, but it is not possible to find the ovary, which is embedded in plastic exudate. As the abscess has been discharged, rather than prolong the operation with our patient somewhat shocked, I will tie off the tube and leave the ovary. By Next the peritoneum must be cleansed of this foul pus. For this purpose I will pour into the belly several pitchers of warm water and irrigate the pus sac by means of a Davidson syringe. The gravity flushing apparatus also affords a desirable method of douching the peritoneal cavity-perhaps the best. removing the pus in this way there is little danger of sepsis or peritonitis. I have seen the foulest pus poured over the bowels by the pint, and yet when it was thoroughly washed away no trouble resulted. In this way but little sponging is required. A short drainage tube of medium size is now inserted. The tube should not reach the floor of Douglas' pouch, as injurious pressure might be made by it, and unnecessary pain would certainly be caused. The drainage tube is the sheet anchor of success in pus cases, and in all cases with many adhesions. Deep and superficial stitches are now placed in position by means of the needle and carrier, and the sponges are counted to be sure that none is left in the abdomen. A nicer approximation of the sutures can be made by tying the superficials first. A strip of gauze is now run down the tube, powdered iodoform and boric acid (one-seventh) is sprinkled along the incision, the gauze is laid over the region of the incision, a liberal layer of bichloride cotton is put in, and the Scultetus bandage is applied. Dressed in this way the tube is protected from atmospheric infection by the bandage and the cotton, and need be cleaned but twice daily, as a rule, because any excess of fluid is taken up by the gauze strip and cotton by capillary action. The patient will now be put in bed and surrounded with warm water cans, to recover from the shock and ether. NOTE.-She made an uninterrupted recovery. TRANSACTIONS. DETROIT MEDICAL AND LIBRARY ASSOCIATION. STATED MEETING, OCTOBER 17, 1892. THE PRESIDENT, FREDERICK W. MANN, M. D., IN THE CHAIR. DR. H. O. WALKER demonstrated the method of DR. MURPHY, of Chicago, in performing gastro-enterostomy and enterostomy, using for the purpose a dog. This method is known as MURPHY's anastomosis without the needle. DR. E. W. JENKS: This method is referred to by MURPHY's collegues as something unprecedented, brilliant in its performance and results. DR. FLINTERMANN: Has it been done on the human subject? DR. WALKER: Yes. Five times successfully. DR. G. W. STONER: Could not decalcified bone be used instead of brass in the manufacture of instruments? DR. WALKER: No; you could not get the proper pressure. DR. F. W. MANN: Could aluminum not be used in the manufacture? DR. WALKER: The metal may be improved upon. PATHOLOGICAL SPECIMENS. DR. J. H. CARSTENS exhibited the following pathological specimens: (1) Cyst of the ovary. It had produced a great deal of pain and discomfort, there were many adhesions, and it was with great difficulty removed. (2) Vaginal hysterectomy. (3) The remnants of an old extra-uterine pregnancy. All the acute symptoms had subsided but this mass was a constant source of irritation to the intestines and surrounding organs. (4) Ovarian tumor. (5) Dermoid |