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the patient, in looking for success after such a procedure.

DR. LUTZ said that in the removal of the axillary lymphatics for cancer, the same condition prevailed as in cancer of the lip with involved lymphatics, and if they were removed in the one instance they should be in the other; but he could not see the necessity in cancer of the lip of converting a simple operation into such a formidable one as the removal of the enlarged lymph glands would require, and beside, that in a great majority of cases the lymphatics were not involved.

Did not think there was much dispute as to the principle involved in antiseptic surgery, that the great object was to prevent putrefaction taking place in wounds, and this was accomplished by removing everything from it that did not possess sufficient vitality to become organized, and the best way to remove all this was by washing thoroughly. Said his idea in the removal of a sequestrum of bone had always been to remove everything which could possibly be unfavorable to the healing of the wound, and therefore he did not consider it wise to leave a blood-clot to fill the gap, as had been recommended.

DR. FAIRBROTHER thought it a damaging conclusion, that all bad action in wounds came from without; that in certain seasons of the year, wounds did not do nearly so well as in others, and he thought it was due to that season; again, in certain persons wounds did not get along nicely; so that there were other elements in the unfavorable progress of wounds besides the introduction of things from without. In response to a question from Dr. Lutz, said he did not know whether crushed parts retained their vitality longer with antiseptics or not. Dr. Fairbrother also recounted in an interesting manner the details of the accident which led to the death of Dr. Jennings of East St. Louis. The symptoms pointed to fracture of the cervical vertebræ, but post-mortem revealed none; a clot was found lying between the medulla oblongata and the cerebellum, and the vertebral artery of the right side was found plugged from its point of junction with its fellow to the foramen magnum. There was no appreciable injury to the coats of the artery externally. DR. GREGORY said that he was positive that frequently, when the external coat of an artery was not injured by a blow or a twist, the lining membrane of it, the tunica intima was torn, and the injury to that coat caused a clot to form in the vessel, when no cause for it could be found upon an external inspection of the vessel, and wanted to make the point prominent, that in an injury to a

limb, not profound and extensive enough to crush and mangle all its parts, in which the distal arteries had ceased to pulsate, not to amputate immediately, but to wait, as the cessation of pulsation might be due to a clot, formed on account of a rupture of the internal coat of the main vessel, and that the limb might be reclaimed from loss by the estab lishment of a collateral circulation. Society then adjourned.

AMERICAN GYNECOLOGICAL SOCIETY.

[CONCLUDED.]

The use of electrolysis is also of service in the treatment of inflammatory effusions. The following case was related. Mrs. X., aged twenty-eight, married, the mother of one child three years old. The present trouble had existed since the birth of the child. A diagnosis of chronic perimetritis was made. The effusion was most marked on the left side behind the uterus. For six weeks or dinary treatment was given without much beneft. For the next two months, the treat ment consisted of hot water injections, applications of iodine and the use of the galvanic current, with the positive pole in the poste rior cul-de-sac and the negative pole over the epigastrium, using as many cells as possible. This was used every other day. This caused a decrease of the sensitiveness, but did not diminish the size of the effusion. At the end of this time, the positive electrolytic needle was inserted into the mass and the negative sponge was pressed above the pubes. A current from eighteen cells was applied for ten minutes. At the end of a month, scarcely a trace of the effusion could be felt. Before resorting to electrolytic puncture, the application of the current as first employed in this case should be tried, as it does not require an anesthetic and avoids the slight risk which accompanies even small wounds. The author presented the following conclusions:

1. Electrolysis is a useful agent in the treatment of certain cases of fibroid tumors of the uterine walls and of chronic circumscribed peri-uterine effusion.

2. When applied to fibroid tumors of the uterus, electro puncture is a most reasonable and efficient method.

3. In the treatment of fibroid tumors by this agency it is unnecessary to apply it often.

4. Cases of perimetric effusion to be treated by this method should be selected with care, in reference to the absence of all acute symptoms.

DISCUSSION.

DR. JAMES R. CHADWICK, Boston.-Ten years ago, I tried electrolysis in one case of fibroid tumor, introducing the needle through the abdominal wall. This caused a smart attack of peritonitis. During the following year there was no decrease in the size of the tumor. A few weeks later I was called in consultation to see a case which had an enor mous pelvic abscess as the result of electrolysis. This deterred me from continuing the treatment further. I shall, however, give it

another trial.

DR. GEORGE J. ENGELMANN, St. Louis.The dangers mentioned by Dr. Chadwick are those which are liable to follow puncture through the abdominal wall. By puncturing through the vagina and, if possible, through the tissue of the uterus, we avoid the dangers of inflammation which accompany abdominal puncture. I believe that the same results can be accomplished without anesthesia and with less danger by one electrode in the tissue and concentrating the total effect upon that electrode, by using a large electrode in connection with the other pole.

DR. MATTHEW MANN, Buffalo.-I have employed this agent in one case, plunging one needle into the tumor from behind through Douglas cul de sac, with a sponge electrode over the tumor on the outside. The current was kept up fifteen minutes. Six applications were employed. The size of the tumor much diminished, and the tenderness and pain were lessened. The patient is now able to attend to her duties.

PERSISTENT PAIN AFTER ABDOMINAL

SECTION.

BY JAMES B. HUNTER, NEW YORK.

Reference was first made to the causes of pain before operation, the chief of which is peritoneal inflammation, and the resulting adhesions.

Abdominal section is performed for the relief of pain, and the organ at fault is successfully removed and the patient recovers, but the pain continues. If there is no marked relief at the expiration of twelve to eighteen months, if the patient has been favorably situated, the operation may be pronounced a failure so far as the patient is concerned. Such pain may be due to former peritonitis, to peritonitis following the operation, or to some defect in the abdominal wall.

Many of the cases which have been cured of diseases endangering life, still suffer pain. Peritonitis following the operation is a cause of pain in a certain number of instances. A slight amount of peritonitis often occurs after

abdominal section, and it may leave some slight adhesions interfering with the mobility of the viscera. Inflammation in the region of the stump often causes its attachment to the abdominal wall and thus causes pain. Pain may result from defective union of the abdominal incision, allowing a ventral hernia. Pain in the cicatrix may occur as in other sit uations.

In the way of prophylaxis, the utmost precaution should be taken to prevent the development of peritonitis. Especial care should be taken to do no violence to the intestines. Antiseptic precautions should be adopted, the stump should be tied with aseptic silk. The early and judicious use of drainage and irrigation will go far toward preventing inflammation. The cold coil with antipyrin should be resorted to if there are any indications of peritonitis.

In the treatment of the pain, rest in the horizontal position is, perhaps, better than any medicine. If all palliative measures have been tried and at the end of twelve or eighteen months there is no improvement, a second operation may be warranted. dangers of operative procedure and the uncertainty of the operation causing any improvement, must be stated to the patient. Conclusions:

The

1. All cases of abdominal section done for the relief of pain, should be carefully followed. up for at least two years, and not counted as cured, simply because the operation has not been fatal.

2. Peritonitis following operation is to be dreaded as much for its remote consequences, as for its immediate danger.

3. Extreme caution is demanded when the operation is undertaken where there exist the physical signs of chronic peritonitis.

4. Secondary operations, as a rule, are of no value, although occasionally they may afford relief.

5. Where the operation is done for the relief of pain, a guarded prognosis should be given. There are certain chances that a perfect cure will not result even if the operation itself is entirely successful.

DISCUSSION.

DR. A. J. C. SKENE, Brooklyn. In tying the pedicle after removal of the ovaries, some traction must be made upon the broad ligament and the nerves must be drawn upon. That form of pain may disappear. Another cause of pain is the application of the ligature just tight enough to arrest hemorrhage without destroying the nerves.

In regard to what constitutes success after

abdominal section, I would say that many of the cases which I have reported as failures have subsequently turned out to be most successful.

DR. W. GIL WYLIE, New York.-The general condition of the patient is important, for what will cause pain in one person will not in another. With reference to peritonitis, I would say that I regard it as a condition behind which there is some disease. In chronic peritonitis, there is often some cause which keeps renewing the inflammation. In many of the cases that suffer after operation, the pain is due to imperfect operation. Sometimes a small portion of diseased tissue is left. I have taken the precaution to destroy the diseased tissue that may be left beyond the ligature, either by carbolic acid or preferably by Paquelin's cautery. This has lessened the mild attacks of peritonitis. Sometimes the inflammation 18 centred around a ligature, leading to abscess and the formation of a sinus. In some of these cases the trouble can be cured by dilating the sinus and fishing out the ligature. In many cases the peritonitis is due to the bursting of a small cyst. I have intentionally burst these cysts on the table, put the patient to bed and watched the case.

Again, in cases where there is chronic inflammation of the lining membrane of the uterus, this is not always cured by the removal of the tubes and ovaries. This may cause pain not only in the uterus. but reflexly in other parts of the body. These pains can often be cured by dilating the uterus and applying carbolic acid.

DR. ROBERT BATTEY, Georgia.-I have had some little experience with the little difficulties alluded to by Dr. Hunter. We are all familiar with the neurotic women. As a result of a carious tooth, an intense neuralgia may be set up which may continue for years and not be relieved by the removal of the diseased tooth. This is probably due to an alteration in the nerve tissue itself. The explanation that these pains persisting after abdominal section were due to inflammation and adhesions has been carefully considered by myself, but I have wholly failed to find a satisfactory explanation in this quarter. The neurotic cases which have given me the most trouble have been almost uniformly those where I was unable to find any such deposit in the pelvis.

The speaker has said that at the end of twelve or eighteen months, we should give up these cases as failures. I should qualify that statement by more than doubling the limit. Some of the cases which were most

unsatisfactory at the end of a year have achieved the most gratifying cure by the lapse of time.

Among the causes which produce this neurotic condition, I am inclined to rank, in the first place, an acquired neurotic habit from long suffering. In looking for causes, I have been much struck by one point, that alluded to by Dr. Skene, that is the use of the ligature and especially a rather loosely tied ligature. Dr. Skene, suggests the use of the cautery and clamp. I formerly used a method which has not been alluded to and that is the separation of the ovary from its attachment by the ecraseur. In these cases I did not have any of these troublesome neuroses and there was no hemorrhage. I have seriously been considering a return to this method of treatment.

With regard to treatment by a second opening of the abdomen, I would call attention to the fact that by a simple opening of the abdomen, purely for diagnostic purposes, unaccompanied by any great disturbance of the parts, the condition of the patient is often greatly improved, especially as regards pain. In a case of gonorrheal inflammation, I opened the abdomen after the failure of all other methods of treatment, finding everything glued down by adhesions. I abstained carefully from all manipulation after satisfy ing myself of the entire impracticability of any operation. The patient, without any deception on my part, gained the impression that the ovaries and tubes had been removed. She has now been under our observation two months and the relief has continued. Before the operation she used full doses of morphia, but since then she has used no anodyne whatever. She has not menstruated since the operation.

I think that after removal of the ovaries and tubes, the uterine trouble will get well, but the cure may be hastened by applications to the interior of the uterus of a solution of iodine in carbolic acid.

DR. H. P. C. WILSON, of Baltimore. I am satisfied that while cases do occur where the pain after laparotomy continues as a result of local adhesions, yet the majority of cases belong to the class of cases described by Dr. Battey, where the condition is due more to the neurotic element than to the operation. Most of these are long standing cases where the mental condition has become so morbid that the patient is almost insane on the sublect of her ovaries and tubes. Even if these organs are removed, the neurotic condition may remain for a long time.

The neurotic condition has been referred

to, but this is secondary, as regards chronic metritis. I agree with Dr. Battey that usually after removal of the ovaries nothing more is required.

I am willing to admit that my limit was too short and should be extended to two or three years. I think that it is not well to expect any improvement after removal of the ovaries and tubes, for at least twelve months. I think that it takes that long for the system to become accustomed to the changed condition. THE BLUE DISCOLORATION OF THE VAGINAL ENTRANCE AS A DIAGNOSTIC SIGN OF PREGNANCY.

RY DR. JAMES R. CHADWICK, OF BOSTON.

The speaker had made it a point in all cases of early pregnancy to make a note of how much discoloration he could detect. He had tables of four hundred and forty cases examined. He had divided the discolorations into four groups: First, Doubtful; where it was so faint that he could not be certain of its presence. Second, Sugggestive; where it

was

more marked. Third, Characteristic; where the discoloration though faint is confined to the anterior wall of the vagina and more particularly to the urethra, just below the meatus and on either side of the meatus. In every instance where this was present the woman was pregnant with one exception; and Fourth, Marked; where the congestion has become deep and exhibits the appearance constantly seen during pregnancy.

He did not claim that the characteristic discoloration is seen in every case, but if carefully looked for, it would be quite pronounced in the majority of cases. The color varies from a violet to a dark, dusky, almost black color. He claimed that this sign was of especial value in cases of retroversion where the size of the uterus could be determined and in extra-uterine pregnancy. He had obtained much assistance from it in a few cases of pregnancy accompanied by fibroid tumors and also where there was an accumulation of abdominal fat. When present, the sign is of decided value in the early months of pregnancy, but its absence should not be accepted as a positive proof against pregnancy. Cases were cited in which the discoloration had been observed in the seventh or eighth week of pregnancy.

DISCUSSION.

DR. H. P. C. WILSON, Baltimore-I consider this one of the most valuable means of diagnosing pregnancy in the early stages. It is invaluable in cases where women wish to deceive you.

DR. A. J. C. SKENE, Brooklyn. This has seemed to me to be a most reliable sign in the early months of pregnancy. I believe that it is an illustration of the physiological hyperemia of the formative stage of development.

DR. JOSEPH TABER JOHNSON, Washington. -Some years ago I referred to this point and the discussion which followed seemed to indicate that the discoloration was a congestion produced by interference with the return of the venous circulation by the pressure of the enlarged uterus. It was held that the same discoloration could be produced by any other tumor which would have the same effect as the pregnant uterus.

DR. WILLIAM H. PARRISH, Philadelphia.In regard to the continuance of the discoloration after labor, I have noted that in primipara where involution of the vagina takes place completely, the discoloration disappears with corresponding rapidity. Where there is sub-involution, the blueness may continue for a longer time. In multiparous women where the blueness was marked, I have associated it with a condition of subinvolution of the vagina.

DR. JAMES R. CHADWICK, Boston.-I have failed to notice any discoloration described. The general discoloration may persist, but the characteristic blueness will I think be found to disappear. I have looked for the sign in forty or fifty cases of fibroid tumor and have not found it in a single instance. Adjourned.

AFTERNOON SESSION.

DR. R. STANSBURY SUTTON, Pittsburg, exhibited the specimens from three cases of supra-vaginal hysterectomy, and made some general remarks on the operation.

DISCUSSION.

DR. W. GIL WYLIE, New York.-I think in many cases of fibroid tumor, however, where hysterectomy has been performed for hemorrhage that curetting the cavity of the uterus would have obviated the necessity for the operation. Where there is hemorrhage, there are nearly always granulations. With the curette, not only may the hemorrhage be brought to a normal standard, but I have seen the tumor diminish in size.

DR. THADDEUS REAMY, President, of Cincinnati. I think that if Dr. Wylie uses the curette in cases of fibroid tumors, he must, notwithstanding the adoption of all antiseptic precautions, have a certain number of cases of septicemia. Curetting is much more likely to be followed by septicemia.

DR. W. GIL WYLIE, of New York.-I invariably use antiseptics before the operation, and douche out the cavity afterwards. I have never had septic poisoning in any case of curetting in my practice. I use the bichloride solution one to two thousand in the vagina and one to five thousand in the uterus.

DR. H. P. C. WILSON, of Baltimore.Where we have excessive hemorrhage from a fibroid tumor, I believe there is no remedy so efficient as the curette. I have never seen any evil results from its use.

DR. JOHN C. REEVE, Dayton, Ohio.-Has any of the members had any experience with incision of the cervix in the treatment of fibroid tumors? This was highly recommended some years ago.

DR. R. STANSBURY SUTTON, Pittsburg.-I have tried division of the cervix and have stopped the hemorrhage, and have seen rapid fatty degeneration of the tumor occur in one

case.

THE HIGH MORTALITY OF THE RECENT CESA-
RIAN OPERATIONS IN THE UNITED STATES
WITH THE REPORT OF A CASE.

BY WILLIAM H. PARRISH, M. D., OF PHILADEL

PHIA.

S. M., married, was admitted to the Philadelphia Hospital while in labor September She 20, 1885. was the mother of two children, the last of which was born twelve years previously. Labor had begun on September 18, the membranes soon rupturing. She was seen by two physicians who had her sent to the hospital. The cord had prolapsed, and the pulsations had ceased before she was sent to the hospital. On admission, she was found much exhausted with the cord protruding from the vagina. The resident physician not recognizing the gravity of the case, Dr. Parrish was not summoned until some hours after her admission. At this time the uterus was in a state of tonic spasm; the patient was etherized. The vaginal examination revealed merely a rigid condition of the cervix. The pelvic canal was roomy. The hand was introduced into the vagina and two fingers into the uterus. This examination showed two hard intra-mural fibroid tumors about the internal os. The author concluded that Cesarean section should be performed without delay, and three of his colleagues were sent for in consultation. They all agreed that attempts at enucleation should not be made, but they did not agree as to the necessity of Cesarean section. They were in favor of craniotomy. The skull was perforated, but it was found impossible to grasp and crush the head.

rious instruments were tried without avail. The necessity for Cesarean section was then conceded by all. The uterus had then been emptied of its waters for at least forty hours.

The vagina and lower part of the uterus were washed out with a solution of corrosive sublimate. The cervix was closed by tying around it a rubber drainage tube. The abdomen was opened and the section of the uterus made. At once a very offensive gas escaped. A large child was removed. The placenta was not in the line of the incision. Antiseptic precautions were employed during the operation. Deep and superficial sutures were introduced into the uterus and the abdominal incision closed. A hypodermic injection of ergotin was at once administered. After the operation the tube around the neck was removed. The patient died twelve hours later from exhaustion and rapidly developing septicemia.

At the autopsy, the lips of the uterine incision were found in contact. Three dense intra-mural fibroid tumors were found.

DR. PARRISH then referred to the great mortality of this operation in the United States, and presented the statistics of Dr. Robert P. Harris, of Philadelphia, of which the following is a synopsis;

54

64

Cesarean operations in the United States 144 Women saved, 37.5 per cent. Children living when delivered, First fifty operations, saved 54 per cent. Second fifty operations, saved 24 per cent. Operations performed in good se son, when the condition of the woman was favorable, have in this country saved 75 per cent of the women and eight per cent of the children.

Cesarian section has been performed in thirteen cases where the obstruction was due to fibroid tumors, and of this number four recovered and five children were living. The time in labor in the saved cases was nine and one half hours, fourteen hours, three days and four days.

The following rules were given for the performance of the operation:

1. Carefully determine the degree of obstruction, and operate early in labor, as soon as the os is sufficiently dilated to permit drainage, and before the rupture of the mem branes.

2. Operate with full antiseptic precautions, but the spray over the abdomen is unnecessary.

3. Control hemorrhage by compression of the cervix either with a rubber tube or manually, preferably by the latter means.

4. Introduce numerous deep and superfiVacial sutures so as to approximate accurately

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