TRANSACTIONS OF THE FIFTH ANNUAL HELD IN ST. LOUIS, MO., SEPTEMBER 20TH, 21ST, AND 22D, 1892, AT THE LINDELL HOTEL. (Abstract. Concluded.) The President, Dr. A. Vander VEER, of Albany, in the Chair. DR. J. H. CARSTENS, of Detroit, read a paper on THE TECHNIQUE OF VAGINAL HYSTERECTOMY.' DR. A. H. CORDIER, of Kansas City.-The point I wish to lay stress on is the importance of the removal of the tubes and ovaries at the same time the operator does the operation of vaginal hysterectomy. It is generally the case that the tubes are diseased to such an extent that they should be removed also. We should operate early in cases of malignant disease. DR. W. H. MYERS presented the histories of some UNREPORTED CASES." DR. A. H. CORDIER, of Kansas City.-I would like to ask Dr. Myers whether he found any involvement of the mesenteric glands in his tubercular cases. DR. MYERS. They were very much enlarged. DR. JOSEPH HOFFMAN. Did you drain in both of the tubercular cases? DR. MYERS.-Yes, sir. DR. JOSEPH HOFFMAN.-I have in mind a case of a woman in which there was simply a large cyst removed, apparently peritoneal. The intestines were glued together, the omentum bound down by marked adhesions and thickened. There was nothing whatever removed except apparently cystic fluid. She was in extreme pain, was unable to move except with the greatest effort; there was extreme emaciation, hectic, and every symptom imaginable of progressive decay. Opening the abdomen of this woman, simply removing the cyst 1 See original article, p. 918. 'See original article, p. 927. and allowing the fluid to escape, and putting in a half-drachm of iodoform, worked wonders for her. In three weeks she was on her feet, and three years afterward did excellent work as both nurse and housekeeper without any pain worth mentioning. At the end of that time her pain returned. A second incision was made; the intestines were found a little more glued together, with a small collection of fluid without suppuration; and another sprinkling of iodoform over the region disclosed by the incision put her on her feet and enabled her to do good work for a year or two, after which she passed out of my sight. DR. H. W. LONGYEAR, of Detroit.-I had a case of tubercular peritonitis in a woman that is of interest in this connection. I removed a large quantity of fluid from the abdomen and found the intestines, ovaries, tubes, uterus, and omentum all studded with miliary tubercles. I washed out the abdomen thoroughly with sterilized water, then a 1: 10,000 solution of corrosive sublimate, after that with sterilized water, then drew off the water by siphon. I closed the abdominal incision by buried suture. The patient recovered without rise of temperature, and has had no return of the dropsical effusion. DR. THOMAS J. MAXWELL, of Keokuk.-I had a case of tubercular peritonitis which simulated a cystic tumor of the Ovary. The greater peritoneal cavity was completely cut off and filled with fluid, so that it simulated the symptoms, appearance, and physical conditions of an ovarian tumor; but when I incised the peritoneum the fluid was discharged from the bowel. I then discovered that I did not have an ovarian cyst. The cavity was thoroughly washed out and the incision closed by buried sutures. The woman made a very favorable recovery and continued so for five or six months. I thought perhaps her recovery was complete, but an accident occurred, and she died of exhaustion as a result of the return of this trouble. I was sorry afterward I did not use a drainage tube in this case. DR. J. H. CARSTENS, of Detroit.—In reference to tubercular peritonitis, I have had a case or two which will bear out what Dr. Hoffman has said. The first case was that of a lady, 35 years old, who had had a great deal of pelvic trouble. I thought she had a pus tube. I operated on her and found it was tubercular peritonitis, and, after the usual manner of draining was resorted to, she made a splendid recovery. DR. W. J. CONKLIN, of Dayton, Ohio.-Not very long ago I operated on a case supposed to be an ovarian tumor. The temperature would rise from 101° to 102° in the evening, and continue so for some ten days or two weeks in spite of all treatment. On making a section it was not an ovarian tumor, but an encysted collection of fluid. A cyst had formed by the gluing together of the intestines. The peritoneum was studded everywhere with miliary tubercles. Immediately following the operation the temperature fell to normal, and in three or four months afterward the patient was quite well. DR. A. VANDER VEER, of Albany.-I am convinced from previous experience that iodoform is the proper thing, then to drain thoroughly and for some time. A patient that I saw had been under treatment by several physicians for the period of a year, gradually losing flesh. Three months previous to the time I saw her the abdomen began to enlarge. One physician pronounced the case an ovarian tumor, and another a fibroid. It was plain to me that the case was one of tubercular peritonitis. When in health she weighed one hundred and ten pounds, was able to attend to her household duties, but now weighed only seventy pounds. I was afraid to give any form of anesthetic. She was put in a good condition of cleanliness, and, after injecting a four-per-cent solution of cocaine, I made an incision, passed in two of my fingers, and found the peritoneum studded with miliary tubercles in all directions. I drew off the fluid and put in a glass drainage tube. The patient came to me a week or two ago, having gained twenty pounds. DR. CHARLES A. L. REED discussed the SURGICAL TREATMENT OF CANCER OF THE UTERUS.' DR. EDWIN RICKETTS, of Cincinnati.-One word as to the early diagnosis of cancer of the uterus. Are we to depend upon the curettings as handed to the microscopists? If so, microscopy has got to advance much further than it is at the present time before we can make as early a diagnosis of cancer of the uterus as is necessary. Two years ago a lady consulted me for operation, and the curettings taken from that uterus, in which I suspected it was cancer, were submitted to four different microscopists. Two of them said it was cancer, the others said it was not. Some of the slides were sent to an eminent Vienna microscopist, and were returned with the reply that he would not venture opinion. an DR. JOSEPH HOFFMAN, of Philadelphia.-The operation of high amputation is one that is applicable in certain cases. If there are any lines to decide the exact degree of invasion of tissue, the operation would have some justification; but it is impossible to tell where the limits of the disease are, just as the surgeon operates and finds it in the broad ligament when it seems only in the cervix or uterus. A great many operators have been working on the lines of experimentation. They 1 See original article, p. 890. have been doing a more difficult operation, one that takes more time and incurs more risk. DR. L. H. DUNNING, of Indianapolis.-A little more than three years since I was an advocate of the operation of high amputation. I did something like thirty-five high amputations with most excellent results. Two or three years ago Dr. Reamy and myself opposed Dr. Martin, at a meeting of the American Medical Association, on this subject, both of us taking the ground that, where the involvement was slight, high amputation offered the best results, for the reason that it was more easily accomplished, with less danger to the patient, and with better ultimate results. I am not entirely convinced yet that high amputation is not quite as good and favorable in its results as total extirpation in very many cases. DR. C. A. L. REED.-I believe that good results have followed high amputation in individual cases. I consider total extirpation a less difficult operation. DR. JOSEPH HOFFMAN, of Philadelphia, read a paper on the DIAGNOSIS AND TREATMENT OF PUS IN THE PELVIS. DR. W. H. MYERS, of Fort Wayne (opening the discussion). With regard to pus in the pelvic cavity, wherever it is we have got to get rid of it. It travels in the direction of least resistance. I look upon pus as an indication of sepsis. I think we ought to attach importance to the use of salines and reject the opium treatment. Unquestionably salines have cured some cases of peritonitis. DR. J. H. CARSTENS, of Detroit. If there is a septic condition after an operation Nature often can take care of it. We can give a good dose of salines to help Nature to remove the effete material by the kidneys and bowels. I am not as fanatic about the use of opium as a great many. I hold it is a good thing to give a dose of opium. One great thing about appendicitis is to know when and when not to operate. I regret we have not a paper on this subject, so that we could thoroughly discuss it. DR. WILLIS P. KING, of Kansas City.-The subject of Dr. Hoffman's paper is one of great importance, and every surgeon who makes laparatomies should go after pus wherever it may be, and let it out, as it has no business in the human economy. The use of opium after a laparatomy is a pernicious habit. While I do sometimes give opium after laparatomies in the case of a woman with agonizing pain, still I do not believe it is best to give it. DR. W. W. POTTER, of Buffalo.-Just a word to illustrate the importance of early operation in acute inflammatory conditions near the head of the colon. On Friday a man was seized with a severe pain in the ilio-cecal region and sent for a doctor, who remained the night with him and administered opium. On Saturday he was removed to a hospital. On Tuesday an experienced abdominal surgeon saw him in consultation with the attending physician. The surgeon was of the opinion that if the man was not operated on at once he would assuredly die. At this time he was very comfortable, all pain had ceased, and the man himself said he was much better. The attending physician stated that he would not like to have an operation made in the absence of the hospital surgeon. The hospital surgeon, the next morning at 10 o'clock, made an operation, and there was pus, leakage, collapse, and death. The history does not show that the man had ever had any previous attacks. I firmly believe that if the man had been operated on Tuesday his life might have been saved. DR. JOHN C. SEXTON, of Rushville, Ind.-I think the temperature curve in cases of inflammatory trouble in the pelvis following painful menstruation is an index of great value if we watch it closely and studiously. The temperature of an ordinary case of peritonitis has a morning remission and an evening exacerbation, just the same as the temperature of any other inflammatory affection. DR. RUFUS B. HALL, of Cincinnati.—I think the gentleman is quite right in reference to the temperature chart in acute cases of the formation of pus in the pelvis. In appendicitis, in a certain number of cases of pelvic trouble-appendage trouble the temperature chart does indicate the presence of pus; but my experience leads me to think that in only a small percentage of cases are we justified in saying that pus is or is not present in the pelvis from the temperature chart. DR. A. VANDER VEER, of Albany. While I believe the curette is a valuable instrument in certain cases, yet placing it in the hands of the inexperienced, men who are not thoroughly alive to the importance of examining the uterine appendages, it does serious harm. The curette is dangerous at times when used in cases of subinvolution or chronic metritis. The rules formulated by Dr. Hoffman in regard to treatment of pus in the pelvis we shall read again and study with care when they appear in the Transactions. DR. JOSEPH HOFFMAN (closing the discussion).-I scarcely expected to be understood in all the points brought out in my paper, and I certainly was not in reference to the use of salines in peritonitis. When I spoke of salines in reference to peritonitis I meant suppurative peritonitis. I mean to say that when there is suppurative peritonitis Epsom salts will not cure it. |