Billeder på siden

tress himself if he does not succeed in removing all the diseased structure, realizing that if free vent is afforded the diseased tissues will be exfoliated and the wound closed by granulation. In the pelvis the sine quâ non is to secure and maintain drainage. In pelvic inflammation where a mass of exudation may be determined, a free vaginal incision should be made, its position depending somewhat upon the situation of the difficulty.

In posterior and lateral masses, the incision should be made through the posterior and lateral fornices of the vagina. The incision should be large and where the collection is posterior to the uterus, it can be reached without difficulty. The posterior incision extended around the cervix laterally, affords ready access to lateral collections without danger to the ureter, or the uterine artery. If the abscess is not reached by the incision, the preferable plan is to dissect upward through the broad ligament with a grooved director, or blunt scissors until the sac is perforated. If the latter is used, the blades should be separated and withdrawn. In this manner an opening may be enlarged to admit the finger and can be still further enlarged by tearing. The cavity is then thoroughly irrigated with plain, hot, sterilized water, hot salt solution, or a solution of sulphurous acid, one to thirty. Peroxide of hydrogen should not be used, for the reason that the decomposing gas not infrequently dissects up recent adhesions and serves as a medium for carrying infection into the peritoneal cavity. Irrigation should be followed by careful gauze packing; an aseptic pad should be applied to the vulva, to be changed as often as it becomes soiled.

The internal gauze may remain fortyeight to seventy-two hours. Its removal should be followed by irrigation and repacking. The gauze should be changed at intervals of two days for a week or ten days, according to the size. and character of the abscess.

It is not claimed that the plan of treatment will cure every case; indeed, occasionally a patient will present symp

toms which will require the exploratory vaginal incision to be immediately followed by an abdominal operation in order to remove pus collections. Other cases will be found in which there is delayed convalescence or relapse, due to the presence of secondary foci inaccessi ble through the vaginal incision.

Even in such cases the vaginal incision does not complicate the secondary operation, and when done at the same sitting affords an opportunity for vaginal (gauze) drainage, which will permit the immediate closure of the abdominal wound.

The class of cases to which this procedure is applicable may best be illustrated by a brief résumé of the history of the following two cases:

Mrs. D., aged 26 years, recently married, began to suffer from pelvic distress shortly after marriage and consulted her family physician, who made an examination and discovered a displacement and some endometritis. He proceeded to curette the uterus, which was followed by an aggravation of the previous inflammatory attack. Her temperature varied from 100° to 103°; abdomen was distended and painful. The uterus was fixed in and surrounded by exudation, which was more marked upon the right side. The rectum was encroached upon by a mass of exudation, which presented to the right side a point of softening. A few days later she was brought to my private hospital and a vaginal incision made, which permitted about half an ounce of pus to escape. Pressure upon the mass through the rectum ruptured the intervening wall and permitted the fingers to come in contact, establishing, much to my discomfort, a recto-vaginal fistula. The wound was carefully irrigated and packed with iodoform gauze. This was renewed at the end of three days and twice subsequently, with the closure of the opening and obliteration of the sac. The remaining exudation was absorbed and the uterus set free under a course of pelvic massage.

Mrs. S., was seen with Dr. Jurist. She had been sick for several weeks with an attack of pelvic inflammation, which had resulted in a large collection

upon the left side, displacing the uterus to the opposite side. Arrangements had already been made for an abdominal operation by a prominent operator, but through some misunderstanding his services had been discontinued. As fluctuation could be distinctly recognized in the mass, it was decided to do a vaginal operation. Accordingly a free incision was made posterior to the left lateral fornix, and the abscess cavity opened. Over a pint of offensive pus was evacuated and a large number of flakes of lymph washed out during irrigation.

The gauze packing was carried up well into the cavity. The subsequent progress was uninterrupted and the patient was able to leave her bed at the end of two weeks, free from any pelvic distress.

In both the cases cited, the patients, after short convalescence and slight suffering, apparently recovered as gratifying a state of health as is usually secured by the more radical operation and escaped the sequelae which must necessarily accompany the removal of the appendages under the most skillful opera


The discussion of the vaginal operation for the removal of the uterus for cancer or prolapse is not appropriate to the title of the present paper, but its slight mortality has led to the consider

DEPOSITS OF RUST IN THE CORNEA. Gruber (Southern California Practitioner) draws the following conclusions from his observations: 1. Particles of iron which have penetrated the cornea vary in their action according to their chemical properties. Metallic iron and ferric oxydule must be regarded as irritating, while ferric oxide is indifferent. The ring of rust remaining after the extraction of a particle of iron, consisting merely of a hydrated ferric oxide, is indifferent and unirritating. 2. Even in cases of non-perforating injury from particles of iron, there often results a deposit of ferric oxide on the membrane of Descemet. 3. The deposit of rust outside the foreign particle follows very rapidly after the injury. 4. The cor

ation of the advisability of vaginal hysterectomy in such cases as require the removal of the appendages for sepsis. As the route of infection is through the uterus, and that organ is the seat of disease which must produce more or less disturbance, aggravating the phenomena of the artificial menopause, and as the organ after the removal of the ovaries no longer serves any useful purpose, its extirpation seems not only justifiable, but wise.

Every student of the subject has seen numbers of cases in which the diseased uterus has been the source of discomfort and distress for years subsequently; the removal of such a uterus is generally followed by a rapid amelioration of the unpleasant symptoms.

In conclusion I would suggest:

1. In all cases in which it can be demonstrated that an abscess cavity can be opened through the vagina, that canal should be the site of election.

2. In doubtful cases it should be tried, as the vaginal incision does not preclude the immediate approach of the diseased tissues through the abdomen.

3. Where the ovaries and tubes are so diseased as to require their removal, the advisability of vaginal extirpation should be considered and practiced whenever the organ is especially diseased.

neal epithelium resists very strongly the entrance of the ferric oxide deposit.

CONTAGIOUSNESS OF CANCER.- The following considerations of the infectious nature of cancer, says the North American Practitioner, were offered by Guelliot, of Reims, at the eighth session of the Congrés Francais de Chirurgie. That it began as a local disease; that cancer is inoculable in animals of the same species; it begins on surfaces irritated, ulcerated, or injured; it is unequally distributed in rural districts, there being apparently abodes of cancer, and in more than forty cases of the 113 collected by him, husband and wife had epithelioma.




The 785th regular meeting of the Medical and Surgical Society of Baltimore was called to order March 28, 1895, by the President, Dr. J. Wm. Funck. The minutes of the previous meeting were read and approved.

Dr. James Bosley was elected to membership.

Dr. J. Henry Conway reported a case of TUBERCULAR MENINGITIS.

On Friday, November 16, 1894, Lizzie H., aged 13 years, colored, an inmate of St. Elizabeth's Home, complained of a severe headache and vomiting. Temperature 101°. Mild chloride was given ingrain doses every hour until six had been taken. She appeared better the next day and on Sunday there was a return of the headache together with an intense pain in the epigastric region. No fever. I first saw the case on Monday, the third day of her illness. Her condition was then as follows: Temperature normal, pulse 84, full and strong; slight cough, intense nasal catarrh, bowels regular, complained of headache and felt very weak. Her condition led me to suspect measles so I ordered her to be placed in a separate room away from the other children. Her temperature to be taken every second hour and quinine sulph. three grains every third hour, given together with the House cough mixture, which contains mx. glyzzh. comp. and am. carb. one grain to the drachm. Her temperature remained normal until the next afternoon at 4 P. M., when it suddenly rose to 102°; at this time an eruption of papules was noticed scattered irregularly over the body; owing to the complexion of the child it was necessarily black. The following day she was much better, headache and fever both absent, catarrhal symptoms almost gone.

From her general condition my theory of measles was considerably shaken. On the following day Dr. Joseph B. Saunders saw the case with me; she was then in

apparently the best of health and strenuously objected to being isolated from her playmates as the eruption was the only symptom present. Dr. Saunders recommended that she be allowed the liberty of the yard and the companionship of her little friends. Acting on the suggestion, she was allowed out and after playing around retired at 8 o'clock in apparently the best of health. About 11.30 the same night the house was aroused by her shouts and when the Sister went to her room she found the child standing in the middle of the room laughing and singing by turns and altogether in a wildly happy mood. She was given a teaspoonful of the house solution containing pot. bromid. 5 grains and put back to bed. In about an hour she quieted down but still continued delirious of the low muttering type. When I saw her the following morning her respiration was sighing and irregular, pulse weak and very rapid, temperature subnormal, pupils unequal and insensitive to light. She lay in a semi-comatose condition, from which she could be aroused by addressing her in a loud tone and would then recognize those around her; stimulation was pushed and she appeared to rally, her temperature changing from 95° at 9 A. M., to 102° at 2 P. M. From the great irregularity of her temperature together with the head symptoms I concluded that she had meningitis and on account of her age, race and surroundings believed it to be of the tubercular form. As I was by no means certain, the following day I had Dr. Sylvan Likes see the case with me. We made a careful examination of the child without eliciting anything new. She appeared to rest easily, ate what was given her and would sleep four and five hours at a time and with the exception of the irregular temperature there were no well marked symptoms of any kind and Dr. Likes would not risk a diagnosis but agreed that it might be meningitis.

This was on Saturday, the seventh day of her illness. She remained in about the same condition until Monday, when involuntary muscular involuntary muscular twitching, together with retraction of the abdomen, was noticed. The following day she

again complained of severe headache and her skin was hypersensitive to the touch. Dr. Saunders being with me confirmed the diagnosis of tubercular meningitis. She was placed on morphia sulphate, grain every fourth hour. She again became delirious of a low wandering type and on the following morning, the thirteenth day of her illness, she had a slight convulsion, after which she quietly passed away. Two days later, at the College of Physicians and Surgeons, Professor N. G. Keirle held a post-mortem on the case and said that it was a typical case of tubercular meningitis. Very little need be said in regard to the treatment, as the case is interesting mainly on account of its close resemblance to measles and absence of most of the characteristic diagnostic signs as usually given in the books, particularly the "hydrocephalic cry," but the treatment pursued in this case was that of a hot pack or hot applications to the extremities for the relief of cerebral congestion. Owing to the extreme weakness of the child the ice bag or ice cap was not used and as the case was entirely hopeless we simply did. everything to relieve its suffering and allowed the child to die quietly without adding any more agony by the way of treatment.

The Society is considering the advisability of locating more centrally for the convenience of our uptown members. S. T. ROEDER, M. D., Secretary.


THE DANGER OF ALKALINE MIXTURES. Every practitioner, says the British Medical Journal, is aware that solutions of potash and soda salts are apt to increase rather than check dyspepsia if given too long or in too large doses. M. Mathieu finds that they may even set up cystitis. In cases of gastric ulcer and acid dyspepsia he has seen the complication occur when the patient has taken a mixture of one part of calcined magnesia and four of bicarbonate of soda. He has learnt that at Vichy the visitors who go through a course of

the Source de l'Hôpital waters often have slight cystitis. M. Mathieu has observed a case of cystitis with hematuria in a patient who took large doses of bicarbonate of soda. He replaced it by a mixture, four parts magnesia and six prepared chalk. The hematuria recurred. This seems to show that the alkalinity of the former medicine, not the fact that it was a sodium salt, explained the symptoms of cystitis. Dr. du Cazal has seen hematuria, but never cystitis, in rheumatic subjects taking large doses of bicarbonate of soda. Dr. Hayem notes that the degree of acidity in the urine must be ascertained, in cases of acid dyspepsia, before alkalies are given, as there is no direct relation between the proportion of acid in the gastric juice and in the urine. When the latter is feebly acid the patient may be much damaged by alkalies.

[merged small][ocr errors][merged small][merged small][merged small]

by the more convenient and reliable instruments for examination, and finer ones for operation.

7. There yet remain a number of cases of squint not explicable by our present knowledge, or amenable to treatment by accepted methods. To bring these under definite law, both as to cause and management, remains for the student of ophthalmology.

* *

DANGERS OF THE CURETTE.Pichevin (British Medical Journal) believes that the curette is of high value, but the more it is employed the more its dangers must be borne in mind. Abortion has been produced, and even relatively advanced pregnancy has been mistaken for simple enlargement of the uterus or interstitial fibroid, to the dismay of the operator. Septic troubles have followed the use of this instrument, but with antiseptics this accident is very rare. Far more insidious is the danger from overlooking pelvic abscess: a pyosalpinx has been burst with fatal results. Uterine atresia due to abuse of the curette has been noted by two authorities only. The most probable and frequent accident is perforation of the uterus by the curette itself. In 1854, Richard, a great supporter of Récamier, noted a case of perforation. It was soon found that, as in the case of perforation by the uterine sound, the results were far less serious than theory would lead one to suspect. Still there is no fear that the operator, discovering the accident, will think it a trifle. As to the causes, softness of the uterine tissues, especially in the puerperium, greatly increases the chance of perforation. The uterus, in some reported cases, may have been wounded by the dilator before the introduction of the curette, which then receives blame it does not deserve. Ignorance and roughness have certainly been the sole causes of the accident in some instances. One operator confessed that he once sent the curette clean through the uterus, till the handle lay so deep that it could not be withdrawn without the aid of a longhandled forceps. The walls may have been soft, but no doubt there was want of caution in this case. As a rule the per

foration takes place close to one of the cornua. Turning to the diagnosis, Pichevin notes that in one case, in which perforation was suspected, the curette had simply slipped into an abnormal cornu. The theory of catheterization of the Fallopian tube has been brought forward to explain certain cases where the curette has slipped far into the patient's body without evil results. The phenomenon itself, however, has seldom been satisfactorily demonstrated, even in the case of the uterine sound. Symptoms of perforation vary from total absence to the most alarming subjective and objective conditions, such as profound collapse and the appearance of a coil of intestine at the vulvar orifice. Hence there is no rule for treatment. Pichevin holds that hysterectomy is too severe a measure in an average case. When the curette has penetrated the wall, and the antiseptic solution injected during the scraping process has entered the peritoneal cavity, Douglas's pouch should be opened and drained.

* *

INDICATIONS FOR TOTAL CASTRATION BY THE VAGINA. At the meeting of the American Gynecological Society held in Baltimore in May, Dr. Charles Jacobs, the distinguished gynecologist of Brussels, read a paper on the Indication for Total Castration by the Vagina, in which he drew the following conclusions: 1. (a) Total castration by the vagina is indicated in uterine cancer at its beginning. (b) In uterine fibroid. (c) In extra-uterine pregnancy and total abortion. (d) In complete genital prolapse, according to the indications I have put before you.

2. It is the best operation in bilateral. purulent or non-purulent diseases of the appendages.

3. It finds its indications in uterine and in chronic incurable diseases of the uterus and its appendages.

4. Complete vaginal castration is not more dangerous operation than is laparotomy.


[ocr errors]

* *

CHLORALOSE AS A HYPNOTIC.-Marandon de Montyel (British Medical Journal) condemns chloralose as a general hyp

« ForrigeFortsæt »