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examination revealed very little thickening posterior to the uterus. Fecal matter escaped through the tubes for only a short time after the operation. On April 5, 1895, Dr. Trenchard wrote: "I heard from Mrs. S. yesterday. She rapidly regained her usual health and has remained perfectly well." In this case abdominal section would probably have resulted fatally.
Miss L. R., aged 18, was admitted to St. Luke's Hospital June 24, 1894. Upon examination a mass was felt posterior and to the left of the uterus, extending above the pelvic brim. Abdominal section revealed an agglutinated mass of omentum, intestines and pelvic abscess. The adhesions were extensive and very firm. A left tubo-ovarian abscess was found which contained about one ounce of pus. The abscess cavity was shut off from the general abdominal cavity by gauze packing, and the abscess was opened, drained, and a portion of the abdominal incision closed. Vaginal section was now made and an abscess of the right uterine appendages opened, irrigated and drained. The patient's temperature soon became normal. The drainage tubes were removed at the end of four weeks. Examination showed the uterus to be fixed and showed some induration in the pelvis. The patient felt perfectly well, however, and was discharged from the hospital. I have been unable to get a recent report of the
Mrs. C. C., aged 32, was admitted to St. Luke's Hospital June 26, 1894. Examination showed extensive induration lateral and posterior to the uterus. The uterus and upper portion of the vagina were pushed forward, and the mass extended upward on the left side of the pelvis. The abdominal walls were exceedingly thick. The patient had no symptoms of septic infection and her history indicated that the abscess had existed a very long time. Vaginal section was made with drainage and irrigation, and about one pint of pus was evacuated. The patient felt perfectly well after the operation. At the end of three weeks the drainage tubes were removed. Examination showed some
thickening to the left of the uterus. Two months later a large mass was found to the left of the uterus, which was opened through the old incision, drained and irrigated. Examination during the operation induced me to think that the abscess was ovarian. The drainage tubes were removed at the end of six months. Examination on May 15, 1895, showed a sinus two inches deep, some discharge of pus, and the uterus not freely mobile. Some thickening was felt posterior and to the left of the uterus, but no distinct swelling existed, and the patient's health was excellent. The abscess caused very little suffering; removal by abdominal section would have been difficult and dangerous.
Mrs. H. S., pelvic abscess following secondary abdominal section for severe hemorrhage. On account of the feeble and anemic condition of the patient blood clots were left in the abdomen, which became infected and produced the abscess. The abscess displaced the posterior-vaginal wall forward. Vaginal section was made in January, 1895, with irrigation and drainage; about one pint of offensive pus and blood clots was removed. Recovery was satisfactory but slow, on account of the anemic condition of the patient. Recent examination shows no evidence of pelvic disease. This patient could not have borne a third abdominal section.
Miss S. L., aged 22, was admitted to St. Luke's Hospital on the evening of January 18, 1895. She had a temperature of 103°, pulse 120, and her general condition was exceedingly grave. She gave a history of induced abortion ten days previous. Examination showed a large mass high up in the pelvis to the left of the uterus. She had marked tympanites, general abdominal tenderness, and constant nausea and vomiting. The symptoms indicated general peritonitis. January 19, temperature 103°, pulse 130. Shreds of offensive membrane and small pieces of placenta were removed from the uterus with placenta forceps and curette. Section of the vagina was made to the left of the uterus, and the finger was forced up between the folds of the broad ligament until it
came in contact with the Fallopian tube. A blunt instrument was introduced along the finger as a guide into the tubal abscess; the opening thus made was enlarged with the finger, and two rubber drainage tubes were inserted into the abscess sac. Two to four ounces of very offensive sanguinolent pus escaped. Frequent antiseptic irrigations were used. The patient became almost pulseless during the operation, which occupied only a few minutes. Her condition improved slightly after the operation, but two days later a similar mass was found on the right side. An incision was made to the right of the cervix and the abscess was treated like the previous one. This abscess contained also from two to four ounces of offensive pus. Both the operations were extra-peritoneal. The patient's temperature immediately dropped three degrees and soon became normal, and her condition rapidly improved. She sat up in about three weeks, and left the hospital thirtyeight days after the operation, feeling perfectly well. The drainage tubes were removed on the thirty-third day. Examination showed a movable mass, probably ovarian, high up to the left of the uterus. Examination of the right side revealed no evidence of disease. Examination made about April I showed no appreciable change in the mass. This will probably necessitate an abdominal section, which can now, I believe, be safely performed. Had abdominal section been attempted in this case, the patient would certainly have died during the operation.
Mrs. B. R., aged 30, was admitted to St. Luke's Hospital, March 10, 1895. She gave a history of a miscarriage two weeks previously, and her last menstruation occurred two months before. She had been curetted twice for supposed retained portions of placenta before coming to the hospital. Temperature 103°, pulse 140; marked anemia; abdomen tympanitic; general condition grave. On examination a mass was found which filled the pelvis and extended above the pelvic brim on the left side and pushed the uterus and vagina forward. Vaginal section was made and from one to
two quarts of very offensive blood clots removed. Digital examination within the sac revealed an enlargement of the left tube, which prolapsed into the sac cavity. The case was undoubtedly one of extra-uterine pregnancy, and the blood clot had become infected during the curettements. The sac was drained and irrigated. The temperature dropped suddenly and gradually became normal. At the end of three weeks she left the hospital. hospital. At this time the discharge was slight and the mass on the left side was small. Her family physician recently informed me that he had removed the drainage tubes, that all discharge had ceased, and that the pelvis was apparently normal. An abdominal section would undoubtedly have been fatal in this case.
Mrs. M. S., aged 37, was admitted to St. Luke's Hospital March 23, 1895. Temperature 102.4°, pulse 118; abdomen tympanitic; severe pain in lower abdomen; patient anemic; symptoms of general peritonitis. Examination revealed a mass filling the pelvis, pushing the uterus and vagina forward, and extending nearly to the umbilicus. Her last menstruation commenced on January 1, at the regular time, but hemorrhage continued until the time of operation. Vaginal section posterior to the cervix was made and about one quart of partly clotted blood was removed. A mass remained to the left of the uterus. The sac was irrigated and drained. The case was probably one of extra-uterine pregnancy. The patient has been practically free from sepsis, pain, or any discomfort since the operation. Examination April 10 showed no evidence of pelvic disease. The drainage tubes were removed and the patient discharged from the hospital.
Technique of the operation. The patient is prepared as for vaginal hysterectomy. The abdomen should also be prepared on account of the possible necessity of a celiotomy. The patient is anesthetized and placed in the lithotomy position; the posterior vaginal wall is retracted by Simon's speculum, and the cervix drawn down with a double tenaculum forceps. The uterus is dilated,
the uterine cavity explored, curetted, irrigated, and packed with gauze if indicated. An incision about one inch long through the vaginal wall is made near the cervix, opposite the most prominent point of the tumor. This will usually be posterior to the cervix, but may be lateral as in case of Miss S. L., and possibly anterior to the cervix. Any connective tissue between the vaginal wall and the abscess is separated with the finger, or it may be necessary to divide some of the fascia with blunt
pointed scissors. Careful exploration is now made to determine whether the peritoneal cavity has been opened; if so, it should be carefully walled off with gauze packing. The finger may now be passed directly into the abscess, or if the wall is tough it may be opened by a blunt instrument, such as a grooved director or sound, and the opening enlarged with the finger or forceps. All of the pus is removed by thorough irrigation with sterilized water. Careful bimanual examination to determine the condition of the pelvic contents is now made with one or two fingers of the left haud in the abscess sac and the right hand over the abdomen. If additional abscesses are found they may be punctured through the abscess wall, may be opened by another vaginal section, or may be removed through an abdominal incision. The mode of procedure must be determined by the indications in each case.
Two drainage tubes sutured together, one large and one small, are now inserted into the abscess cavity. The large tube is perforated for a distance of one or two inches, the end split, inverted, and sewed so as to form a shoulder on each side which retains it in place after the abscess wall has contracted about it. The drainage tubes are fastened to the cervix by a suture for retention until the abscess and vaginal walls contract about them.
The after-treatment consists principally in the use of peroxide of hydrogen, frequent irrigations, and antiseptic douches. Any gauze left between the vaginal and abscess walls should be removed twenty-four or forty-eight hours
after the operation. The drainage tubes should be left in place as long as the discharge continues. This may be for from three weeks to six months. When the rubber tubing becomes offensive it should be changed.
Indications for the operation.-1. When the condition of the patient is such as to make abdominal section extremely dangerous.
2. When the abscess is large, of long standing, and situated low in the pelvis, and when the patient gives a history of peritonitis.
3. When abdominal section reveals extensive and firm intestinal adhesions. 4. When the abscess is on the floor of the pelvis and is complicated by rectal fistulae.
5. Vaginal section may be indicated. for the separation of adhesions which fix the ovaries and tubes on the floor of the pelvis, and for examination of the ovaries and tubes. 6. Puerperal abscesses. These abscesses frequently do not involve the Fallopian tubes or ovaries, and satisfactory results usually follow thorough drainage of them.
Results. 1. Immediate. I have done vaginal section for pelvic abscess nineteen times, and in every case with relatively satisfactory results. In two cases operations for secondary abscesses were required; in one case abdominal section was necessary to complete the operation. Excepting in the two cases which developed additional or secondary abscesses, the temperature has become practically normal within a short time after the operation. The patients have suffered very little after the operation in fact, pain has usually been absent. The patients have almost invariably been out of bed at the end of two weeks. Aside from the accidents consequent upon anesthesia the operation is devoid of danger.
2. Remote.- Many of the operations are of too recent date to permit a satisfactory report of the ultimate success. Some of the operations, however, date back three years. None of the patients have, to my knowledge, suffered especially from pelvic disease after the opera
tion. Three of the patients have some enlargement to the left of the uterus which may later on require abdominal section, and two of them have a sinus.
Advantages of the operation.-1. It is not dangerous to life.
2. It is followed by little or no suffering.
3. Recovery is rapid.
4. No raw surfaces are left in the ab- which I have described. dominal cavity to cause adhesions.
Objection to the operation.—1. It is applicable in only a small per cent. of the cases of pelvic abscess.
2. Diseased tissue is not removed. The tissues may, however, become normal after the abscess is opened and drained, as has frequently been the case after spontaneous rupture or puncture of the abscess. The favorable results which have followed simple incision and drainage of abscesses in other parts of the body may indicate that some cases of pelvic abscess have been treated by too radical measures. The nature of the abscess may be a guide in the selection of the method of treatment. For example, tubercular or gonorrheal abscesses indicate excision more than abscesses due to some other infection.
Remarks. This operation should take the place of vaginal puncture or
THE USE OF DIPHTHERIA ANTITOXIN FOR IMMUNIZATION. Hermann M. Biggs, M. D., of New York (British Medical Journal, August 31) said: Remarkable results have attended the use in New York of diphtheria antitoxin for immunizing purposes. The conditions under which it has been employed have been peculiarly favorable for demonstrating its exact value. From May, 1892, to February 18, 1894, no cases of diphtheria occurred in the New York Infant Asylum, which ordinarily has about 400 inmates. From February 18 to September 1, 1894, there were 22 cases of diphtheria and 15 deaths. In September there were 16 cases, and from this time to February 10-108 days107 cases of diphtheria occurred. These were very evenly distributed over this time, about 30 cases developing in each
aspiration, which has been the usual vaginal operation for pelvic abscess. In the latter operation the bladder, rectum or some other portion of the intestinal tract and large blood-vessels have been punctured. I know of two cases in which large blood-vessels have been injured with fatal results. These accidents are avoidable in the operation
Many authors advise, in cases in which doubt exists as to the choice between abdominal section and vaginal puncture, that celiotomy be first performed, and then, if indicated, that puncture through the vagina be made. In such a case I would advise vaginal section, which could be immediately followed by abdominal section, if necessary. Should the latter operation be necessary the previous vaginal section would not compromise the chances of recovery, but, on the contrary, would afford a perfect avenue for drainge and would remove the pus which otherwise would be liable to escape into the abdominal cavity.
For suspected disease low in the pelvis, vaginal section permits of thorough and satisfactory exploration without subjecting the patient to the dangers consequent upon abdominal section.
month. In the latter part of October
MIRACULOUS HEALING.-But we must
frankly confess, says the Lancet, that we have a strong conviction that the great majority of those "cures" belong to a wholly different class; that they are, in fact, identical with those neurotic cases with which hypnotism has made us so familiar. It will always be observed in reading the accounts of the phenomena alleged to occur at Lourdes, Knock and elsewhere, that the cures occur precisely in the sort of patient and in forms of disease most likely to be af fected by forces identical with, or analogous to, hypnotism. Highly strung, enthusiastic and visionary girls figure largely in these accounts, while the diseases alleged to be most amenable to cure are such affections as catalepsy, paralysis, blindness, etc., all of which occur frequently as functional affections liable at any moment to be dissipated by any cause that makes a strong impression on the nervous system. No doubt cures of such conditions as ad
vanced phthisis have been repeatedly alleged, but so far as we know, a careful investigation by competent persons has always disproved the genuine cure of such cases. Often the marked temporary improvement has been merely the result of an extreme exaltation of the nervous system, to be quickly followed by the resumption of all the old symptoms and the inevitable end.
REPORT OF 900 EXTIRPATIONS OF GOITER. In commenting on his "Report of Extirpation of Goiter" (Journal Nervous and Mental Diseases), Kocher remarked during the past ten years in which he had performed the operation on 900 patients, he had met but one case in which cachexia strumipriva had developed. This was entirely owing to the fact that he always left a part of the thyroid gland, which was sufficient to carry on the functions of that organ. In the single case in which the cachexia developed, the extirpation was unilateral, but after the operation it was found that the other side was atrophied.
A very interesting statement by Kocher is that he had several times noticed that tetany, which he is pleased interesting, likewise, to hear that the to call acute cachexia, developed. It is patient in whom cachexia strumipriva developed, recovered through thyroid feeding.
In speaking of the mortality in his operations, Kocher says that he deducts. thirty cases of malignant goiters in which unusual and peculiar difficulties militated against success. Of the remaining 870, eleven died; but in six only was death the direct result of the operation, and of these, three were operated on for Graves' disease. The extirpation of the goiter in the latter disease he regards as dangerous. For the latter he prefers to ligature the thyroid arteries; but never more than three of them.
Referring to some researches that had been made under his observation by Lanz and Trachewski in the treatment of goiter by the injestion of thyroid extract, the author said that in the long run this method may determine complete atrophy of healthy parts of the thyroid gland. He further remarked that all the symptoms of Graves' disease had been produced in healthy animals by these experiments. He found also that the symptoms of exophthalmic goiter improved greatly under treatment by phosphate of sodium.
CASTRATION FOR PROSTATIC HYPERTROPHY.-Kummel (British Medical Journal), in a lecture on the operative treatment of enlarged prostate, reports eight cases of this affection in which he performed double castration. The operation was followed by considerable relief in these cases, but one patient, aged 77, died from exhaustion after an interval of four weeks. In a review of his own cases, and those published by other surgeons, he states that in a large majority of instances of senile enlargement of the prostate, White's operation is certainly followed by a more or less rapid shrinking of the prostatic tissue. This result of double castration in most cases en