THE WEEKLY MEDICAL REVIEW, ST. LOUIS, NOVEMBER 12, 1887. VOL. XVI. No. 20. REPORTS ON PROGRESS. GYNECOLOGY. Y. H. BOND, M. D. I. JUNIPER CATGUT: ITS USE IN GYNE IV. ON EXTRA-PERITONEAL EXTIRPATION TERMS: $3.50 A YEAR. of particles of tissue suared between the running loops, and the frequent occurrence of considerable hemorrhage attending the healing process, forbade anything like over-enthusiastic expression in its favor. Since then, in consequence of his fingers becoming accustomed to the juniper oil, the improved character of the material, and a more extensive experience as to the proper degree of constriction to which the tissues should be subjected, the advantages of both the material and the method had impressed themselves, viz., "simplicity of the procedure, freedom from all irritation in the wound, extensive coaptation of the raw surfaces, and delivery V. ON A CASE OF SPONTANEOUS INVERSION from that often so annoying necessity of reOF THE UTERUS.-Ibid. The extensive favorable experience of Martin in the use of catgut sutures in plastic gynecological operations, as set forth in an article upon the above subject, will serve to increase that unity of sentiment upon this subject that has been generally obtaining with the profession for the past several years. The author states that previous to 1885 in operation for prolapsus he had been in the habit of using the button suture of silk. In a limited number of cases he had used button sutures with braided catgut, and finally with juniper catgut and the continuous suture. That up to that time, whilst appreciating the simplicity of the method, yet the drawbacks in the way of brittleness of material and the disagreeable sensation in the fingers of the operator, the occasional premature absorption moving the suture from a cavity, but recently in this way the material possesses great te nacity, so that the threads break very rarely. At the same time they become so flexible that they can be readily tied, provided the wound margins to be united do not offer too great a resistance to coaptation. The catgut threads must always be tied with a triple knot and a long end allowed to hang free. In using the button suture the necessity of drawing the catgut more tightly than would be the case were silk used, is pointed out, as well as the consequent injury to which the operator's fingers are liable, etc. But the advantages possessed in the non-irritating nature of the material, the fact of its dissolving after having kept the wound surface sufficiently long together, and thereby rendering removal of sutures unnecessary, are more than sufficient to counterbalance the drawbacks. He states that in sewing with the running thread, he commences by inserting it at one end of the wound margin and making a double knot. "A short end of the thread thus remains on the one side, and is drawn taut by the assistant by means of a ligature for ceps; the needle is then inserted far enough from the wound margin for the latter to have a moderate strain, this differing with the tissue. In wounds of slight extent the needle passes at once under the entire wound surface, emerges on the opposite side at a point corresponding to that of insertion, drawing the whole thread after it. The thread is drawn taut, and so held by the assistant that the wound surfaces come in complete contact. Whenever the accurate coaptation is effected with difficulty, the needle is not carried through the entire wound surface at once, but only through a part. A tier is to be placed in the depth of the wound-that is to say the wound surface is to be so far united, first in the median line, as this can be done without undue traction on the raw surfaces. In forming this tier the several needle punctures need not be too close together. The thread must not be drawn too tight, nor should too much tissue be taken on each needle. The tier is contin ued as far as the external margin of the wound to the border of the skin. Here the needle comes to the surface and takes a few stitches into the adjoining skin. If the edges of the skin can now be easily approximated the wound is at once closed and the suture completed. If the wound margins come together with difficulty a second tier is formed above the first. The suture is completed either by knotting the ends, if they have come close enough, or else by knotting only the end which is in the needle. In that event the fore end is drawn far enough out of the eye of the needle so that after the last stitch it hangs sufficiently far from the distal end of the su ture track. Then this end held here is knotted with the double thread which has remained in the needle." He directs attention to two difficulties lia. ble to be encountered by those who have never seen catgut used, the one consisting in the liability of drawing the suture too tight, and thus bringing about strangulation, to obviate which a simple approximation of the wound surfaces only should be aimed at. The second difficulty, the liability of the suture breaking, can be met by passing in the tissues, beneath the broken suture, a deep suture, and knotting it, and continuing the running su ture. Irrigation of the suture line is deprecated, and only a weak solution of carbolic acid is used on the external parts after urination. (The retentive power of the catgut might possibly be prolonged could the line of the forming cicatrix be occasionally dusted with iodoform, provided its proper applica. tion did not involve any sundering influence upon the suture line.) Forcible stretching of the cicatrices by feces or flatus in case of all operations on the bowel is obviated by placing in the bowel immediately after the operation, a soft rubber canula, through which luke warm oil is poured into the rectum on the fourth day, and on the fifth day a laxative given to effect the propulsion of the softened fecal mass. In operations involving the perineum patients are kept perfectly quiet in bed, with knees tied together, for about three weeks (a need lessly long time, it seems to me), the bladder and rectum evacuated on a low bed pan. Dr. Martin has performed 87 plastic operations, using the uninterrupted catgut thread, on the perineum and vagina, with uniform success. He enters into a detailed description of his method of procedure in the special operations of perineoplasty, recto-plasty, etc., the features of which in large part, are a rep etition of his generalizations upon the subject of the running catgut suture. MASSAGE IN GYNECOLOGY. Profenter (Braumuller, Wien, 1887) here considers the effect of massage in subacute and chronic inflammatory processes in the female pelvis. In a short preface Prof. Schultze, of Jena, states that he has tested the results of the method and found them good, and he believes "that the method of Brandt gives valuable results in stretching and slackening old parametric exudations, as well as restoring fixation in prolapsus uteri." He points out, also, that the treatment requires very accurate diagnosis as well as great expenditure of time. In the introduction Profenter gives the history of the application of the method. It is due to a Swede, Brandt, who was not a medical man, and who, apart from professional instruction, gained much insight into pelvic disorders. In 1847 he treated prolapsus recti in a soldier by rubbing up, as it were, the sigmoid flexure. He next turned his attention to prolapsus uteri, and cured, it is said, three cases in a few weeks. The method was then extended to retroflexed and fixed uteri, chronically inflamed ovaries, and chronic cellutis and peritonitic adhesions, all with good results. Profenter studied Brandt's results for a week, found them good, and had his scepticism removed. Cases are then recorded. Of these a selection is appended. It must, of course, be noted that the massage is local and bimanual, and is not to be confounded with the general massage of the body practised in Weir Mitchell's chronic ovaritis, and slight cystitis.-Oct. 2:3 patient has pain on urination. Bladder washed out from October 24 to November 10: rest in bed; alterative tampons also tried. November 18, status presens as follows: Movement of the uterus to the front restricted; left utero-sacral ligament shortened, thicked, and painful on pressure; left ovary slightly painful on pressure. The treatment consisted in systematic stretching of the shortened ligament, and massage of the left ovary. On December 4, the uterus had its fundus to the left of the median line, and movement, even to the neighborhood of the symphysis, was painless. CASE 12. Chronic parametritis and perimetritis.-Condition under narcosis: Marked induration of the broad ligaments. The patient complained of pain of the left side and head; pain on micturition and defecation, with hysterical attack eight days before menstruation. By massage the exudation disappeared, and the uterus and ovaries became normal. (There are moral objections to the use of massage, when applied through the vagina, especially as the efficiency of that mode of treatment is questionable). INSANITY AND OOPHORECTOMY. Leszynsky (N. Y. Med. Journ., June 25, 1887) gives an account of two cases in which oophorectomy was performed for insanity. While he admits that we may have reflex irritation from a diseased uterus or ovary, he points out the preponderance of psychical causes and criticises the practice of oophorectomy in the insane, alleging that "the premature and indiscriminate removal of the ovaries in cases of insanity and other neuroses, has of late become so frequent and flagrant a procedure as to demand an emphatic protest against such reprehensible measures, and such illegitimate practice." Leszynsky would only advise oophorectomy when a distinct pathological condition was present, and had a preponderating influence. CASE I. Chronic parametritis posterior, The effect of septicemia in mania is well treatment. known. Clouston, in his "Mental Diseases" (London 1883) says, "I believe that some day we shall hit on a mode of producing a local inflammation or manageable septic blood poisoning, by which we shall cut short and cure attacks of acute mania." (Op. cit., p. 190). ON EXTRAPERITONEAL EXTIRPATION OF THE UTERUS. Frank (Arch. f. Gynak., Bd. xxx. Heft 1) describes a series of extraordinary cases 1887) records a case of spontaneous inversion of the uterus, following the expulsion of a fibroid polypus. The remarkable feature in the case is that, after attempts at manual reinversion had failed, re-inversion was brought about by the repeated use of the hot douche. He considers that the hot water acted by lessening the bulk of the organ, and bringing about contraction of the longitudinal fibres, with widening of the constricting ring. GYNECOLOGICAL OPERATIONS. where he performed what he terms extraper- THE APPLICATION OF COCAINE IN PLASTIC itoneal extirpation of the uterus. In this pa per he does not detail his method specially, but he evidently in certain cases, by a process of enucleation, removes the greater part of the uterine substance without opening the peritoneal cavity—i. e., he leaves the peritoneum intact. The summary of his chief cases fully justifies the term "tumor operations," applied by Stratz (Centr. fur Gynak., April 23, 1887). In regard to risk of bleeding, Frank alleges that the traction on the uterus hinders it. The suturing of the peritoneal folds also checks it, and, if necessary, ligatures can be passed up as far as the Fallopian tube angle, so as to control the ovarian artery, or iron solutions can be applied. Kustner (Verh. der deutschen gesellschaft fur Gynak., Erst. Koupres, 1886) considers here the effects of cocaine as a local anesthetic in some of the plastic operations in gynecology. Frankel limits the use of cocaine to short operations, only to those needing merely an incision or scissor's cut; while Schramm would employ it in all plastic operations. Kustner takes an intermediate position, and thinks the value of cocaine can best be esti mated by trying it in painful plastic operations, viz., those at the posterior commissure. He tried it, therefore, in 42 operations, as follows: 5 posterior colporrhaphies, 31 partial Frank alleges that the enthusiasm for total plastic operations in the perineum, 4 total extirpation of the uterus is greatly dimin-plastic operations in the perineum, 1 hymen ished. When the disease has advanced so excision, 1 cyst excision on the left side of the far as to affect the body, the parametrium is vagina. sure to be infiltrated too. He advocates his operations not so much in carcinoma as in old adherent displacements, pruritus uterinus, and adenomatous degeneration. One could understand this operation in certain cases of carcinoma uteri. Marion Sims, in one of his last papers, records a case of carcinoma uteri where he curetted thoroughly, so that he could have inverted the thin peritoneal sac of the uterus and ligatured it. He did not do so, and adds that he nearly performed a brilliant operation. [Quoted from memory]. ON A CASE OF SPONTANEOUS INVERSION OF The parts to be operated on were first disinfected, and then repeatedly brushed with a 20 per cent. solution until the mucous membrane was somewhat pale. Poisoning, never occurred. The results were as follows: In 8 cases, bad; the patients complained of great pain; in 23 cases it worked well, and in¦10 there was complete anesthesia. Kustner recommends cocaine strongly in plastic operations. --Dr. Bartlett, in a paper on the question as to whether quinine acts as an abortifacient or not, takes notice of the fact that an answer was sought to this query by Sydenham, in 1680, and regards it as curious and interesting that the specific action of a drug put forth at that date should be Dr. N. T. Brenis (Edin. Med. Jour., July, adhuc sub judice. ORIGINAL ARTICLES. DIPHTHERIA OF THE EAR. BY ROBERT BARCLAY, A. M., M. D., Read before the St. Louis Medical Society, October, 22, '87. The subject of diphtheria, which has of late been receiving your earnest attention, and which as a throat disease, has in a recent address been so ably discussed, deserves a broader consideration by you as general practitioners of medicine. Dr. H. C. Moir, in his Manual of the Practice of Medicine, which is a careful resume of the standard works of Niemeyer, Roberts, Loomis, DaCosta, Bristow, Hartsthorne, and others, says "It cannot be well denied that it [diphtheria] is first, a constitutional, and secondly, a local disease; for it seems proven there is a local manifestation of a constitutional development, by the fact, that the disease cannot be destroyed by taking off the various layers of the mucous membrane. It is unquestionably a constitutional disease, and the local changes depend entirely upon the amount of infection." Intelligent treatment will depend mainly upon a correct determination of the mooted question, whether diphtheria is a constitutional disease primarily, and local secondarily, or vice versa. This solution will prove less difficult by making a broader study of diphtheria than is possible in the literature and observation of diphtheria of the pharyngolarynx alone. which have been prematurely pronounced "cured" of their diphtheria. In the excellent recent address upon the "local", i. e.,the faucial and nasal treatment of diphtheria, owing to its author's having been unfortunately misled in his search for the literature of diphtheria of the ear, the opinion was hazarded that the ear was but rarely attacked by this disease. Lest this should mislead you into carelessness in noting the condition of the organ of hearing,and, through ignorance of the truth, into neglect to protect from an invasion of these parts the patients of diphtheria who may now or hearafter be under your professional care, you are here offered a statement of the facts, to. gether with a brief resume of the American and European literature concerning diphtheria of the ear, so far as I have found time and opportunity to consult it. Passing over the cases which, in the recent address, are said to have been reported by Urbantschitsch, I give you the following: Dr. S. Moos (Archiv. Ophthal. and Otol., N. Y., 1861, Vol. I. No2 pp. 634 et seq. Trans. by Clarence J. Blake, M. D. Boston, Mass.) publishes a full history of a case of idiopathic diphtheria of the external auditory meatus. As this case is so often referred to by writers on this subject before us, and as it is so typical, I append an abstract of that history as follows: A boy, ten years old, had been twice under treatment by Dr. Moos for purulent otitis media of the left side; first, from July 24,till Nov. 20, 1864, when he was discharged cured, and with the perforation closed; and, secondly, after an attack of measles, from Jan. 29, till March 19, 1865, when he was discharged cured of otorrhea but with persistent perforation. On August 18, he returned to Dr. Moos, [] having suffered intense, constant and increasing earache for thirty-six hours preceding, with fever, loss of appetite, excessive thirst, and during the second night delirium. Deglutition was easy, but mastication impossible because of its painfulness; patient pale and exhausted; pulse weak and 108 to the minute; furred tongue, and [] the |