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of the maritime hospitals at Arcachon and Banyuls-sur-Mer. These regions, on account of their mild, bracing climate and general salubrity, are admirably adapted for these sanitariums, of which M. Armaingaud showed the plans.

MM. Livon and Alezais summed up the results of their investigations on the urine of tabetic patients as follows: the characteristic phenomena observed in the urine were, first, the proportion of phosphoric acid eliminated was lessened; second, there was a proportionate increase of acid in combination with gravel; third, the quantity of chlorine varied. There was a tendency to hyperchloruria. The urine of tabetic patients is toxic; 12, 14, 33, 43 and 44 centimeter cubes to one kilogramme of the animal, administered to some dogs in intra-venous injections, resulted in death.

at the Faculte de Medecine of Paris, was named delegate of this section to the committee of the French Association for three years. Dr. Drouineau (of La Rochelle) was elected president of the section of hygiene for 1888. Dr. Henrot, professor at the Ecole de Medecine, of Rheims, was named delegate for this section,during three years, to the committee of the association; and Dr. Rochard, member of the Academy of Medicine, was elected member of the commission for government grants (subventions). The section of hygiene unanimously assented to a proposition made by Dr. Basset, in favor of a law by which vaccination is made compulsory.

At the Congress of the French Association for the Advance of Science, M. Bernheim recorded an instance of menstruation regulated by hypnotism. The period of menstruation was thus reduced from 15 to 4 days.

M. Berillon cited the case of a woman who suffered from flooding; he suggested to her that the menstrual flow should cease during half an hour; the suggestion was fulfilled.

M. Burot stated that he cured amenorrhea, in a young girl, by suggestion.

M. Decle has produced irregular menstruation by the same means.

M. Berheim (Nancy) described a case of lingual monoplegia, unaccompanied by facial paralysis. The patient was a girl of 23 who was treated for generalized multiple sarcomatous tumors during eleven months. On January 8, 1887, a marked deviation of the tongue toward the right was observed. There were no symptoms of facial or other hemiplegia; the grasp of the left hand was stronger than that of the right. The patient succumbed on February 2. The necropsy revealed, in addition to the general sarcomas, a sarcomatous area in the cortical region, containing a clot of blood; this area had produced a hollow measuring from five to six millime-hypnotism, but he is doubtful of the efficacy ters in diameter and in depth, and was situated near the lower edge of the lower extremity of the ascending frontal convolution, on the anterior surface of this convolution, six millimeters behind the furrow which separates it from the third frontal convolution.

M. Aug. Voisin stated that he had cured inveterate habits of onanism in two little girls of 8 and 9 by suggestion.

M. Grasset has observed an instance in which hemorrhage was arrested by suggestion.

M. Bernheim has succeeded in diminishing the quantity of urine in diabetic patients by

of this method in influencing the proportion of glucose or albumen in diabetes.

M. P. Topinard is engaged in collecting statistics concerning the color of eyes and hair in France. Over 2000 persons have consented to lend their assistance in this undertaking. Among these are nasal and military surgeons, directors of workhouses and factories, doctors, chemists, etc. M. Topinard has At the close of the meeting of the French already received over 87,000 observations Association for the advance of science, M. from different persons. The undertaking Grasset, professor at the Faculte de Medi- promises to be very successful, and next year cine, of Montpellier, was elected president of we may look for a complete map or census on the section of medical science at the Con- which the different shades of hair and eyes of gress of 1888. Dr. Troisier, professor agrege | the French population will be indicated by

departments, arrondisements, and different localities in their relative proportions.

SOCIETY PROCEEDINGS.

ST. LOUIS MEDICAL SOCIETY.

Stated meeting. October 29, the President, S. Pollak, M. D., in the chair. F. D. Mooney, M. D., Secretary.

Dr. A. H. Ohmann-Dumesnil.-I have here under the microscope a specimen taken from a lady who had a miscarriage at four and a half months. The doctor in attendance administered ergot in ordinary doses. After a few days there formed a reddish violaceous line of demarcation on the nose and feet; she died and the report was that she died of anemia. I took specimens from the ankle. I found that the arterioles and capillaries of the skin were filled with coagulated blood, which,of course,leads to such inference that, in time, had she lived, gangrene would have set in.

It was a condition which is rarely seen in this latitude; few cases occur on account of the rarity of the idiosyncrasy, and I don't know that this peculiar condition has been written up. The same changes have taken place in the subcutaneous tissues.

Dr. Y. H. Bond.-How much did she take, and how long was it continued?

Dr. Ohmann-Dumesnil.-I am not acquainted with the clinical details, but I believe she took about an ounce and a half during the space of a week.

Dr. Bond.-I wanted to know if the ergot was responsible for the disease. Have you ever examined the skin of a patient suffering from purpura hemorrhagica?

Dr. Ohmann-Dumesnil.-Yes, sir; in that disease the clot is extravasated; in this the clot is in the vessel itself. This is probably an idiosyncrasy.

Dr. Bond.-There may be these idiosyncrasies, but I I have never seen them. I have used ergot to a large extent and have never seen a bad result. I have a patient who has taken three grains three times a day for some mouths. Dr. Nelson, of Chicago, reports a case which has taken thousands of grains without any bad result. I am incredulous as to the influence of ergot in producing such results as you speak of.

Dr. Ohmann-Dumesnil.-Notwithstanding Dr. Bond's incredulity, he is well aware of the fact that in certain districts of Europe, gangrene of the extremities takes place in many cases where the bread is made of rye. Why one case should not occur where there is an idiosyncrasy, I do not understand. For instance morphia in minute doses will produce marked effecis on those having an idiosyncrasy with reference to that drug. If the doctor will tell me what produced this peculiar condition I will be under obligations to him. Of course we don't know what produced idiosyncrasy. She was a blonde, 38 years old. anemic, naturally so. This was not the first child; she had had two or three before. She was a widow.

Dr. Bond.-We all know that it has been claimed that ergot produced gangrene, but I am not disposed to think that claim well grounded. In certain sections of Europe it is claimed that such is the case, but when we administer the ergot directly we don't get such results, and it is fair to think some other agent is the cause.

Dr. Ohmann Dumesnil.—I hardly think it fair to criticise me that way, as I did not attend the case; I was fortunate in securing the specimen. I was always under the impression that ergot would produce the disease: I sup

posed naturally that it was gangrene of the skin. I know of no other cause that will produce this disease.

Dr. N. Guhman.-I was a little astonished about the ounce and a half producing ergotism. One ounce of er got has often been given in one day. Could it not be pos sible that the circulation of the capillaries was so weak that there may have been a coagulation of the blood in the capillary system? As to eating bread producing ergotism those people eat the bread the whole year round and there is a great deal of ergot in it; that is a very different thing.

Dr. W. Coles.—I suppose a great deal depends on the character of the ergot employed, allowing that the fluid extract represents about 1 grain to the minim, I should say that an ounce and a half given in one day woutd be a pretty good quantity. I have never seen anything like ergotism, no poisonous effects; don't know that I have ever seen a case reported. The trouble generally comes from repeating large doses, which brings on nausea. Dr. Guhmann's patients must have pretty strong stomachs if they can stand that without nausea being produced.

Dr. Guhman.—I think Dr. Coles misunderstood me; I meant an ounce and a half in succession. I know of a case where an ounce was given in an hour for placenta previa.

Dr. A. D. Williams.-I have a case here I would like to present. It is a cyst of the orbit. Several years ago this young man, while walking rapidly in the dark, butted against a tree, striking the inner extremity of the left or bit. The part swelled and remained sore a while, and then gradually passed away. In about six months the injured part inflamed and suppurated. This abscess be opened with a needle and it discharged quite freely, and the inflammation passed away. The discharge has continued up to the present time. In the meantime a quack told him he had a cancer and applied some kind of an escharotic, which ate away a large portion of the flesh and the result was that the inner end of the upper lid was drawn upward and outward. Afterwards another physician opened the abscess and put lint into the cavity for a while and then allowed the opening to close. The mistake that he made was that he didn't keep the opening free until the cavity closed up. On Monday I opened this cavity quite freely, expecting to find necrosis, but was somewhat sur prised not to find any bone disease. The cavity was the size of a small hen egg. I washed it out; a large amount of unlaudable pus came away. I cauterized it with the solid nitrate of silver, and put a lead tube into the opening. The cavity assumed somewhat of an unhealthy appearance and the cicatricial tissue, through which I cut, was absorbed and the tube came loose and I removed it. I think the starting point of this cyst was about in this way: At the time he was hurt quite a large blood clot formed on the edge of the orbital bone, which remained there for several months, and then gradually assumed the suppurative condition, and he opened it. The treatment of these cysts is as follows: The opening must be kept patent until the cavity closes from the bottom This kind of a cavity is slow in its recovery because the bones will not allow the cavity to collapse. I take an ordinary lead tube, whittle it down to make it as thin as possible so the flesh will bear the pressure; make a flange on the outer end to keep it from going into the cavity, and a bulge on the inner end to keep it from coming out except by being pulled out. When you have this tube in, you can take it out and medicate as you please. The usual application is the tincture of iodine. Don't use escharotics because you denude the bone and get up serious trouble. [The Society here took an intermission of ten minutes to examine the case.] Dr. Prewitt thinks that this cavity is connected

with the frontal sinues; I don't believe it for the reason that if the sinues were involved, when I would inject water into it, it would force itself down into the nose. There is absolutely no connection with the nose. Then if the sinuses were involved, we would have more trouble. Of course, , I don't know whether there is no bone trouble, but I did find this large cavity lined by flesh-by periosteum. At first the whole interior was lined with some fibrinous substance, like fibrin of blood, and this material I destroyed by the caustic, so that it is now very free from anything of the kind. The surface inside, when you look with reflected light is very smooth, showing that it is periosteum. I have had two other cases; in one the entire orbit was filled with the cyst, so that I could pass my finger clear to the apex of the orbit where I opened it. That case I presented here, and some of the gentlemen thought that itwas malignant, and others that it would never get well. I have been treating it, and now there is only a small cavity left in the bone right where this is, towards the nose. The other case was that of a young man, and when I opened it a large amount of the same kind of material came out of it, and I passed my finger clear to the apex of the orbit. He also got well.

Dr. T. F. Prewitt.-In the first place, the doctor speaks of this as a cyst; I think it is an abscess. I think it passes too deep to be simply an abscess in the soft parts; there is no reason why it should be so difficult to heal. It seems to me to pass beyond the depth of the wall of the orbit, and in the direction that would carry it seemingly through the wall of the orbit, into the root of the nose if not into the frontal sinuses. I have met with abscess in this region, and in one instance there was periosteal inflammation leading to abscess. I found no difficulty in making it heal by keeping it open.

Dr. Williams.-How can it heal without coming together?

Dr. Prewitt.-Simply by packing and washing it with bichloride. Abscesses of the soft parts that are superficial, as that appears to be, and are readily accessible, do not take a great while to heal, and I don't know why it should in this case. The statement that it was lined with fibrinous substance, I don't understand. I should imag ine that that was the ordinary pyogenic membrane that we find in cold abscesses.

Dr. Williams.-The doctor speaks of this as an abscess, and of an abscess as being so ready to heal. That we all know. A recent abscess gets well easily, even in the orbit, but when it has lasted for six or seven years. it gets to be a cyst-the cavity is lined by membrane which secretes pus; and that I take to be the condition here. Gradually the cyst wall was formed around the cavity, so this is very different from an acute abscess. The treatment of this cavity by the insertion of lint and rags and antiseptics not only will not cure it, but will keep it from getting well; they would keep it distended, which you must obviate.

Dr. A. H. Meisenbach.-What became of this cyst membrane?

Dr. Williams.-It is still there. The soft material was destroyed by the escharotic.

Dr. Meisenbach. -1 think that Dr. Williams' appellation

of "cyst" is misleading in this instance, because a cyst is a cavity that has a distinct lining, that contains something; for instance a fœtal cyst, sebaceous cyst, etc. I think Dr. Prewitt has rightly remarked that it is an old abscess cavity that has been pressed upon by the contents, and in the course of time the granulations have been pressed upon, fatty degeneration has taken place,

and it looked like membrane, or capsule, but in reality it was not a capsule. If that membrane were still there, it would be impossible for it to heal.

Dr. F. J. Lutz.-I would like for Dr. Bond to detail the case of cystocele on which he operated to-day.

Dr. Y. H. Bond.-The case was a true cystocele in a young woman, unaccompanied with prolapse or displacement of the uterus and was one of the most marked cases I have ever seen. I had read Emmett, Thomas, Goodell, etc., on the method of procedure in these cases in which they advised the Sim's position. I visited the patient before performing the operation to determine the most desirable position, and determined that by the dorsal position I could expose her and perform it to the greatest advantage. I placed her on the back that evening, and by the Sim's speculum, depressed the perineum, and then with retractors separated the labia, and with a catheter depressed the cystocele. With the compression forceps I seized the sides of the cystocele that came beyond the catheter that was depressing the vaginal wall, and that constituted my line of incision. Commencing about half an inch from the urethra, I made an incision down to the cervix, having previously placed a vulcellum in the anterior lip of the cervix, and by drawing it to the vulvar orifice, I was enabled to bring the entire cystocele readily within action. Then by dividing the mucous membrane at the lower point, I dissected the entire mucous membrane off and removed it. I used the continuous catgut suture. The objection to the use of catgut is that it is brittle, which is disagreeable to the operator. But by putting it in oil of Juniper, one part, and alcohol two parts, and keeping it there 6 days it becomes strong, and it is almost impossible to break it. Commencing with the suture at the lower angle of the wound, I tied a double knot, leaving one end long enough to be seized by an assistant; passing sutures at about % inch from the line of mucous surface that had been denuded. At the upper and lower portions I passed the sutures through the mucous membrane and the wall of the bladder. As

I approached the central line, I made the needle emerge and enter again at the central point of the section removed, and then re-inserted it into the mucous surface on the opposite side, and made the continuous suture. The knot was effected by drawing the suture through the needle so as to leave a free end engaged in the mucous surface, then with that free end I tied the double knot.

SELECTION.

TOTAL EXTIRPATION OF THE UTERUS THROUGH THE VAGINA.

BY DR. A. MARTIN, DOCENT IN THE UNIVERSITY OF BERLIN.

My method for vaginal extirpation is as follows: After a complete disinfection of the vagina by irrigation, and a thorough emptying of the bowels, the patient is placed in position lying on her back and hips, and is brought

under the influence of chloroform. The vault of the vagina is exposed by means of a speculum and side-pieces; then the cervix is seized with bullet-forceps on its posterior border and drawn forward as far as possible towards the symphysis pubis. (Fig. I.) In this way the posterior arch of the vagina is stretched, so that the insertion of the vagina in the uterus

can generally be well determined. Then I make an incision through the entire extent of this insertion, in order to advance into Douglas' culde sac as quickly as posible. If the attachment of the wall of the vagina to the cervix has not developed very thick, then the opening of Douglas' cul de sac is generally secured by the first cut. But if, however, the mass of tissue which must be cut through is very thick, then this penetration will be very difficult and troublesome, and indeed, it is the more so the more we must advance towards the uterus in order to reach the limits of this attachment

When the opening into Douglas' cul de sac has been attained, I enlarge the cut so that the forefinger of my left hand can enter, and then with a small needle, which is very much curved, I sew around the entire extent of the border of the cut in the vagina. (V. Figs 1 and 2.)

The needle is thrust throngh the vagina wall to the forefinger, which at this poin presses forward the peritoneum, which it now includes, and comes out again into the vagina about a centimetre from the point where it entered. Of such sutures I generally use

[graphic][merged small]

four or five, which unite the peritoneum of Douglas' cul de sac to the vaginal wall and all bleeding at this point is stopped. (Fig.II) Opposite these sutures, if the uterus bleeds very much, I thrust a single great needle through the cut surface of the uterus, and secure thereby a restraint against any farther trouble of the kind. It is only when the hemorrhage is entirely stopped that the operation is further continued. If the opening of Douglas cul de-sac presents diffculties, and also if there be considerable hemorrage, I sew in a similar manner the broad cut surface itself to the vaginal wall before opening into Doug-| las cul-de-sac, and then, while I draw this

mass of tissue away from the uterus with the forceps, I force my way deeper and deeper along the posterior wall of the cervix uteri. The peritoneum appears like a delicate, glistening membrane, behind which there is sometimes a small amount of fluid. As soon as the opening has been obtained, then the union of the peritoneum to the vaginal wall is secured throughout the whole extent of the floor of Douglas' cul-de-sac in the same manner that has been described. The hemorrhage must always be completely controlled at this first stage of the operation before going any further.

Next I sew up the stump of the broad ligment,

for which purpose I use large needles armed with a double thread, thrusting them from the vaginal wall toward that place on the side of Douglas' cul-de sac, which my finger within presses towards me. (V. Fig.2) These threads must also unite the peritoneum and vaginal wall. Often it is impossible to draw out the needle again directly through the vagina, without first having thrust it completely through into the peritoneal cavity. In these cases I guide the needle-point, protected by my forefinger, through the open wound, out into the posterior part of the vagina, and while I hold firmly the eye of the needle with oen hand, I secure the point of it with a sec

ond needle-holder. Only then do I take off the needle holder from the end which has the eye; and now I draw the whole needle through, in order to thrust it, grasped anew, and again under the guidance of the forefinger, from the peritoneum towards the vagina, and to bring it out here about a centimetre from the point where it entered. These threads must be tied by using great force. Generally I use three on each side, by means of which I firmly unite the floor of the pelvis and the vagina as far as the anterior border of the cervix. By this union the vessels which pass through are secured with greater safety before they are

cut.

[graphic][merged small]

The separation of the cervix from the floor of the pelvis as far as its anterior border, and the further stitching of the same, is often accomplished without any loss of blood. The knife is thrust directly forword along the cervix until, on both sides, this lies entirely free, i. e., as high as the fundus. As soon as all hemorrhage has been stopped, I cut around the anterior periphery while drawing the uterus forcibly backwards, and putting the anterior vaginal wall on the stretch. After eatting through the vaginal wall I push back along the cervix with my finger nails that portion of the bladder which is united to the cervix, as far as I can discover such attach

ment. The extent of this attachment, and also the union of the cervix uteri to the posterior vaginal wall, varies exceedingly in different cases. Occasionally I have found it perhaps a centimetre thick, and in other cases it is five centimetres, or even more. Not unfrequently is it necessary to use the knife in order to separate the firmest bands of union. In this portion, also, we must sew, as exactly as possible, the separated surface to the vaginal wall, with small needles, which enclose the whole tissue directly under that surface of the wound which is next the bladder. Here four sutures generally suffice to stop the hemorrhage, and for the restoration of the

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