as long as they are allowed to remain. Now incision per vaginam will reach the pus, but cannot reach the fetal parts. These must needs come away piecemeal, even as where nature establishes an outlet-"a tedious and exhausting process, under which death usually takes place either from exhaustion or blood poisoning." The surgeon, therefore, should make his incision at a point where not alone the pus, but the fetal parts as well may be removed, and this is through the abdomen. The sac may be better cleansed, free drainage established through a counter incision in Douglas' cul-de-sac, and, above all, repeated absorption of putrid matter is at once prevented. Now what objection, if any, is there to abdominal section in these cases? None, I confess, that I can see. The patient, I have supposed, is already septic, and therefore, it may be said, she cannot stand the shock of such a major operation as laparotomy. Can she stand any better, I would ask, the "tedious and exhausting" process necessitated by incision per vaginam? Is the shock from laparotomy under the supposed conditions after all so great? For we must remember that we are not dealing with a new peritoneum, so to speak, but with a peritoneum the endurance of which has been severely put to the test for months. Under the circumstances, and after careful weighing of the arguments pro and con., I would plead for laparotomy in these cases. Lusk' tells us: "During the last decade, the success of secondary laparotomy, as distinguished from that performed during the life of the fetus on the one hand, and simple incisions designed to enlarge fistulous openings on the other, has been such as to warrant its being placed in the category of justifiable operative procedures. In thirty-three cases collected by Litzmann (twenty-four between 1870 and 1880), there were nineteen recoveries. Of the two dangers inherent to the primary operation, hemorrhage and septicemia, the former is greatly lessened by the cessation of the fetal circulation, and by the gradual thrombosis and obliteration of the maternal vessels, and the cutting off of the blood supplies to the placenta." It may be said, however, that, in the case I have supposed, whilst the danger from hemorrhage during laparotomy would be slight, the operation would avail nothing in the presence of sepsis. To such as own to this belief I would recall a case recorded by 1 Loc. cit., p. 325. 2 Trans. Obst. Soc. of London, 1883. 2 2 Meadows, of London, where a fetus was successfully removed by abdominal section from a suppurating abdominal cyst, this fetus having been carried six months beyond the normal term of gestation; I would recall a case recorded by Thomas', of which he says: "The constitutional state of the patient was so much depreciated that for some time after her entrance into the hospital I was afraid to operate, and when I did so I felt almost hopeless of a successful result." His patient recovered, however, although he removed the remains of a full-grown degenerated fetus. And further, what do they say, who, from personal experience and study, are entitled to speak authoritatively, should be the treatment of cases similar to the ideal one I have outlined? Lawson Tait says that "vaginotomy should always give place to abdominal section, as being more scientific and less risky." Prof. W. A. Freund says: "When the fetus has died spontaneously-if there were no reaction I would wait; if there were peritonitis I would treat the symptoms, and then operate as in circumscribed exudation-that is, open, evacuate, and drain. . . . When local and general symptoms of reaction appear, especially those of general infection (italics mine), I would do laparotomy." Parry, whose opinion is entitled to great weight, since he has conscientiously studied five hundred cases of extrauterine pregnancy in the preparation of his book, says,' speaking of opening through the vagina, "If this operation is resorted to, it should be confined to cases in which some portion of the child, and especially the head, presents in the pelvis ;" and again he says, "If septicemia, peritonitis, or exhaustion endangering life (italics mine), or rupture of the cyst should supervene, gastrotomy is indicated." According to the same authority, the mortality following the vaginal operation (primary and secondary combined) is 60%, which is a higher percentage than where the cases are left to nature's eliminative efforts― 52.65%, and higher still than the mortality following secondary laparotomy, which varies from 15.7% (according to Keller) to 38.88% (according to Parry). Parry's summary of cases is comLoc. cit., p. 325. * Med. Times and Gazette, August 2d, 1873. 3 Trans. Edinburgh Obst. Society, vol. viii. 4" Extrauterine Pregnancy," p. 259. 'Loc. cit., p. 261. Billroth's "Handbuch der Frauenkrank.," Part V., p. 90. second. laparot., with three deaths. 4 19 cases plete up to 1875. Deschamps, in his thesis' for the doctorate, has collected 114 additional cases of extrauterine pregnancy, reported between 1875 and 1880. The, conclusion he reaches from a study of these cases is: "If the fetus be small and situated in the pelvic cavity, if the posterior cul-de-sac is filled by the tumor, incision by the vagina may be resorted to. Otherwise, laparotomy should be performed, and usually this operation is indicated" (p. 123). Of these 114 cases, 59 went beyond term, and the course of events was the following: lithopedion or encystment. In 11 cases opening into rectum with 8 deaths. In 2 66 66 at umbilicus (3 secondary laparot.) with O deaths. opening into bladder with 2 recoveries. The general conclusion to be drawn from Deschamps' figures are: When Nature establishes an outlet in the abdominal wall, the patient is more likely to recover than when she establishes an outlet elsewhere; and thus she endeavors to teach us the point at which incision should by preference be made. Of the elytrotomies included in these figures, the cases recovered, but in one case, Schmitt's, where the opening was spontaneous, the fetus could not be extracted. The mortality from the secondary laparotomies is only 22.3%, a slightly higher rate than Keller's, but better than Parry's. Such then are the figures prior to 1880. Since this date, operators have grown bolder and proportionately more skilled; the value of cleanliness, not to speak of antiseptics, has become more widely disseminated; the technique of laparotomy has been, in many minor details, improved. We, therefore, to-day have the right to expect even better results, and I, hence, reiterate my belief that laparotomy, and not vaginal incision, should be the operation of choice in the cases I am considering, in the face even of a prognosis so ominous against the recovery of the unfortunate patient. 1 "Thèse pour le doctorat en Médecine," par B. Deschamps. March, 1880. A CASE OF TUBERCULOSIS OF THE UTERUS WITH SPECIAL INVOLVEMENT OF THE PELVIC PERITONEUM. BY W. J. JONES, M.D., Resident Physician of Bay View Asylum, ALTHOUGH tuberculosis of the uterus cannot be regarded as a very rare pathological process, this case is of special interest from the condition of the pelvic peritoneum which accompanied it. A. H., colored, æt. 21 years, was admitted into Bay View Hospital on May 25th, 1885, with a well-marked tuberculous history. She had been a prostitute for several years past, and was addicted to the dissipation of her class. There was no history of a tuberculous inheritance, and her whole trouble began with a severe cold in November last, which gradually became worse, and was accompanied with fever and night sweats. At the latter part of her illness she was much troubled with a leucorrheal discharge. She had given birth to one still-born child several months previously. Physical examination of her chest, at the date of her admission, showed evidence of softening and breaking down at the apices of the lungs. She rapidly became worse, and on July 1st, an examination revealed the presence of cavities in both lungs. Obstinate diarrhea was present for ten days before her death, which took place on August 10th, 1885. The autopsy, made a few hours after death, revealed the following: Body small, slightly built, emaciated and anemic. The meninges and brain pale. The mucous membrane of the larynx, pharynx, trachea, and esophagus normal. The mediastinal lymph glands and bronchial glands enlarged and caseous. Both lungs adherent to the pleura at the apices and posteriorly. In the apex of each lung was a large, ragged, tuberculous cavity, and elsewhere in the lungs numerous small cavities and areas of caseous consolidation. In each pleural cavity there was a considerable amount of clear serum, and on both the parietal and pulmonary pleuræ numerous miliary tubercles. The pericardial cavity contained several ounces of clear fluid. Heart small, valves normal. Liver, spleen, and kidneys amyloid. In the liver, a few miliary tubercles were found. The intestines, in some places, were dherent. In the omentum and elsewhere on the peritoneum were large, caseous nodules. Some of these nodules were formed by a conglomeration of miliary tubercles, others were single. The pelvic peritoneum was very much thickened, and contained numerous irregular tubercle nodules of various sizes. The thickened peritoneum passing over the uterus and bladder had united and adhered to the peritoneum over the rectum, and in this way a sac was formed which occupied the space known as Douglas' cul-desac. This sac contained about twelve ounces of thin purulent fluid. On raising the small intestine, and looking into the pelvic cavity, it seemed as though a distinct roof was formed over it, on which the intestines rested. The uterus was verted sharply to the right side. The cavity of the fundus was slightly dilated, and contained a small amount of caseous material. The entire mucous membrane lining the cavity of the fundus and the upper portion of the cervix was ulcerated. This ulcerated surface was irregular and caseous, and at numerous places miliary tubercles could be seen. The ovaries and Fallopian tubes were normal. The vagina was wide, and contained numerous erosions, which were covered with a thick, dense, diphtheritic membrane. In the lower portion of the rectum, just above the anus, was a large, circular ulcer with indurated edges. The ulcer was covered with a black, stinking, necrotic mass. The loss of substance occasioned by the ulcer was large and extended through into the vagina. The opening between the two was half an inch in diameter. In the vagina, the mucous membrane around this opening was ulcerated and covered with a diphtheritic membrane. The mucous membrane of the rectum and large intestine was very much thickened and hyperemic, and contained numerous ulcerations. The mucous membrane of the small intestine hyperemic. No alteration was found in the bladder, stomach, and other organs examined. Microscopic examination of the uterus showed a caseous inflammation, combined with miliary tubercles. In the caseous tissue and in the miliary tubercles, swarms of tubercle bacilli were found. Examination of the ulcers in the rectum revealed them also in large masses. The diphtheritic ulcerations in the vagina and rectovaginal fistula were examined microscopically, but unfortunately the examination was not conducted with a view to the presence of tubercle bacilli. The diphtheritic patches in the vagina were found to consist of a necrosis of the mucous membrane, extending deeply down into the submucous tissue. Numerous micrococci and putrefaction bacteria were found in the necrosed tissue. It is well known that, in the ordinary peritoneal tuberculosis, the part of the peritoneum which is first invaded, and on which the full stress of the pathological condition falls, is Douglas' cul-de-sac. This very fact can be taken as a proof of the nonsoluble nature of the tuberculous virus; for it is here that all foreign solid matters gravitate, and the case would not be different were these insoluble particles tubercle bacilli. Along with the eruption of tubercle on the peritoneal surface, there is more or less inflammation, with formation of false membrane, |