all the untoward surroundings which have been shown to be about our patients, or whether it is that the presence in the system of a specific germ of each infective disease simply acts as a disturber of the normal attempts at repair, or encourages the growth of the septic germ, or facilitates the formation of "les ptomaines," or kindred results of decomposition, in either case, before we finally can settle the much and long-vexed question of the nature of so-called puerperal fever, we must patiently work, accumulating information from all sources, and, not the least, with constant inquiry into the environment of our patients. It is the constant attempts of obstetricians to deliver a final opinion on the subject that has hindered, and will continue to hinder, our advance, retarding our investigations, both clinical and pathological.

A CASE OF RETENTION OF MENSES FROM AN IMPERFORATE HYMEN-OPERATION-CURE.

REPORTED BY

WM. H. PINKNEY, M.D.,

Resident Physician Harrisburg Hospital, Harrisburg, Pa.

THAT cases of hematometra and hematokolpos (Ziemssen, Vol. X., page 48) are of infrequent occurrence in this country is inferred from the fact that so little is said on this subject in our works on gynecology, many authors not noticing it, and others only devoting a few lines to its consideration.

In Europe this operation is believed to be fraught with more or less danger to life. In what little has been written (so far as my limited means of ascertaining extend), I find a diversity of opinion in regard to the mode of operating, and the danger resulting therefrom. Dr. T. G. Thomas advocates repeated operations (every three or four days) by aspiration, or by keep ing a trocar having a stop-cock, in situ, through this a given quantity of the fluid is allowed to escape at stated intervals until the cavities are emptied. He does not speak of the operation as being dangerous. Dr. Emmet has operated four times; he approves of a free incision. Had his attention not been

called to fatal cases, he would not have considered the danger worthy of notice. Baker Brown ("Diseases of Women") recommends that the hymen be removed entire, and in reference to the danger attending the operation, says: "This appears very simple and easy, yet many young women have lost their lives by this operation, from subsequent peritonitis." Barnes (on "Diseases of Women") advises drawing off small quantities of the pent-up fluid at a time, by the "aspirator trocar." As to the danger, he writes: "And it is to be apprehended that cases will continue to occur in which a fatal result will follow any method of treatment." Drs. Ramsbotham and Lefort collected several cases in which simple puncture resulted fatally. Dr. Holmes, in his "System of Surgery," vol. V., speaking of this operation, says: "We have to show that even the simplest operation, when performed after menstrual accumulations have taken place, are attended with peculiar danger." He relates a fatal case of a perfectly healthy girl sixteen years old, from whom he evacuated the fluid by a simple thrust of a common lancet. The patient died of peritonitis. Dr. McLane, in his lectures on gynecology, when speaking about the methods for the relief of retention of menses from imperforate hymen, says: "A great source of danger is the admittance of air to the confined fluid, causing decomposition and possible subsequent septicemia."

The successful course of the case that I now relate inclines me to believe that the danger lies not so much in the method of operation, as in exposure to septic poisons, and that by the proper use of antiseptics, most, if not all, danger can be avoided.

S. S., aged fifteen years, was admitted to the hospital, Nov. 24th, 1885. She first made known her trouble to her mother four months prior to her admission, when an enlargement of the lower zone of the abdomen was well marked.

She was suffering from pains closely resembling labor pains. Examination showed the labia to be widely separated and protruding from between them was a hemispherical tumor, appearing much like the fetal head when the face is about traversing the perineum. The uterus was enormously distended, reaching above the umbilicus. The vagina could be plainly felt through the anterior wall of the rectum, like a large soft sausage. The bladder was contracted and forced down upon the pubes, and could retain but a small quantity of urine. The tumor fluctuated plainly.

On Nov. 26th, Dr. T. J. Dunott, Visiting Surgeon, removed thirty-nine ounces of retained menstrual blood by aspiration. A gum catheter was then introduced into the bladder and made to perforate the antiseptic dressings which completely covered the

external parts, the whole being retained by the ordinary T bandage.

The fluid aspirated was liver-colored, having the consistency of syrup, coagulated soon after removal, aud was devoid of odor.

After the operation she was given the sulphate of quinine gr. x., and kept perfectly quiet in bed. Nov. 27th. Slept well; temperature 98.5°; pulse 78. Has no pain or tenderness in hypogastric region. About half an ounce of fluid escaped during the night. Appetite excellent. Second operation, performed by Dr. Dunott, consisted in passing a grooved director through the puncture and opening the hymen by a Y shaped incision; the upper extremities of the Y extending laterally upwards and outwards, nearly to a level with the meatus urinarius. Over a quart more of menstrual fluid was rapidly discharged. The vagina was then thoroughly douched with a solution of corrosive sublimate (1-1,500), and a glass rectal speculum, filled with borated cotton and thoroughly sprinkled with iodoform, was inserted. She expressed a sense of great relief. Vagina syringed twice a day with hot carbolized water, and urine drawn by catheter. Temperature normal, appetite excellent, bowels regular, no abdominal tenderness, and no discharge. Dec. 1st. Speculum removed and patient allowed to sit up for two hours. Evening temperature 99.2°; given the sulphate of quinine gr. x.; the temperature soon became normal, and did not again rise during her stay. She steadily improved, the speculum being withdrawn during the day and replaced upon retiring. Discharged cured, Dec. 5th, 1885.

The antiseptic dressings consisted of four layers of surgeon's lint, three layers of Lister's antiseptic gauze thoroughly soaked in a solution of corrosive sublimate, 1 part to 1,500 of water, and sprinkled with iodoform, the whole being covered with gutta-percha tissue.

CORRESPONDENCE.

OÖPHORECTOMY IN UTERINE FIBROIDS.

EDITOR OF THE "AMERICAN JOURNAL OF OBSTETRICS."

SIR: In the last number of your Journal, a short paper from Horatio R. Bigelow, M.D., appears, in which he says that he recently had occasion to take issue with me in regard to my very absolute statements concerning the merits of oöphorectomy in the treatment of myo-fibromata of the uterus. In the discussion to which this alludes, which appeared in the British Medical Journal

for September of last year, the concluding communication from myself was to the effect that "Dr. Horatio R. Bigelow showed me completely that he had an aptitude for misrepresenting the views of other people, and no very great power of expressing his own. I can supply the facts and arguments, but I cannot supply the intelligence necessary to understand them." It is a matter of very great regret to me that I am obliged to repeat this language in your columns, but it is absolutely necessary that I should do so, for any one who reads Dr. Bigelow's article, without knowing something of my work, would fall into the mistakes out of which it seems perfectly impossible for Dr. Bigelow to extricate himself.

In the first place, I have never said one word about the merits of oophorectomy in the treatment of myo-fibromata of the uterus. The operation which I advocate, and the advantage of which I have conclusively proved, is removal of the uterine appendages in uterine myoma; and if the conclusions which Dr. Bigelow summarizes in the paper in your Journal refer to the operation which I speak of, I think the easiest method is to dispose of them categorically.

The following are his conclusions and my answers to them, and in order to save space, I put Dr. Bigelow's words in italics.

1. A rare percentage of tumors are dangerous by reason of hemorrhage. What Dr. Bigelow ought to say here, of course, is, that a rare percentage, or at least, some percentage unknown, of all myomatous tumors are dangerous by reason of hemorrhage, because we know from the post-mortem records that there are countless cases of myoma that never draw any attention to their existence during life at all, whilst, on the other hand, cases are coming to us constantly by reason of suffering chiefly hemorrhage. Therefore, Dr. Bigelow ignorantly misrepresents the true facts of the case. Of course, we are not concerned with cases that do not come to us-that is to say, cases where there is disease found by accident on the post-mortem table, but which had no clinical importance during life.

2. The bleeding may be from sources posterior to the tumor. I have studied the pelvis very carefully for many years, and I think I may be admitted to know something about its anatomy and its surgery, and unless this refers to the accidental occurrence of hemorrhage from piles, this sentence is wholly unintelligible.

3. Enucleation of ovaries and tubes will not always necessarily arrest the bleeding. I have published my first fifty cases in detail (see British Medical Journal, August 15th, 1885), and in all

of these, with one exception, on the evidence of others, not upon my own evidence, the hemorrhage will be found to have been completely arrested. The exception to which I allude was the exception which proved the rule, because I have since (see British Medical Journal, Oct. 3d, 1885) removed the tumor, and found that the operation which I thought I had performed completely, I had performed incompletely. The patient had only one Fallopian tube, and instead of wholly removing that, as I ought to have done, I had removed only about a third of it.

4. Il cannot be predicted beforehand that the operation will be successful. Of course, we cannot insure that the sun will shine to-morrow, but as it has shone on previous days with unerring certainty, and as our experience now, without any exception save that to which I have alluded, is that the bleeding is arrested by removal of the appendages, we may be as sure about this proceeding as we can be about anything in surgery, that it will completely arrest the bleeding. There is, of course, the further exception that we may make, as I have made, occasional mistakes, or the tumor may be malignant, in which case, of course, the bleeding will return and kill the patient.

5. The sequela will be fatal, if Tait's logic be correct, for a mass deprived of its nutrition is left within the abdomen to undergo degenerative changes, the products being absorbed or carried away as best they can. This is perfect nonsense. The mass is not deprived of its nutrition, because no vessel supplying the uterus is interfered with at all. What we do is to imitate nature's own process at the time of the menopause by arresting menstruation, and the sequelae of the operations have not been fatal in a single instance. This brings me to speak of the extraordinary blunders of which only Dr. Bigelow and Mr. Spencer Wells seem to be capable. It is not, as Dr. Bigelow seems to imagine, the tying of the superior vessels of the uterus which has anything to do with the success of the operation, and it is not necessary, as Dr. Bigelow and Mr. Spencer Wells seem to think, to cut off the blood supply from the uterus to cure these tumors. I never make any attempt to strangulate any blood-vessels, and yet my operations are successful.

Dr. Bigelow asks, "Why, then, should it be supposed that an operation which has for its object the arrest of the growth of a tumor, by strangulating its circulatory supply, should not exert a similar influence upon the whole body of the uterus ?" It never has been supposed so by anybody except Dr. Bigelow and Mr. Spencer Wells; and I altogether object to the supposition as un