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the pelvis, taking its course above and across the fundus uteri and opening in the side of the rectum. The collection of pus was entirely above the pelvis, and it was necessary to cut through the muscles and fascia to get into the pus cavity and then establish a process of drainage through the rectum. It would have been impossible in that case to have effected the opening through the vagina.

DR. J. H. ETHERIDGE said he had had no experience in opening the abdomen for treatment of abscess in the pelvis. He had seen one abscess opened through the abdominal wall, which had a spontaneous opening into the rectum. It was done at the Presbyterian Hospital about a year ago. The top of the abscess could be felt through the wall, and an attempt was made to find the opening, wash it out and inject it; but this being regarded as impracticable, abdominal section was decided upon, and a very curious combination of pathological conditions was discovered. The abdomen was opened, and a protruding something was discoverable; there was a discharge of perhaps an ounce and a half of serum, then it was cleaned. It was really a cystic growth, and upon introducing the finger another cyst, apparently, was discovered, that was opened and thoroughly evacuated, then another protruding by it was discovered, which was found to be the abscess cavity itself. That was opened and cleaned out and a drainage tube introduced and fastened to the wound, and the patient dressed, but she died within twenty-four hours. Post-mortem examination was made, and the track of the opening readily marked out. He had seen pelvic abscesses that opened in all directions through the abdominal cavity, into the bladder, vagina, and rectum, but never saw one that opened into the uterus. He saw at the Woman's Hospital an abscess that opened through the vagina and abdominal wall. The patient died. Dr. Etheridge said he had under treatment a pelvic abscess that opens into the rectum, in which general cellulitus is present. About once in six weeks the woman would have a fever, and after undergoing a great deal of suffering, nights of pain in which she would have to take large quantities of opium, there would be a discharge of pus into the rectum. She was put on tonics, and her general health improved greatly. Now she goes a great many weeks at a time without any return of the symptoms. A slight amount of pus is present with every passage from the bowels. It seemed to him as if the true estimate to make of the justifiability of laparotomy for abscesses is the ability to reach the top of the abscess through the abdominal wall, and where it cannot be reached it seemed to him that purulent discharge of the abscess into the abdominal cavity would surely take place.

DR. EDWARD WARREN SAWYER thought it a matter of regret if the discussion were to conclude without the special indications being given for a line of treatment in given cases. For his own satisfaction, he would like to have an answer to the following questions: First, in case of pelvic abscess, in which there is already an opening established, either by the bowel or by the bladder, is laparotomy ever justifiable? Second, in a case of supposed pelvic suppuration, without any external manifestation, as an opening through the bowels or bladder, is laparotomy ever justifiable?

DR. A. H. FOSTER said he had not been present long enough to learn the scope of the discussion, and had but little to add. He

did not recollect any case of pelvic abscess in his experience, although it was that of constant care of cases of pelvic cellulitis, more or less extensive. He always expected to have a larger crop of such cases, of more or less gravity, at this time of the year than at any other, especially those cases that are non-puerperal, but are menstrual. The cause seemed to be carelessness in regard to clothing, especially of the feet, and the exposure which comes from the varying weather in this climate, hot and cold, wet and dry. In regard to treatment of these cases, his did not differ from others. He always relied on prompt doses of mercury and opium until the acute symptoms subsided; fomentations externally and hot douches internally, and then followed either with the muriate of ammonium or the iodide of potassium, reducing the opiate as fast as possible and continuing quinine, its substitute.

DR. PHILIP ADOLPHUS said that in the absorption of recent inflammatory deposits in the pelvis, he depended on the action of the skin, kidneys, and bowels, stimulated by proper medication. In regard to hot douches, it depended whether the surroundings of the patient were such that they could be given properly; if otherwise, to attempt it would result injuriously. If symptoms point to suppuration, and fluctuation can be felt per vaginam, the use of the hypodermic syringe will disclose serum or pus. If serum, he trusted to absorption; pus, however, necessitated a speedy incision, with subsequent drainage, etc. If formation of pus is suspected at any time, it is best to look for it, and if it cannot be found, it is best to wait for its pointing. However, if the patient is in great danger, laparotomy is indicated.

DR. F. E. WAXHAM was sorry that he had not been able to hear the whole discussion. He was reminded, quite forcibly, of a laparotomy upon one of his own patients; however, it was not a case of pelvic cellulitis-it was acute peritonitis, with effusion within the abdominal cavity. This patient presented all the characteristic symptoms of peritonitis, intense abdominal pain, exceeding tenderness and great abdominal distention; the patient passed from bad to worse, and finally fluctuation was detected in the lower portion of the abdominal cavity. An eminent surgeon was called in consultation, who recommended laparotomy as the only hope of saving the patient's life. It was supposed there was pus within the abdomen, and, although very feeble and greatly exhausted, it was considered proper to give the patient the benefit of the operation. Frequent hypodermic injections of brandy were given, in order to support the flagging pulse during the operation. The abdomen was opened, but no pus was discovered in the abdominal cavity: a thin, serous fluid was discovered. The patient barely survived the operation, dying about six hours later from prostration and shock. In contrast to this patient, he remembered another-a case of peritonitis in a child-that had all the characteristic symptoms of acute, violent peritonitis. This patient was seen by Dr. W. H. Byford, who gave valuable assistance in the treatment. The child, who was but seven years old, was obliged to take twenty drops of tincture of opium every hour and a half for two days at a time, in order to control the intense pain, and it seemed as if it was impossible for it to live from one hour to another; fluctuation was found more marked in this case than in the other, but, notwithstanding all these unfavorable symptoms, this little patient made a gradual, slow, tedious, but

yet permanent recovery. He believed we ought not to subject a person to so dangerous an operation as laparotomy without proof of the presence of pus. It seemed to him that a serous fluid might become absorbed and the patient recover, where an operation would very likely cause death.

DR. CHARLES WARRINGTON EARLE said he had nothing new to add in regard to the ordinary general treatment of pelvic cellulitis or abscess, but he was practically interested in exactly the questions that had been asked by Dr. Sawyer. He spoke of the terrible cases which he supposed all physicians meet occasionally. He had probably seen half a dozen during his fifteen years of practice. These cases have a history of pelvic pain and inflammation, and finally a discharge of pus, which continues for weeks and months, and sometimes years. At last some of us are called in and find that the woman is suffering from chills, a high temperature, feeble pulse, and is greatly exhausted. He wanted the older members to tell what should be done with such cases. Is there any hope for a woman in this condition? A few months ago he was called in consultation with another physician to see a lady who had a constantly discharging abscess, until she was nearly dead from exhaustion. The question in his mind was, and it was one he would like to have discussed, would it do any good to open the abdomen of such a woman and clean out those pus pockets? Have we any experience which will give us a moderately safe rule by which to proceed in such a case, where death is absolutely certain if something out of the usual line is not done? He hoped some light would be thrown on this question.

DR. HENRY T. BYFORD thought that the treatment of the first stage had been spoken of too slightly. He had seen much irreparable harm done by the failure of physicians to promptly recognize and properly treat the acute attacks. There is no doubt of the positive influence of opium on the peritoneal part of the inflammation, of sedatives on the arterial excitement, of absolute quiet of body (opium acts largely by quieting all motion in the bowels), and of the local application of heat. But he protested against the early indiscriminate use of the vaginal douche. He had known it to do decided harm.

He attributed the lack of hopefulness, in speaking of the management of suppurating cases, to the lingering influence of past experience. In the light of our present knowledge, the lines can be drawn much more definitely. A pelvic abscess should, of course, be opened wherever it may point, whether in the vagina, rectum, or under the skin. When the primary outlet is made through the skin, the treatment, being entirely antiseptic in character, leaves nothing to be desired; when made through the vagina or rectum, the outlet must be as nearly as practicable at the most dependent portion, for strict antisepsis being impossible, drainage should be perfect. Spontaneous primary openings through the cutaneous surface that do not admit of a thoroughly antiseptic management must be modified so as to admit of it; and openings through the vaginal or rectal walls, that do not secure adequate drainage, must be made to do so. The most troublesome of these abscesses are those that have formed an opening into the bladder or alimentary tube beyond reach, and do not completely empty themselves through it. When such is the condition, rather than cut through solid tissue by the vagina or rectum, we must, if the condition of the patient be critical, have recourse to laparotomy.

But making an outlet through the abdominal walls is of questionable benefit, unless accompanied by the more important part of the operation, viz.: the obliteration of septic pockets and establishment of perfect drainage through the vagina or rectum. But there are some abscesses producing serious symptoms before pointing below or externally, which were originally, or have become, abdominal or supra-pelvic in character. These, according to the latest experience, should unquestionably be evacuated by means of laparotomy, whenever they cannot be reached extraperitoneally. But a large majority of them are hematoceles, very many of which could and should have been operated upon from below, before a threatening abdominal abscess had developed. Therefore, under proper and timely treatment from the beginning of the attack, but few cases of pelvic abscess would require laparotomy.

DR. W. H. BYFORD wished to make two or three remarks with regard to certain abscesses which had not been touched upon during the evening, viz.: such as do not break, do not discharge but remain as chronic cavities for a number of years. He had had an opportunity of tracing three such cases for twenty-three or four years, and in each of them there had been found serous in place of pus cavities. He accounted for it in this way: the lining membrane is an ulcerated surface, and he thought that in some of these cases, instead of the pus being discharged, these surfaces underwent cicatrization, and that there was then a cicatrized cavity in which there was an amount of serum that dissolved the pus-corpuscles, and thus causing their disappearance so as to leave nothing but a clear collection of serum-a serous sac. In the three cases mentioned, when the sac was opened, it was found to contain serum instead of pus. He had been very much interested in them, and followed them until he had proved to his satisfaction that this change actually did take place; a cicatrization of the whole lining membrane, converting it into a non-suppurating cavity containing serum.

DR. A. REEVES JACKSON said, replying to the questions that had been asked in regard to those cases in which an opening of the abscess was already established, and when the health of the patient was not unfavorably influenced by the discharge, that he would let the woman alone unless he could so enlarge the opening as to establish a thorough drainage. And in cases in which there was no opening, and in which there seemed to be evidence of the existence of pus, he would endeavor to find it with the aspirator needle introduced through the vagina or abdominal wall, in preference to opening through the rectum. In case drainage could be established perfectly through the vagina and abdominal wall, he would rely upon that. Dr. Jackson said that he had failed to make himself understood clearly in regard to the estimate he placed upon the treatment of the early stages of pelvic cellulitis. He approved of the vaginal douche, hot applications over the epigastrium, and opium, the latter being his sheet anchor, more particularly in peritonitis than in cellulitis. He thought that in many cases, by lessening the pain, the pulse was reduced and the temperature lowered. He simply felt that these methods of treatment do not reach the bottom of the difficulty, but in the absence of any thing better he had always used them. He had never used leeches, but thought they might be beneficial. The blood is not withdrawn directly from the congested vessels, but its loss may affect the

part as would venesection in the arm or elsewhere. In conclusion, in a case of pelvic abscess, when a woman was dying from rapid pulse, high temperature, and the constitutional disturbance that these things always bring in the train, other means having been tried unsuccessfully, he would perform laparotomy, because in many of these cases, even if the operation should fail, the patient is not made materially worse. He had come to believe that constant invalidism is not preferable to death.

DR. DE LASKIE MILLER reported a

CASE OF EPITHELIOMA OF THE UTERUS-TREATED BY MERCURIC NITRATE-RESULT SIX YEARS AFTER TREATMENT.

This case derives its interest from the extent of the disease, the treatment, and the condition of the patient since treatment and

now.

Mrs. R., wife of a physician, came under my care about eight years ago, affected with epithelioma of the uterus. When the case was first examined, a considerable portion of the cervix had disappeared, and the disease had extended to the os internum. The hemorrhage had been frequent and severe, and the ichorous discharge was constant. The general health had been greatly impaired.

Treatment.-Granulations were removed by the curette, and nitric acid was applied. Tonics and a generous diet were added. After a few weeks she left the city for her home, feeling better. She again visited the city three months later. The disease had made further inroads upon the tissues of the uterus, and upper part of the vagina. Chloride of zinc was applied and reapplied. Apparent improvement followed.

The patient came to the city at intervals for about two years, and submitted to actual treatment for several weeks each visit. Still the disease evidently advanced, though the symptoms were occasionally suppressed. The vaginal portion of the cervix had quite disappeared. The cavity of the uterus became involved, and the disease was extending over the upper part of the vagina, both anteriorly and posteriorly. The appetite, digestion, and general strength were impaired to that degree that it was manifest the patient would succumb unless the disease could be promptly arrested.

The acid nitrate of mercury was chosen as the agent, and in the presence of Dr. Jackson it was applied in the following manner: A roll of cotton, two and one-half inches in length, and as large as the canal would admit, was saturated with the acid nitrate of mercury, and introduced, reaching into the cavity of the uterus, and filling the cervical canal, and a small portion left dependent into the upper portion of the vagina. This application was left undisturbed in situ for seventy-two hours, and undoubtedly it is to this fact that the result is due.

After the cotton was removed, an extensive slough came away.

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