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Another rather remarkable thing is how much peritonitis may exist, and yet these women may be going about. Only one of the patients in this series was taken from her bed; the others were still walking about and appeared to be in a fair state of general health.

I want to say a word in reference to a combined method of drainage which I have recently used in some bad cases. I do not know whether there is very much advantage in it, but if there is an advantage it is illustrated by the results in case of the gangrenous ovary which I have reported. In this case I carried the drainage tube down to the bottom of the denuded space, then packed gauze around outside of it. Your first idea will be, of course, as has been frequently expressed, that gauze will only drain for twenty-four hours, and during this time it will do all the draining. But this is not so; the serum or other material goes into the drainage-tube through the gauze; the gauze hardly drained at all; the tube did all the draining, so I do not know but the woman would have done as well without the use of gauze.

Another thing, I believe statistics will show that much of the improvement in the results in these cases is due to absolute attention to hemostasis. My asepsis at present is no better than it used to be; I wash my hands and sterilize my instruments no more carefully now than I did ten years ago, but infinitely more pains are taken to arrest every particle of oozing and have the cavity as dry as possible before closing the abdoinen, so that drainage is rarely necessary longer than twenty-four hours. I use hot sponges freely and keep every thing dry. Formerly I was not so particular about hemostasis, believing that the peritoneum was able to take care of a considerable quantity of fluid, which of course is in a measure true, and I then depended more upon drainage, hurrying through with the operation sometimes, when perhaps better results would have been obtained by more attention to hemostasis, depending less upon the ability of the peritoneum to take up the fluid, and also depending less upon drainage.

One other point, not one of these four cases was operated upon in the general stereotyped fashion, that is, going down and pulling up the diseased structures, followed by enucleation, then transfixing the pedicle, applying a double ligature, tying each half, etc. In all these cases the diseased structures were first thoroughly loosened, then the ovarian artery was tied out near the pelvic wall, a pair of forceps applied, and a very small pedicle made. Little or no blood was lost, and instead of taking up a bundle of broad ligament, making a pedicle which must

necessarily be fleshy and broad, and its ligation cause the patient a great amount of pain after the operation, a very small pedicle was made, and I believe this is one of the greatest advances in the operation. In all inflammatory cases now I tie the ovarian artery out near the pelvic wall, then transfix in the usual way. In making a broad pedicle the ligature is likely to slip off and secondary hemorrhage result, and it causes great pain, both of which are avoided by the method I have referred to.

Discussion. Dr. C. Skinner: I congratulate the reporter upon his success in these cases, and desire especially to offer my commendation upon the conservatism which he practiced. I intended to ask a question, which he has answered in his remarks, if the last specimen exhibited was not tuberculous in character, and what per cent of these cases does he find to be tuberculous; also if he did not suspect tuberculous trouble in that patient before the operation, mainly from the fact that she had lost flesh continually. My observation has been that in extensive pelvic disease due to gonorrhea, sepsis, etc., there is less constitutional effect upon the patient, and she does not lose flesh and strength to the same extent as when the condition is tuberculous. One pathognomonic sign of tuberculous trouble, local or constitutional, is continued loss of flesh, evidently because of absorption of pus. I have seen extensive inflammatory disease of the pelvis, with the presence of a large amount of pus, as proven by operation, yet the patients were able to go about. In tuberculous cases they go down hill faster, fever is higher, they have chills, sweats, with perhaps but a small amount of pus and local destruction.

Dr. L. S. McMurtry: The specimens presented by Dr. Cartledge illustrate one of the most interesting and instructive chapters in pelvic surgery, ard one in which the ground has been more hotly contested thau in any other department of pelvic surgery within the last fifteen years, during which time it has made such wonderful advancement. It has not been more than a decade since you could find in all cities like this teachers of gynecology and surgery who absolutely denied the existence of pathology such as you see illustrated before you, claiming that such cases were simply pelvic cellulitis. At the present time no one can question the pathology as stated. Then, again, the operative treatment has been the debatable ground of pelvic surgery, and it is not yet over. What Dr. Cartledge has presented this evening represents the very best surgery that is being done in the country, and the

best surgery that is being done in this line of work is in the United States of America. In France every one of these cases would have had a vaginal hysterectomy performed by leading operators and teachers in that country. The same may be said of Germany, and in Great Britain, with the exception of that school of surgeons lieaded by Mr. Tait, operative work is done in a very different manner from what has been described here this evening. The great fight that is now being made in pelvic surgery is in regard to the question of drainage. The last fasciculus of the Johns Hopkins Hospital Reports is entirely occupied by a very elaborate paper by Clark, the whole trend of which is that drainage in pelvic surgery is absolutely useless, whether it be by tube, gauze (capillary drainage) or otherwise; that it is unnecessary and useless.

I have long since convinced myself, after seeing the operative work done by the French school of surgery headed by Pean and Richelot, that they do not cure these cases. Convalescence after the French operation is not easy; the women recover with general adhesions; they suffer with the slightest distension of the intestines by gas; they may get over the effects of the operation quickly, but are not cured of the disease for which the operation was undertaken.

In regard to the technique: Dr. Cartledge spoke of the changes he had made in the years he has been operating, in the increased attention to hemostasis, etc. I think this is an illustration of the greatest advance that has been made in this country in this class of work. The establishment of this class of surgery upon a permanent basis has been done necessarily by a few who have had the greatest experience in this work, and these few are almost a unit in regard to the method of procedure, viz., to enucleate from before backward, to keep the enucleation in the direction of the sacrum and then come forward, to make hemostasis perfect, to relieve all possible tension, to restore the intestines of the pelvic basin, to pack the uterus and omentum down firmly in place, to keep the patient still on her back in bed for forty-eight to sixty-four hours, and drain when necessary. As the doctor has stated, these represent a class of cases that were formerly considered the opprobrium of pelvic surgery, but at present, with our improved methods of operating, convalescence is usually smooth and recovery prompt.

In regard to drainage: I have never been shaken in my faith, because I have seen a great deal of the work of those who do not drain,

and there are two reasons why these cases should be drained for the first twenty-four hours. That is, where adhesions are stripped loose, admitting that your cleansing is perfect and complete, there will be a weeping surface which will continue to weep for hours, and it is advisable to rid the peritoneum of such a culture bed as is necessarily left by drainage and aspiration every fifteen minutes to half an hour or hour, and later every two hours, as the discharge subsides. Second, there is another use of the drainage-tube, and that is an indication of hemorrhage. One of the most difficult things to distinguish in intra-peritoneal surgery and one of the most difficult things to diagnosticate is hemorrhage. In neurotic women who have a flighty pulse, rapid respiration, etc., you will be at a loss oftentimes to determine whether or not hemorrhage is going on unless a drainage-tube is used, and if hemorrhage occurs without the drainage-tube, its extent can not be determined. I take it these are of themselves sufficient reasons for drainage, and as the doctor has said, the glass tube with suction is the method of drainage par excellence in these cases. I have almost discontinued the use of gauze except when there is some positive indication for it, and believe that better drainage is secured by a tube properly placed.

One other point: I am sure great harm is done by failing to complete the toilet with great deliberation and care, by hurrying through the operation and failing to take care of the patient as she leaves the table, and as she is placed in bed, and as she is kept in bed for some time. She ought to be kept absolutely quiet; the intestines, omentum, and all replaced organs ought to be kept still, so as to avoid the dangers which will come from disturbing the relations, and secondary complications during convalescence.

Dr. A. M. Vance: One of the lessons to be drawn from the series of cases reported is, how absurd it would be for any one to attempt to take out such masses as we have seen by the vaginal route, even if the uterus was also removed. With eighteen or twenty inches of adhesions to the intestines, much damage might be done by attempting separation with the fingers through the vagina, and such damage might not be discovered until a post-mortem was performed. Vaginal operations for conditions of this kind are similar to subcutaneous ligation in conditions about the scrotum; they are necessarily operations done in the dark, and are fast becoming obsolete, as they should.

I am a firm believer in the use of the glass drainage-tube, the glass

well, as it is called, as it goes to the bottom of the pelvis, and that is where the fluid to be drained gravitates. I have been pleased, however, with the use of the gauze drain as advocated by Morris in appendicitis cases, that is, making a gauze well which acts as a capillary drain without introducing a mass of gauze into the tissues themselves. By wrapping this gauze in rubber tissue you really get a tube which can be removed as easily as a glass tube, and it acts with more integrity than does the ordinary gauze drain, and also avoids disturbing the tissues in its removal.

The technique as described by Dr. Cartledge is the very best, especial attention being directed to complete hemostasis. I know in olden times we used to think the peritoneum could take care of a great amount of fluid, blood, blood-clots, etc., but it was oftentimes at the loss of our patient.

The two lessons to be emphasized are: that it is impossible to operate upon such cases as Dr. Cartledge has reported by the vaginal method; second, that direct drainage by the glass tube or gauze well is absolutely necessary.

Dr. Louis Frank: I have been an earnest believer in the abdominal route ever since the discussion between the abdominal and vaginal methods has been brought prominently before the profession, and these cases confirm me more than ever in the position I have taken and frequently expressed. I have held that we do not know when we undertake an operation just what we will find; no one can tell previous to the operation just the condition which will be encountered, and in working through the vagina we are working in the dark. The cases reported illustrate the absolute futility of vaginal operations for the relief of such conditions. Like Dr. McMurtry, I am aware of cases which have been operated upon by the vaginal method and were not cured of the disease for which the operation was undertaken. I believe, however, that there are some cases that can be operated upon successfully by the vagina, but we are unable to tell previous to the operation which cases these are. Could we always make perfect diagnoses, we might then select the method best suited to the condition present. I take it that the majority of the work through the vagina should be merely preliminary to the work which is to be done from above.

Drs. Cartledge and McMurtry have expressed fully the latest points in the technique of operations in this class of cases.

It has been my custom since I have been doing this class of work to always bring down

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