« PreviousContinue »
examination revealed very little thicken- thickening to the left of the uterus. ing posterior to the uterus. Fecal mat Two months later a large mass ter escaped through the tubes for only a found to the left of the uterus, which was short time after the operation. On April opened through the old incision, drained 5, 1895, Dr. Trenchard wrote: “I heard and irrigated. Examination during the from Mrs. S. yesterday. She rapidly operation induced me to think that the regained her usual health and has abscess was ovarian. The drainage remained perfectly well.” In this case tubes were removed at the end of six abdominal section would probably have months. Examination on May 15, 1895, resulted fatally.
showed a sinus two inches deep, some Miss L. R., aged 18, was admitted to discharge of pus, and the uterus not St. Luke's Hospital June 24, 1894. freely mobile. Some thickening was Upon examination a mass was felt pos felt posterior and to the left of the uterus, terior and to the left of the uterus, ex but no distinct swelling existed, and the tending above the pelvic brim. Abdom- patient's health was excellent. The inal section revealed an agglutinated abscess caused very little suffering ; remass of omentum, intestines and pelvic moval by abdominal section would have abscess. The adhesions were extensive been difficult and dangerous. and very firm. A left tubo-ovarian ab Mrs. H. S., pelvic abscess following scess was found which contained about secondary abdominal section for severe one ounce of pus. The abscess cavity hemorrhage. On account of the feeble was shut off from the general abdominal and anemic condition of the patient cavity by gauze packing, and the abscess blood clots were left in the abdomen, was opened, drained, and a portion of which became infected and produced the abdominal incision closed. Vaginal the abscess. The abscess displaced the section was now made and an abscess of posterior-vaginal wall forward. Vaginal the right uterine appendages opened, irri. section was made in January, 1895, with gated and drained. The patient's tem- irrigation and drainage ; about one pint perature soon became normal. The of offensive pus and blood clots was redrainage tubes were removed at the end moved. Recovery was satisfactory but of four weeks. Examination showed slow, on account of the anemic condition the uterus to be fixed and showed some of the patient. Recent examination induration in the pelvis. The patient shows no evidence of pelvic disease. felt perfectly well, however, and was This patient could not have borne a discharged from the hospital. I have third abdominal section. been unable to get a recent report of the Miss S. L., aged 22, was admitted to case.
St. Luke's Hospital on the evening of Mrs. C. C., aged 32, was admitted to January 18, 1895. She had a temperaSt. Luke's Hospital June 26, 1894. Ex ture of 103°, pulse 120, and her general amination showed extensive induration condition was exceedingly grave. She lateral and posterior to the uterus. The gave a history of induced abortion ten uterus and upper portion of the vagina days previous. Examination showed a were pushed forward, and the mass ex- large mass high up in the pelvis to the tended upward on the left side of the left of the uterus. She had marked pelvis. The abdominal walls were ex tympanites, general abdominal tenderceedingly thick. The patient had no ness, and constant nausea and vomiting. symptoms of septic infection and her The symptoms indicated general peritohistory indicated that the abscess had nitis. January 19, temperature 103°, existed a very long time. Vaginal sec pulse 130.
Shreds of offensive memtion was made with drainage and irriga- brane and small pieces of placenta were tion, and about one pint of pus was removed from the uterus with placenta evacuated. The patient felt perfectly forceps and curette. Section of the vawell after the operation. At the end of gina was made to the left of the uterus, three weeks the drainage tubes were re and the finger was forced up between moved. Examination showed some the folds of the broad ligament until it
came in contact with the Fallopian tube. two quarts of very offensive blood clots A blunt instrument was introduced removed. Digital examination within along the finger as a guide into the tubal the sac revealed an enlargement of the abscess ; the opening thus made was en left tube, which prolapsed into the sac larged with the finger, and two rubber cavity. The case was undoubtedly one drainage tubes were inserted into the of extra-uterine pregnancy, and the abscess sac. Two to four ounces of very blood clot had become infected during offensive sanguinolent pus escaped. the curettements. The sac was drained Frequent antiseptic irrigations were and irrigated. The temperature dropped used. The patient became almost pulse- suddenly and gradually became normal. less during the operation, which occu At the end of three weeks she left the pied only a few minutes. Her condition hospital.
hospital. At this time the discharge improved slightly after the operation, was slight and the mass on the left side but two days later a similar mass was was small. Her family physician refound on the right side. An incision cently informed me that he had removed was made to the right of the cervix and the drainage tubes, that all discharge the abscess was treated like the previous had ceased, and that the pelvis was apone. This abscess contained also from parently normal. An abdominal section two to four ounces of offensive pus. would undoubtedly have been fatal in Both the operations were extra-perito- this case. neal. The patient's temperature imme Mrs. M. S., aged 37, was admitted to diately dropped three degrees and soon St. Luke's Hospital March 23, 1895. became normal, and her condition rap- Temperature 102.4°, pulse 118 ; abdoidly improved. She sat up in about men tympanitic ; severe pain in lower three weeks, and left the hospital thirty- abdomen ; patient anemic; symptoms eight days after the operation, feeling of general peritonitis.
of general peritonitis. Examination reperfectly well. The drainage tubes were vealed a mass filling the pelvis, pushing removed on the thirty-third day. Ex the uterus and vagina forward, and examination showed a movable mass, tending nearly to the umbilicus. Her probably ovarian, high up to the left of last menstruation commenced on Januthe uterus. Examination of the right ary 1, at the regular time, but hemorside revealed no evidence of disease. rhage continued until the time of operExamination made about April 1 showed, ation. Vaginal section posterior to the no appreciable change in the mass. cervix was made and about one quart of This will probably necessitate an abdom- partly clotted blood was removed. A inal section, which can now, I believe, mass remained to the left of the uterus. be safely performed. Had abdominal The sac was irrigated and drained. The section been attempted in this case, the case was probably one of extra-uterine patient would certainly have died during pregnancy. The patient has been practhe operation.
tically free from sepsis, pain, or any disMrs. B. R., aged 30, was admitted to comfort since the operation. ExaminaSt. Luke's Hospital, March 10, 1895. tion April 10 showed no evidence of pelShe gave a history of a miscarriage two vic disease. The drainage tubes were weeks previously, and her last menstru removed and the patient discharged ation occurred two months before. She from the hospital. had been curetted twice for supposed Technique of the operation.—The paretained portions of placenta before com tient is prepared as for vaginal hystering to the hospital. Temperature 103°, ectomy. The abdomen should also be pulse 140 ; marked anemia ; abdomen prepared on account of the possible netympavitic; general condition grave. cessity of a celiotomy. The patient is On examination a mass was found which anesthetized and placed in the lithotomy filled the pelvis and extended above the position ; the posterior vaginal wall is pelvic brim on the left side and pushed retracted by Simon's speculum, and the the uterus and vagina forward. Vagi. cervix drawn down with a double tenacnal section was made and from one to ulum forceps. The uterus is dilated,
the uterine cavity explored, curetted, after the operation. The drainage tubes irrigated, and packed with gauze if in should be left in place as long as the dicated. An incision about one inch discharge continues. This may be for long through the vaginal wall is made from three weeks to six months. When near the cervix, opposite the most prom the rubber tubing becomes offensive it inent point of the tumor. This will should be changed. usually be posterior to the cervix, but Indications for the operation.- 1. When may be lateral as in case of Miss S. L., the condition of the patient is such as and possibly anterior to the cervix. to make abdominal section extremely Any connective tissue between the va dangerous. ginal wall and the abscess is separated 2. When the abscess is large, of long with the finger, or it may be necessary standing, and situated low in the pelvis, to divide some of the fascia with blunt and when the patient gives a history of pointed scissors. Careful exploration peritonitis. is now made to determine whether the 3. When abdominal section reveals peritoneal cavity has been opened; if so, extensive and firm intestinal adhesions. it should be carefully walled off with 4. When the abscess is on the floor of gauze packing. The finger may now the pelvis and is complicated by rectal be passed directly into the abscess, or if fistulae. the wall is tough it may be opened by a 5. Vaginal section may be indicated blunt instrument, such as a grooved di for the separation of adhesions which rector or sound, and the opening en fix the ovaries and tubes on the floor of larged with the finger or forceps. All the pelvis, and for examination of the of the pus is removed by thorough irri ovaries and tubes. gation with sterilized water. Careful 6. Puerperal abscesses. These ab. bimanual examination to determine the scesses frequently do not involve the condition of the pelvic contents is now Fallopian tubes or ovaries, and satisfacmade with one or two fingers of the left tory results usually follow thorough haud in the abscess sac and the right drainage of them. hand over the abdomen. If additional Results. 1. Immediate.- I have done abscesses are found they may be punc- vaginal section for pelvic abscess ninetured through the abscess wall, may be teen times, and in every case with relaopened by another vaginal section, or tively satisfactory results. In two cases may be removed through an abdominal operations for secondary abscesses were incision. The mode of procedure must required ; in one case abdominal section be determined by the indications in was necessary to complete the operation. each case.
Excepting in the two cases which deTwo drainage tubes sutured together, veloped additional or secondary abone large and one small, are now in. scesses, the temperature has become serted into the abscess cavity. The practically normal within a short time large tube is perforated for a distance of after the operation.
after the operation. The patients have one or two inches, the end split, in suffered very little after the operation verted, and sewed so to form a in fact, pain has usually been absent. shoulder on each side which retains it The patients have almost invariably in place after the abscess wall has con been out of bed at the end of two weeks. tracted about it. The drainage tubes Aside from the accidents consequent are fastened to the cervix by a suture upon anesthesia the operation is devoid for retention until the abscess and va of danger. ginal walls contract about them.
2. Remote.- Many of the operations The after-treatment consists princi are of too recent date to permit a satispally in the use of peroxide of hydro- factory report of the ultimate success. gen, frequent irrigations, and antiseptic Some of the operations, however, date douches. Any gauze left between the back three years. None of the patients vaginal and abscess walls should be re have, to my knowledge, suffered especimoved twenty-four or forty-eight hours ally from pelvic disease after the opera
tion. Three of the patients have some aspiration, which has been the usual vaenlargement to the left of the uterus ginal operation for pelvic abscess. In which may later on require abdominal the latter operation the bladder, rectum section, and two of them have a sinus. or some other portion of the intestinal
Advantages of the operation.– 1. It is tract and large blood-vessels have been not dangerous to life.
punctured. I know of two cases in 2. It is followed by little or no suffer which large blood-vessels have been ining
jured with fatal results. These acci3. Recovery is rapid.
dents are avoidable in the operation 4. No raw surfaces are left in the ab which I have described. dominal cavity to cause adhesions.
Many authors advise, in cases in Objection to the operation.- 1. It is ap which doubt exists as to the choice beplicable in only a small per cent. of the tween abdominal section and vaginal cases of pelvic abscess.
puncture, that celiotomy be first per2. Diseased tissue is not removed. formed, and then, if indicated, that The tissues may, however, become mor puncture through the vagina be made. mal after the abscess is opened and In such a case I would advise vaginal drained, as has frequently been the case section, which could be immediately after spontaneous rupture or puncture followed by abdominal section, if necesof the abscess. The favorable results sary. Should the latter operation be which have followed simple incision and necessary the previous vaginal section drainage of abscesses in other parts of would not compromise the chances of the body may indicate that some cases recovery, but, on the contrary, would of pelvic abscess have been treated by afford a perfect avenue for drainge and too radical measures. The nature of would remove the pus which otherwise the abscess may be a guide in the selec would be liable to escape into the abtion of the method of treatment. For dominal cavity. example, tubercular or gonorrheal ab. For suspected disease low in the pelvis, scesses indicate excision more than ab- vaginal section permits of thorough and scesses due to some other infection. satisfactory exploration without subject
Remarks.— This operation should ing the patient to the dangers consequent take the place of vaginal pancture or upon abdominal section.
The Use of DIPHTHERIA Antitoxin month. In the latter part of October FOR IMMUNIZATION. Hermann M. systematic bacteriological examinations Biggs, M. D., of New York (British of the throats of the healthy children Medical Journal, August 31) said : Re- showed that diphtheria bacilli were presmarkable results have attended the use ent in so large a number that in order in New York of diphtheria antitoxin for to isolate these, nearly one-half the inimmunizing purposes. The conditions mates were quarantined. All efforts under which it has been employed have directed to checking the progress of the been peculiarly favorable for demon- epidemic were unattended with success strating its exact value. From May, up to the time that antitoxin was em1892, to February 18, 1894, no cases of ployed for immunization. By the use diphtheria occurred in the New York of antitoxin it has been possible to comInfant Asylum, which ordinarily has pletely stamp out diphtheria in four about 400 inmates. From February 18 great institutions for children in which to September 1, 1894, there were 22 it was prevailing in epidemic form. In cases of diphtheria and 15 deaths. In no instance have there been, so far as September there were 16 cases, and from can be determined, any serious results this time to February 10–108 days, from the administration of the remedy 107 cases of diphtheria occurred. These
for this purpose.
The duration of imwere very evenly distributed over this munity is apparently not more than 30 time, about 30 cases developing in each days in many cases.
A very interesting statement by Kocher is that he had several times no
ticed that tetany, which he is pleased MIRACULOUS HEALING.–But we must frankly confess, says the Lancet, that interesting, likewise, to hear that the
to call acute cachexia, developed. It is we have a strong conviction that the great majority of those " cures " belong developed, recovered through thyroid
patient in whom cachexia strumipriva to a wholly different class; that they feeding. are, in fact, identical with those neurotic cases with which hypnotism has
In speaking of the mortality in his made us so familiar. It will always be
operations, Kocher says that he deducts
thirty cases of malignant goiters in observed in reading the accounts of the
which unusual and peculiar difficulties phenomena alleged to occur at Lourdes,
militated against success.
Of the reKnock and elsewhere, that the cures
maining 870, eleven died; but in six occur precisely in the sort of patient and in forms of disease most likely to be af: only was death the direct result of the fected by forces identical with, or analo: operation, and of these, three were op
erated on for Graves' disease. The exgous to, hypnotism. Highly strung, enthusiastic and visionary girls figure tirpation of the goiter in the latter dislargely in these accounts, while the dis
ease he regards as dangerous. For the
latter he prefers to ligature the thyroid eases alleged to be most amenable to
arteries ; but never more than three of cure are such affections as catalepsy,
them. paralysis, blindness, etc., all of which
Referring to some researches that had occur frequently as functional affections
been made under his observation by liable at any moment to be dissipated
Lanz and Trachewski in the treatment by any cause that makes a strong im
of goiter by the injestion of thyroid expression on the nervous system. No doubt cures of such conditions as ad
tract, the author said that in the long vanced phthisis have been repeatedly plete atrophy of healthy parts of the
run this method may determine comalleged, but so far as we know, a careful investigation by competent persons
thyroid gland. He further remarked has always disproved the genuine cure
that all the symptoms of Graves' disof such cases. Often the marked tem
ease had been produced in healthy ani
mals by these experiments. He found porary improvement has been merely the result of an extreme exaltation of goiter improved greatly under treatment
also that the symptoms of exophthalmic the nervous system, to be quickly fol. lowed by the resumption of all the old
by phosphate of sodium. symptoms and the inevitable end.
CASTRATION FOR PROSTATIC HYPERREPORT OF 900 EXTIRPATIONS OF TROPHY.-Kummel (British Medical GOITER.-In commenting on his “ Re- Journal), in a lecture on the operative port of Extirpation of Goiter” ( Journal treatment of enlarged prostate, reports Nervous and Mental Diseases), Kocher eight cases of this affection in which he remarked during the past ten years in performed double castration. The operwhich he had performed the operation ation was followed by considerable relief on 900 patients, he had met but one case in these cases, but one patient, aged 77, in which cachexia strumipriva had de died from exhaustion after an interval veloped. This was entirely owing to of four weeks. In a review of his own the fact that he always left a part of the cases, and those published by other surthyroid gland, which was sufficient to geons, he states that in a large majority carry on the functions of that organ. of instances of senile enlargement of the In the single case in which the cachexia prostate, White's operation is certainly developed, the extirpation was unilat followed by a more or less rapid shrinkeral, but after the operation it was found ing of the prostatic tissue. This result that the other side was atrophied, of double castration in most cases en