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MISSISSIPPI

Continuation of the discussion of the paper of DR. L. H. DUNNING, of Indianapolis, Ind., on

TUBERCULAR PERITONITIS.

DR. R. S. SUTTON, or Pittsburg, had seen a good many cases of tubercular peritonitis, upon several of which he had operated successfully. Until within a year he had been in the habit of washing out the cavity with hot water, but now he pays no attention to it, but simply opens the abdomen and cleans out everything. He is con vinced that while hot water does no harm, it does no good in that it has no influence upon the disease. He believes in removing, so far as possible, all diseased organs.

DR. HENRY O. MARCY, of Boston, operated in 1887 for the first time on a case of tubercular peritonitis, the patient making an easy recovery. He had operated several times since then for this disease with excellent results.

DR. A. H. CORDIER, of Kansas City, Mo., called attention to the fact that Mr. Wells, as early as 1862, operated for tubercular peritonitis, simply incising the abdomen and draining, thus curing the cases. He thinks that drainage is the principle thing that brings about a cure in this disease, but how is not definitely settled. He said the theory had been advanced by Dr. Morris, of New York, that it is due to the admission of saprophytes into the peritoneal cavity.

DR. BAYARD HOLMES, of Chl cago, related an interesting case of adhesive peritonitis cured by operation.

The paper was further discussed by Dr. W. S. Caldwell, of Freeport, Ill.; Dr. Entriken, of Findlay, O., and Dr. B. M. Ricketts, of Cincinnati, O.

DR. DUNNING, in closing, said that Linder's observations were the most complete of any, and he found very little tendency to recurrence of the disease where it was primary and

of the adhesive form; but where the disease was secondary and of the adhesive form, there was a strong tendency to recurrence. His own experience had not been sufficiently extensive to funish reliable data in this regard.

HYSTERECTOMY FOR PUERPERAL SEPSIS.-WHEN SHALL IT BE PERFORMED? WITH A REPORT OF FOUR CASES.

The author of this contribution was DR. BAYARD HOLMES, of Chicago. The paper was divided into five parts. (1) a report of four cases of puerperal sepsis, treated by four different methods. (2) The pathology of puerperal sepsis in various stages. (3) Curettements in the hands of its advocates. (4) Puerperal sepsis as a cause of death in Chicago, New York, Brooklyn, and in the Charity Hospi tal at Berlin, with an abstract of 79 deaths from puerperal sepsis in 6,635

cases.

The first case was a multipara, 26 years of age, of Irish extraction, having a history of tuberculosis of the lungs, confined under unfavorable circumstances with retained placenta, post partum hemorrhage, delivery without an anesthetic with the hand of a physician, arrest of hemorrhage, gradual sepsis, failure of curettement, and death seven weeks after confinement.

The second case was a woman 30 years of age, normal confinement, with sepsis appearing upon the fourth day of a mild character, gradually increasing until six weeks after delivery. Temperature was high, pulse rapid, and symptoms of peritonitis with ob struction of the bowels. Laparotomy. Removal of the right broad ligament, tube and ovary; drainage through the vagina; death after eight days without peritonitis, from phlebitis, and pulmonary embolism.

The third case was in a multipara with gonorrhaeal history, an abortion followed by pelvic inflammation, pertonitis and obstruction three weeks af

ter delivery.

Removal of both tubes and abdominal drainage; death after ten days without peritonit's through phlebitis and pulmonary embolism.

The fourth case was a multipara, 32 years of age, delivered by midwife, with a bad history of puerperal infection, rapid onset of a mild infection, no curettement. Obstruction of the bowels, vomiting six weeks after delivery, with evidences of peritoneal effusion. Laparotomy: removal of the uterus and its adnexa, abdominal drainage and recovery. This uterus and these appendages were carefully examined microscopically. There was evidence of necrotic endometritis, suppurative endometritis, suppurative metritis, suppurative lymphangitis in both tubes with abscess of the ovarian ligament upon the right side and adjacent peritonitis. The blood vessels throughout the broad ligaments were found indicating a progressive infective thrombosis. The uterine tissue was filled with pus cells occupying the perivascular and lymph spaces with occasional obliteration of large bloodvessels. A great number of mastzellen were found throughout the infected tissues. The author held that the progress of puerperal infection was in this case through infective thrombosis and suppurative lymphangitis and that the removal of both tubes and drainage would have been ineffectual. He then proceeded to recount the pathological findings in cases of noninfected puerperal women dying from accidental causes during the first, third and sixth weeks after labor, and also cases dying at somewhat similar times after labor, stating the comparison of the normal and the abnormal uterine and periuterine tissues.

Fourth division. In the city of Chicago, during the years 1881 to 1894 inclusive there were 2,127 deaths from puerperal fever. In New York during six years ending May 31 1880, there were 250,000 deaths, of whom onesixth were females, and 2,236 of these deaths were due to the pregnant state. In Brooklyn, with 112,000 deaths during the same period, 53,000 were females, and of these 867 died of the puerperal state, 462 dying of puerpera' sepsis. These figures show the importance of the subject.

The question of treating puerperal infection by evidement or curetting,

was discussed by presenting the work of its own advocates, showing that out of 7,600 cases of labor in the hands of one of the advocates of curettement 101 were treated by repeated curettement and irrigation. Of these 96 recovered and five died.

An abstract of the history of these five cases was presented, showing that there was every reason to believe that after curettement had failed, hysterectomy would have proved efficient in saving the patients.

A series of 6,635 cases of confinement occuring in the Charity Hospital in Berlin, under the care of Hensoldt, Schwarze, Huenermann, and Hochselter during four successive years were then analyzed. Seventy-nine deaths from all cases occured. Of these deaths 33 resulted from puerperal sepsis, and in order to fully understand the possibility of these cases, a short epitome of the history of each was presented, showing that only three out of 633 cases were of such a character as to give rise to the suspicion that they might not have been saved by an hysterectomy.

The author gave the following conclusions: (1) Puerperal sepsis has its origin in the endometrium, and usually travels by the lymph channels or by the thrombosed blood vessels and the lymph channels together. (2) It still causes almost one-half of the deaths which occur in the puerperal state. (3) Curetting is ineffectual in many cases of puerperal sepsis. (4) The removal of an infected broad ligament and the drainage of the pelvic abscesses or peritonitis is often ineffectual. (5) Hysterectomy should be performed, therefore, in such cases of puerperal infection as do not yield to uterine curetting and irrigation. (6) Hysterectomy should be done whenever peritonitis is present in the course of puerperal fever. (7) Hysterectomy may not be helpful in the course of diphtheritic vaginitis and endometritus. (8) It should be performed in cases of puerperal mania, where there is a history of endometritus without uremia. (9) Hysterectomy may not be helpful in cases of rapid early infection. (10) It may not be useful in cases of Septic phlebitis reaching outside of the pelvis.

ATIVE PERITONITIS, WITH THE
REPORT OF A CASE.

This paper was read by DR. MILES F. PORTER, of Fort Wayne, Ind. The author first quoted Prandin, who says regarding general puerperal peritonitis: "The women die, no matter what the form of treatment employed." Dr. Baldy says: "To my knowledge, there has never been reported an undoubted case of general purulent peritonitis from any cause whatever, in which an abdominal section or any other line of treatment has succeeded in saving the patient's life." That the mortality of general septic peritonitis is large all will agree, but that it is always fatal is certainly not true. Dr Porter then reported the case, and closed by saying that the object in writing the paper was to assist in arousing a sentiment against the tooprevalent idea that in general septic peritonitis death is inevitable, and to encourage in these cases prompt operative interference.

DR. J. HENRY CARSTENS, of Detroit, followed with a paper entitled

THREE CASES OF HYSTERECTOMY FOLLOWING

TUBES.

CELIOTOMY FOR

The author summarized his remarks as follows:

(1) "It seems to me in the light of my present experience in cases of bilateral pus-tubes, that a more perfect and complete operation can be performed by abdominal section, with less danger of injury to the bladder and intestines, and with smaller mortality and better ultimate results

(2) "That in certain cases a better immediate result is obtainable by vaginal hysterectomy and drainage but these cases frequently require a second operation to remove the ovarian tissue and parts of the tube, which at first in many cases cannot be removed, before a perfect ultimate cure is established.

(3) "Where the sympathetic and other nerves are affected, the cause is not in the uterus, ovaries or tubes alone, but part in each. We are unable to state which organ is at the bottom of the trouble. Sometimes it may be only one, sometimes the other sometimes two or all three; hence, in such cases I would say.

555

(4) "In many cases with marked nervous symptoms, the best results are obtained only after the compete removal of every particle of the generative organs-that is, uterus, tubes, and ovaries be thus accomplished at one,two or three operations, per vagina or by abdominal section."

DR. R. S. SUTTON, of Pittsburg, favored abdominal section for pus tubes. He maintained first and foremost that a uterus deprived of its appendages is of no use. Second, that it is an organ, which, if left, is liable to tuberculosis, gonorrhea, syphilis, nasty discharges, adhesions, etc. When it is decided to remove the appendages, the uterus should be taken out.

DR. GILLIAM, of Columbus. O., argued against the removal of the uterus with the appendages in order to safe life, the objection being that the shortening of the vagina resulted.

DR. B. M. RICKETTS, of Cincinnati, believes total extirpation will be relegated. The dangers are cystocele, hernia, increased danger of prolonging the operation and shortening of the vagina.

DR. HENRY O. MARCY, of Boston, favored retaining the cervix when it is healthy, and pointed out the reasons why it should not be removed. It helped materially in acting as a support to the vault of the vagina.

DR. HOLMES, of Chicago, in discussing Dr. Cordier's paper, said that drainage was a sort of vicarious redemption for poor surgery. Whenever it is impossible to make a wound clean we must drain, and sometimes we drain when the wound is clean, but we are unable to arrest the hemorrhage. He could conceive of no other indication for drainage, whether in the abdomen, the brain, or any other part of the body, than failure to meet one great indication of wound treatment-to keep the wound clean.

explict are the directions how to use these agents for good, intelligently and correctly. This diversity of opinion among authors leaves the inexperienced beginner in a position of perplexity and doubt as to the special course he is to pursue in his early work. The same principles hold good in draining the peritoneal cavity that are applicable to other parts of the body. No surgeon, with all the antiseptic precautions possible to be used in opening a diffuse abscess of the thigh or other part of the body, would think of such a thing as at once closing a wound hermetically, leaving many broken down shreds of diseased tissues dangling in the abscess cavity. He might have irrigated the cavity thoroughly with a 1-1000 solution, yet he would not feel it safe to close the wound until after he had made counter-openings and introduced a drainage tube, this being as near ideal surgery as it is possible to obtain in these cases. Freshly boiled distilled or filtered water, cooled to 102 degrees, F., to 110 degrees F., should be used in irrigating.

The author drew the following deductions: (1) Drainage is a life-saving process when properly used. (2) To use it is not an admission on the part of the surgeon that his work during the operation is imperfect. (3) The use of the tube alone does not produce or leave any condition that favors the development of hernia. (4) The omen tum, or other structures do not become entangled in the openings in the tube. (5) A small-sized flint-glass tube, with small openings and open end should always be selected for pelvic drainage. (6) The tube should be used when in doubt as to the absence or presence of drainage indications. (8) To depend upon microscopic findings as to whether a given case should or should not to be drained is seemingly scientific, but is neither necessary nor practicable. (9) Gauze drains should be rarely used, and should always be supplemented by a glass drain. (10) There is no danger of infecting the patient through a tube if the attendant is properly instructed.

[TO BE CONTINUED.]

556

American Association of Obstetricians and Gynecologists.

This society convened in Chicago on Tuesday, Sept. 24, under the management of Dr. J. H. Carstens, of Detroit, president, and Dr. Wm. Warren Potter, of Buffalo, secretary.

OFFICERS FOR 1896. PRESIDENT-Joseph Price, Philadelphia, Penn.

FIRST VICE-PRESIDENT-A H Cordier, Kansas City, Mo.

SECOND VICE-PRESIDEN г-Geo. S. Peck, Youngstown, O.

SECRETARY-W. W. Potter, Buffalo,

N. Y.

TREASURER-X. O.Werder, Pittsburg,

Pa.

Place of meeting-Richmond, Va.
Time-Second Tuesday in September,

1896.

CHLOROFORM DURING SLEEP. The following case is of interest as bearing on the question whether a sleeping person can be chloroformed without awakening.

The reporter was asked to take two teeth out for a girl aged 7, and, going to her home he found her lying on her back in bed sound asleep. Having poured about two drachms, probably more, of chloroform cn a folded towel, he gradually brought it to about two or three inches of her mouth and held it there. She went on breathing quite quietly, and neither coughing nor making any unwonted movements. In a very short time she was so well under its influence that her hand fell down when raised, and the conjunctiva was insensible to touch.

She was then lifted out of bed, carried into another room and laid on a sofa, without her giving any sign of consciousness. On opening her mouth, however, she put up her hands and turned her head on the pillow. More chloroform was given, and almost immediately she was in a state of complete anesthesia and the teeth were extracted. She was easily aroused, but almost momentarily fell asleep again and slept for two hours. When she awoke she was much astonished to find that her teeth were out.-Therapeutic Gazette.