anterior suspension, and not too low down. It is very easy to interfere with the capacity of the bladder by making suture too low. There is a proper tendency nowadays to avoid fixation to the peritoneum. I prefer the operation usually known as the modified Noble operation. I make a cross incision just within the hair line; reach into the canal secure the round ligament, bring it to the center and there suture it. This brings the uterus up. The round ligament does not stretch out after this operation and allow the uterus to drop back. I am in favor of the use of pessaries. I also believe that office treatment is very useful in these cases of subinvolution.

Dr. Park. I have seen very much of the work of the German operator, Amann. He makes an incision at the pubis, cuts through to the middle of the rectus, brings up the round ligament, and sutures it to the middle of the rectus. His results furnish the least number of bladder symptoms.

Dr. Brown (closing). I regard any position of the uterus as fairly normal when the uterus is fairly mobile. Tamponade is of little use except in recent cases. The postural treatment of retrodeviations is valuable.

CLINICAL SOCIETY OF THE NEW YORK
POLYCLINIC MEDICAL SCHOOL
AND HOSPITAL.

Stated Meeting, Held January 9, 1905.

(Continued from page 100.)

The paper of the evening was read by Dr. Joseph Y. Mangum, and was entitled:

THE ABDOMINAL VS. THE VAGINAL ROUTE IN GYNECOLOGICAL OPERATIONS.

He said, in part, that whether to approach a pelvic lesion by the abdominal or the pelvic route was a question often difficult to answer. It can only be answered correctly after a careful examination of the history, and especially of the physical conditions has given the surgeon a clear idea of the intra-pelvic conditions and of what he must accomplish to secure the greatest possible permanent benefit.

The choice of a route is never difficult in cases of recent extensive bilateral pelvic suppuration, pelvic abscess, puerperal sepsis, or in any collection of pus, blood or other fluid low down in the posterior cul-de-sac. Here the way through the vagina should usually be chosen, because by this route we can evacuate the septic material, drain and cure, with the least possible danger of infecting the general peritoneal cavity. You have by this route the advantages of a small wound, a

small raw area to absorb the septic material, · and a natural sewer to drain through, avoidance of exposure in handling the intestines, and consequently less immediate risk and shock.

The vaginal route is, for a large proportion of cases, impracticable, and especially for the man of limited experience. The long, narrow vagina, the small vagina, or small vagina from senile atrophy may render the field almost inaccessible. Enlarged uteri, with short, thick, broad ligaments and enlarged appendages, and with adhesions extending beyond the reach of the finger, may cause it to be impossible to complete the operation satisfactorily. Under these circumstances the abdominal route is much to be preferred and much safer.

The abdominal route is also preferable in abdominal cyst, cystic ovaries, fibroids, myoma, tubal pregnancies, general conservative work on the appendages, such as occluded tubes, adherent ovaries and tubes, hyprosalpinx, broad ligaments, cysts and displacements of the uterus. First, there is a larger field for operation, which is exposed, and the operator is not compelled to rely entirely upon the sense of touch. Diagnosis of unsuspected pelvic and abdominal lesions and complications is much easier, and pathologi. cal conditions are revealed that would pass entirely unnoticed if the operation had been The field performed by the vaginal route.

of operation is much cleaner as the surgeon does not operate through one sewer of the body and between two other sewers, and one that it is impossible to sterilize. The chances of adhesions are great, especially when gauze packings or instruments are left in the VAginal incision. Also, there is no danger of secondary infection, as in the vaginal route, and if the uterus, bladders or intestines are wounded, they can be repaired at once and satisfactorily. Also, the abdominal route presents more light for conservative work on the appendages, and there is almost always a sensitive scar after vaginal incision, and not after abdominal route.

Dr. C. H. Child, Jr., opened the discussion of Dr. Mangum's paper. He said that in his opinion no route was advisable for all cases, but he thought that the vaginal route should be used much oftener than it was by the average gynecologist, though not as often perhaps, as by the vaginal operator, and had a much greater field of usefulness than the writer of the paper allowed. The operator who drains a pus pocket through the posterior vaginal fornix is only following out the way pointed out by Nature. It is a very simple procedure, but celiotomy through the anterior vaginal fornix discloses the whole pelvic

field for treatment, and by this method of approach any abnormal pathological condition limited to the pelvis can be satisfactorily treated.

As to the writer's statement that sensitive scars persisted after the vaginal incision more frequently than after the abdominal, it has been the speaker's experience that the opposite was the case, there being a far greater nerve distribution in the site of incision in the abdominal wall than in that of the vagina. A tense sensitive condition of the utero-sacro ligaments frequently persists for some time after posterior incision for pus drainage, and very probably this condition is what the writer considered sensitive scar.

Dr. J. H. Burtenshaw said it was preposterous to lay down a hard and fast rule as to operations by the abdominal or vaginal route. To a certain extent each and every abnormal pelvic condition requiring surgical intervention is a case unto itself, and the character of the lesion and the depth of the pelvis the size of the vagina, the skill of the individual operator are all factors which must be duly considered. He deprecated the teaching that one method of attack should be followed to the exclusion of the other. While it is well known that vaginal section is far less productive of shock, in the majority of instances, it by no means follows that it should be adopted in all cases.

Dr. B. Torrens said that the lesions best treated by the vaginal route were those which lie below the brim of the pelvis, and which are the products of infection which have found their entrance through the vagina. In this list should be included not only puerperal infections and free pus in the pelvis, but also pyosalpinx, occluded and adherent tubes, cysts of every ovary and broad ligament, adherent and retroverted uteri, and also early ectopic gestations. The advantages of the vaginal route in the above classes of cases are that in entering the peritoneal cavity, but two anatomical layers are cut, which reunite without suturing, the lesions lie between your opening and the intestines, which are less liable to injury and infection, also, absence of hemostasis and ligatures; perfect drainage; shorter operation; less profound and shorter narcosis; no subsequent hernias; lower mortality.

Dr. B. H. Wells believed that in many instances the choice of route was a matter of in

dividual skill or preference. Personally, he found the abdominal incision, in operations for the relief of uterine displacement, conservative work on the uterus or appendages, extrauterine gestation, most cases where hysterectomy was required, and where long tumors had to be removed. With extensive

or recent pelvic suppuration, the vaginal method was the best.

Dr. C. C. Taylor said that over 50 per cent of gynecological operations were performed for pus. Now, Dr. Mangum said that with free pus in the pelvis and free fluid in the pelvis, he advised vaginal method; but cases of fibroids, tubal pregnancies, pyosalpinx, ovarian cysts, etc., should be done through the abdomen. The hospital records of St. Luke's, Woman's and Roosevelt Hospitals for the past five years show that the pus operations done through the abdomen show a fatality of 10 per cent The operations done by the late Dr. Pryor and Dr. Cleveland through the vagina show a mortality of less than 1 per cent. If patients operated on through the abdomen do get well, there will be either adhesions of the omentum and intestines or the risk of a hernia in many cases. If a tubal pregnancy, for instance, ruptures before the sixth week, it will be found in the pelvic cavity, and should be opened there.

Dr. Goffe said that he found the field of the vaginal operator being gradually extended. Dr. Noble, of Philadelphia, a few years ago, operated on all pus tubes through the abdomen, with a mortality of about 20 per cent, now attacks them through the vagina with a mortality of less than 1 per cent. Nothing was heard about sensitive vaginal scar until the opposition arose to the vaginal route for minor pelvic surgery. Hysterectomies had been done for years and no objection made to the operation on account of sensitive scar, and the scar from that operation is much more extensive than when that arising from an anterior or posterior vaginal section for dealing with the appendages. As a matter of fact, the speaker had never met with a sensitive scar in any of his cases after vaginal section, and had probably examined as many as anyone.

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CORRESPONDENCE

A PLEA FOR HIGH GRADE SIMPLE
PREPARATIONS.

We are pleased to be able to print in this number of the Medical Fortnightly, a communication from Dr. Frederick M. Trask to the Searle & Hereth Co., the well and favorably known Chicago pharmaceutical house. Dr. Trask is an old time teacher of materia medica in one of the oldest of the Chicago medical colleges, and while resting from his teaching labors, is nevertheless, as would appear, still alive to the interest of high class materia medica. The doctor's views are our own in the matter of pleading for a change of front on the part of the leading manufacturing pharmacists, urging them to give the profession special preparations that are special because of special care in manufacture, and by all means special as being simple.

CHICAGO, February 3, 1905. THE SEARLE & HERETH Co, City.

Gentlemen:-I have long been impressed with the thought that many of the countless preparations put out by the pharmaceutical houses of the present day are really needless. Of course manufacturers, and yourselves among the number, will reason that you are but meeting a demand, that the medical profession demands preparations that are compounds. Laxatives with a dozen ingredients; cough medicines with a shot for every possi

ble germ that ever caused a cough or might could, would or should ever think of causing a cough; genito- urinary, remedies that will, because of the many ingredients, be absolutely sure to do everthying required, from numbing the backache to chasing the gay and sportive gonococcus to his lair, wherever that may be in every possible variety of case and straight way throttling that breeder of such varied disturbances in the human economy. Of course if we must have the ready-made compounds, all well and good-we are glad there are houses such as your own, that will make them for us and tell us truthfully of what these compounds consist; but I write this today as a plea for some simpler medication, to stir you up to an endeavor to win back the profession to the freer use of simples. Our fathers, perhaps our grandfathers we should say, in medicine used the simples and were successful; our mothers, the old wives, used the simple herb teas and were successful, as we know, when doctors were as few as they are now numerous. Now in this age of skill in pharmacy we can have our herb teas, our infusion, or better our extracts and tinctures, made so that while as good as in the old days in curative effects, they are infinitely more palatable and more pleasant in every way.

If this is so, why not have them? Because of pure, unadulterated laziness on the part of our profession. We don't want to take aim. We want to load our gun with grape or shrapnel, shut our eyes and fire. We'll bring something down-perhaps the patient-but we've done something, we've given medicine and we've eased the patient's pocketbook.

Now why do not drug manufacturers put some time and money into a careful study of the simples our forefathers used, find out what things were certainly good, put them up in forms as palatable as possible and advertise them to the profession as simples? This would be an innovation Searle & Hereth

might well inaugurate. Do as you can do, collect the roots and leaves when they should be collected, prepare the infusion or extract as it should be done so that we can depend on getting the best that can be got and then give them to us without combining them with other things. At least do this with some part of your products for those of us who want simple preparations at most times and want to do our own compounding when it is compounds we want. You have already done with at least two drugs what I am suggesting you do with many. Your Tr. F. F. Digitalis is probably the best made. You have procured the best leaves, washed them free from nauseating principles, made your tincture and given it to us as a simple. I am pleased to

know you are putting on the market washed leaves of the German digitalis for the making of an infusion that will not nauseate. "Bully for you," as our newly inaugurated president would say. This is what we want. My record book gives a long and interesting testimony to the efficacy of this "simple," such testimony must be appreciated by the manufacturer, it is a great satisfaction to the practitioner.

Your tritica is another illustration of the point I am making. It is of course, nothing but an excellent, skillfully made extract of couch grass. You have done as ought to be done in every case; you have obtained the crude drug, not by picking it up haphazard, but by going where it is found to be the richest in triticin. You have carefully selected the drug even from the selected stock and by a process evidently eminently suited to the requirements, have given us a remedy for inflammation of the urinary tract better than all the compounds, pills, tablets, capsules hard and capsules soft or nauseous liquid mixtures ever devised; more useful too than the many high priced synthetic chemicals that are in such common use. Do not think I am sample grafting when I say this. am simply making a point. In tritica, this special extract of triticum repens, you have given us a remedy that does simply splendid work, that has to my knowledge relieved complete urinary retention due to acute cystitis complicating acute prostatitis, and given the relief in a few hours; that has saved from catheter life numberless cases of chronic senile prostatic hypertrophy, that acts apparently almost as a specific in gonorrheal cystitis, relieving pain, tenesmus, being used by many men of my acquaintance as their only internal remedy in these cases in all stages of the disease.

I

Now in the case of tritica, you have wisely left it alone. You have suggested useful combinations, it is true, but have left compounding to be done by the physician. This, I claim, is what should be done with many useful drugs.

Now I am through. If I have made you think, I have done as much as I set out to do, as I have found that when the S. & H. people think and think hard, "there is something doing" sure. I would like to give you a list of drugs which might advantage. ously be handled as I have suggested. If you are doing with others as with tr. F.F. digitalis and tritica, I wish you to send me literature. Very cordially,

FRED'K M. TRASK.

SUBSCRIBE for The Medical Fortnightly.

CLINICAL THERAPEUTICS

A forum of original experience, to which scientific contributions are invited. Responsibility for views promulgated limited to author.

MEDICATION CONFINED TO ABSORPTION IN THE DUODENUM.

FREDERIC S. MASON, M. P. S.

The problem of administering certain drugs per the duodenum without interfering with the stomach or large intestines is often of great importance. For instance, when it is desired to correct Pawloff's reflex, (i.e., the process by which the acid chyme stimulates pancreatic and intestinal secretions) the requisite amount of alkali or acid as the case may be, must be introduced into the duodenum in order to reduce or increase the acidity of the chyme.

The corrective medication should not be absorbed or altered before reaching the small intestines and the point where its reflex action is required, and it should not, during its passage, affect gastric digestion.

There are besides the alkaline and acid medicaments, a number of drugs which cannot pass through the stomach without disturbing its functions. turbing its functions. Among these we have the salicylates, opium, antipyrine, digitalis, etc. It is for this reason very desirable to find means for the administration of therapeutic agents, otherwise than per os. rectal method by suppositories and by enema, as well as the hypodermic method and absorption by inunction through the skin are good, but cannot always be utilized.

The

A number of devices may be contrived by the intelligent prescriber for introducing into the duodenum, such medicaments as interfere with gastric functions. This can be done by combining the drug to be administered, with an insoluble substance or one which is but little disintegrated in the stomach by mechanical friction, yet which is immediately affected by contact with the intestinal juices. A good example of this method is found in the phenolic ethers. These are but slowly attacked by the saliva are unaffected by the gastric juices but are rapidly decomposed by intestinal secretions, in which way powerful antiseptics can be introduced into the intestine, without affecting the stomach. Amongst the drugs that are decomposed only by the intestinal secretions, are salipyrin, salol, benzonaphthol, etc. Another method is to mechanically cover the drug to be administered in the duodenum, with a coating which will not be affected by the gastric juices. Keratin has been used in this way, to coat pills and compressed tablets, and

capsules coated with wax, paraffin and some resins serve the same purpose, but none of these methods can be considered absolutely reliable.

All fatty substances pass through the stomach without being notably altered, so that a convenient and very desirable method of administering drugs intended for the intestine, is to dissolve them in some oil and then to administer this in keratin-coated capsules. Their progress through the stomach and disintegration (on their arrival) in the intestinal tract, can easily be demonstrated by the radioscope, and an examination of the excreta shows that the absorption has taken place entirely in the intestine. This is one

of the best methods.

In anti-syphilitic treatment, mercury can be given in this way, thus avoiding the disadvantages of the proto-iodide pills and ensuring certainty of absorption.

A solution of mercuric iodide in sweet almond oil is much prescribed in France under the name of cypridol (a 1 per cent solution dispensed in 20 centigramme capsules). These usually pass through the pylorus into the duodenum undissolved, but even if the liquid contents of the capsules escape in the stomach, they do not adversely affect the gastric digestion. In the intestines, the oil is emulsified by the pancreatic juice and the bile, and the mercury easily absorbed without producing any irritation. Strange to say, there is no salivation when the dose is pushed and continued regularly for a year or more, even in doses equivalent to one-half grain of the biniodide daily. This may be explained by the fact that as no opium need be given with the mercury, the functions of the lymphatics are not impeded. It is well to recall in this connection, Robin's theory of the more powerful action of nascent remedies. All mercurials are reduced to the metallic state before producing their anti-syphilitic effects. For instance, the solution of mercuric iodide in oil, is first slowly emulsified, reduced to infinitesimal particles of mercuric oxide by the intestinal alkalinity, and as such, taken up by the villi and further reduced to metallic mercury in the blood current. Here it seems to produce that specific action, which is yet unexplained, but which is probably connected with the stimulation of the phagocytes, the activity of which is so important for syphilitics. In this class of patients, the already congested lymphatic system is overburdened by the breaking down of giant cells and the accumulation of debris, morbid tissue and toxines. Lecithine is another product which is conveniently administered in oily solution. This product of organo-therapy, heralded as the ideal phos

phatic medication, has not yet fully justified the claims made for it by excellent authorities. This we believe is due to two causes. Impurity of the commerical product, and the rapid decomposition of lecithine when exposed to the air. Vial's process for obtaining pure lecithine does away with the first difficulty and its administration in capsules of one grain dissolved in oil, preserves it indefinitely, and ensures its absorption in the duodenum in great purity and without previous taint of decomposition.

The fallacy of giving lecithine in emulsion or as pills is evident, if one reflects that if taken up in the stomach, it is elaborated like any other food product and therefore can either produce appreciable results in neurasthenic cases and degenerative changes or relieve the epuisement of patients suffering from such chronic diseases as cancer, phthisis, diabetes, etc.

These examples will suggest others where remedial agents, introduced unaltered into the small intestines will produce effects which are not obtainable when the drug has previously been modified by the gastric secretions.

THE USE AND ABUSE OF CURETTAGE OF THE UTERUS.-E. K. Browd says that the apparent simplicity and security of the operation has led to the frequent performance of curettage of the uterus in cases in which the procedure is not only of no service, but may even be directly contraindicated. It is use ful in cases of endometritis not associated with pelvic inflammations, exudates, or diseased adnexa, in subinvolution of the uterus or retained secundines, in endocervicitis as a prophylactic against carcinoma, in mole pregnancies and in all cases of endometritis of socalled hyperplastic nature. In postparum infections there is room for much judgment, for while saprophytic cases with retained membranes, etc., are benefited by curettage, the measure is distinctly contraindicated if the infection is of the septic type. Curettage should not be regarded as a routine treatment for sterility, for it may aggravate existing pathological conditions, while the danger of perforation is very great in vuretting for syphilitic, tuberculous, sarcomatous or cancerous degeneration of the endometrium. It should never be performed without an anesthetic, owing to the danger of perforation due to sudden movements of the patient, or in dirty surroundings that cannot be rendered aseptic. A number of cases are cited in which disregard of these rules was followed by serious consequences.-Medical Record.