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my experience by seven vaginal hysterectomies in the last three months, of ill secondary results.
A few words as to my method. The cervix is grasped by a modified Nelaton's pedicle forceps, after thoroughly removing the necrosed tissues with the curette in malignant disease of the cervix, thus obtaining a firm grip upon the uterus and enabling all necessary manipulation, and the circular incision in its entirety is rapidly made with blunt curved-on-the-flat scissors; stripping of the tissues away from the uterus both anteriorly and posteriorly is done by means of the finger nail, or more preferably, in most instances, by means of a gauze sponge in sponge-holder until the peritoneum is reached, which is perforated anteriorly and posteriorly and the opening enlarged freely with the fingers.
A large hot sponge with string attached is then introduced to prevent injury to the intestines, following which a grasp of the broad ligament (I usually begin with the patient's left) is taken with the electric clamp, being careful to include, if possible, in one grasp of the instrument all of the ligament and attached tissues. This protector, which I made by dividing in half longitudinally a hard rubber cylindrical speculum and hinging the two halves on one side with a fenestrum or slot extending in on each side about two and a half inches from the end to be introduced to allow the protector to be pushed in above and below the ligament in the grasp of the clamp, and thus protecting all tissues not to be removed from the effect of the heat, is next put in place. The electrical connection is then made (I generally use a storage battery, but a “suitable primary battery or the current from electric mains," to quote Dr. Skene, may be used) the current to be continued for from two to three and a half minutes, dependent upon the power of the current, of which the operator is able to judge by the appearance of the tissues in the grasp of the hemostatic clamp and which can be distinctly seen, thanks to the protector.
My first two cases were slightly burned, one on the lateral wall of the vagina and the other on the left labium, though I had thoroughly, as I thought, protected the parts by sponges, the heat extending through. Since using the protector I have had no such unfortunate mishap. The burns in both instances, though slight, yet gave the patients practically the only distress they had. When from the appearance of the tissues or from the lapse of sufficient time the process of desiccation-actually baking—has been accomplished, the current is turned off and in incision with the scissors severs the tissues grasped by the clamp on the uterine side. The clamp is removed without the loss of a drop of blood, and re-applied on the same side if the first grasp did not include all of the tissues necessary, or the same process repeated on the other side.
In some instances I have found it better to remove but the uterus at first and the ovaries and fallopian tubes afterward, depending upon their condition. Frequently they can all be removed with one application upon each side.
After testing the bladder for possible injury and its repair, if such exists, the sponge protecting the intestines is removed, all oozing, if there be any, from vaginal or peritoneal incisions, controlled by hot compresses, and, using a sponge on holder, the intestines are pushed up and peritoneal first and vaginal incisions afterward accurately approximated. The vagina then, for from one to two inches from the introitus, is partially and gently packed with bichloride gauze for possible drainage and to be removed at the expiration of twenty-four hours. A vulvar pad is applied on T bandage and patient removed to bed. The usual treatment for vaginal hysterectomy follows.
The recoveries are uneventful. The operation, as far as I know, is new in that, without the use of ligatures or sutures, a security from possible secondary hemorrhage is guaranteed by means of the electrical hemostat.
There is no pain whatever from the desiccation of the tissues, and the absence of ligatures and sutures avoids the ill results so frequently following their use.
With your indulgence, I will show you the result of the work upon a patient who was operated upon three weeks ago to-day for complete procidentia with rectocele and cystocele of fifteen years' standing. Time of operation, thirty-six minutes. Her temperature has not been above the ninety-nines and in the ninety-nines but infrequently.
My object in presenting the patient this evening is to refute the criticism which I have been told has been made upon the method of placing no sutures in the vaginal incision—the critic claiming that good coaptation would not result. You will see that the contrary is the fact. There has been no discharge from the vagina and but two vaginal douches—one following the removal of the packing twentyfour hours after operation, and the other just prior to leaving the hospital to come here.
THE MANAGEMENT OF TYPHOID FEVER.*
BY WM. H. HODGE, M.D.,
Niagara Falls, N. Y.
HE vastly superior results obtained at the present time in the
treatment of typhoid fever over that of twenty years ago, is due in great measure to skilled trained nursing. There is no disease, perhaps, in which proper care counts for more and drugs for less than the one under consideration. I do not wish to be understood as advocating no medication in typhoid fever, for no one will deny that here homeopathy has won some of her grandest laurels, but I believe in the management of this disease, skilled nursing stands pre-eminent. The follies of old-school methods have no better example than in the so-called "Woodbridge treatment,” which is being very extensively used at the present time. By this method the physician is not called upon to select a remedy; he wastes no brain matter in determining what is best for his patient, he has only to determine that the disease under consideration is typhoid, and the pharmacist does the rest, after the principle of the "nickel in the slot" machine. Yet this is called scientific medical practice of the nine
In order to obtain the very best results in treating it, just as soon as a diagnosis is made, the patient should be placed in the largest and best ventilated room to be had, all superfluous furniture and drapery removed, and under the care of a competent nurse, absolute quiet maintained. No one except the attendant should be allowed to see the patient and every source of mental and physical wear should be reduced to the minimum, the body and mind having as near as possible perfect rest.
Diet. --Much has been written regarding the proper diet in typhoid fever, and it is a question of prime importance. From a considerable experience, I am convinced that a routine diet is not advisable. The proper diet should be selected in each individual case. Fresh acid fruit juices, such as orange, lemon, grape, etc., I believe are of considerable value, the latter especially, in the form of unfermented grape juice I have found to be the only food required in some cases. Milk when well borne.will be suitable in the greatest number of
* Read before the Homeopathic Medical Society of the State of New
cases, but in others it is not well digested, and appears in the evacuations undigested, even when it has been peptonized before feeding. Under these circumstances it should always be discontinued, substituting therefor liquid beef peptonoids, buttermilk, malted milk or similar preparation. I have been in the habit of discarding broths, such as chicken, mutton and beef teas; they contain very little nutriment and are ill adapted where a concentrated easily digested food is required. I believe that the prevailing tendency is to overfeed these cases. Food once in three hours is frequent enough and the quantity should be small at each feeding. Too much importance cannot be attached to the necessity of supplying the patient with plenty of cold water at frequent intervals. This is often neglected because the patient is unable to ask for it, or does not realize the necessity for it.
Baths.—Tepid sponge baths should always be used, their frequency depending upon the height of the temperature and the effect produced. Ordinarily I order them repeated every two or three hours. In severe cases with a high temperature it may
be necessary to repeat them every half hour. The abdominal ice coil is valuable in reducing the temperature and has the advantage of doing so without in any way disturbing the patient. If the temperature runs very high, it may be left on continuously. By these means, I have never seen the necessity of using ice-cold baths. I believe that the sponge baths with the ice coil will in nearly every instance keep the temperature within a safe limit.
Stimulants.—Stimulants are necessary I think in only a small proportion of cases, not more than ten per cent. Among the most valuable I have found, outside of alcoholic stimulants, is oxygen gas, and I consider it not only as a stimulant, but a curative agent of great value in this disease. I have used it in many cases and am inclined to resort to it much earlier in the course of the disease than formerly. Theoretically, it is an ideal agent where the blood current is loaded with poisonous material, and in practice it has given good results. With a failing circulation, alcohol should improve the quality and increase the rate of the pulse, and unless it has this effect, it should not be administered. Strychnia I have found very useful in some cases; it may be administered by the mouth or hypodermically, and repeated every two, three or four hours.
Complications. For the general treatment of this disease, nothing equals the indicated, homeopathic remedy, but complications will arise where palliatives and temporary expedients must be employed. In intestinal hemorrhage I have found nothing better than morphine by the rectum in the form of suppositories repeated frequently enough to produce the mechanical effect of keeping the bowels absolutely quiet, and it should be resorted to as quickly as possible. The objection has been raised that this is not good homeopathy, and that the indicated remedy, the similimum, will best control it, but iny experience has been that it is just as necessary to get the mechanical effects of morphine in this condition of the bowels as it is to ligate a bleeding vessel when it can be reached. In order to lessen blood pressure, the foot of the bed should be elevated, pillows removed from under the head, and the patient not permitted to move in any way. For the diarrhea, which is sometimes very troublesome, I have t!e best results from irrigation of the rectum with one of the following: Take of hydrogen peroxide, 2 ounces; water, i quart; mix. Or, take of borolyptol, 3 ounces; water, i quart; mix. These injections are repeated after each movement until their frequency is diminished. Ordinarily two or three injections will materially reduce the number of the evacuations, and will greatly promote the comfort of the patient. If the bowels are constipated they should be moved by the use of an enema of olive oil or glycerine and water every second day.
The principal remedies I have used in the order of their frequency have been bryonia, gelsemium, baptisia, rlius, arsenicum and phosphoric acid. I have also used echinacea in a number of cases and have been gratified with the results obtained. It seems indicated in putrid cases where baptisia is ordinarily employed and is prescribed in the tincture, 10 to 30 drops in a half glass of water, a teaspoonful every hour or two.
It is difficult to estimate accurately the average death rate under homeopathic treatment in private practice, but I believe that it does not exceed three per cent., while under the old school treatment it
is certainly very much greater.