manner. Only the major operation in any given case has been mentioned in the series, although all pathological conditions were attended to as encountered during the course of the operation. There were 29 laparotomies. The appendix was removed in 27 cases. In 12 gynecological laparotomies the appendix was removed 11 times, the uterus curetted 6 times. and the cervix or perineum, or both, were repaired 8 times. The following operations were performed, in all of which it was necessary to administer an additional general anesthetic. Chloroform was used in each instance: Abscess, pelvic... Amputation, upper humerus Finger.. Curettage, uterus. Herniotomy, gastro-epiploic... 1 Operations performed in which one tablet was given and no additional anesthetic was administered: Cystic calculi, female, removal.. 1 Exploratory incision Curettage, uterus Curettage, bladder.. 3 Circumcision... 1 Perineorrhaphy. 222 11 Antidolorin was applied to the line of skin incision in the two exploratory laparotomies. In cases operated upon without chloroform, there was not a single instance where there was complete absence from pain. Total time of operations, 2805 minutes. An average per patient of almost forty-five minutes. Total amount of chloroform given, 3775 minims. An average of a little over fifty minims per patient. The greatest amount of chloroform used was 480 minims. The smallest amount used was five minims. Not in any patient was it necessary to give more than a very few drops to induce complete relaxation, and in no instance did the time occupy over five minutes. The average pulse rate for the entire series, just before giving the tablet, was 78. Highest pulse 128, lowest, 56. Average plus rate after patient was placed on the table, 84. An average increase of the pulse rate of six. Highest pulse rate 102, lowest, 58. Average pulse rate during the operation and when operation was about half completed, 78. A fluctuation of six. Highest pulse 110, lowest 66. Average pulse rate one hour after the operation, 80. Average respiration prior to the administration of the tablet, 21. Highest 32, lowest 15. Average after being placed on the table, 20. Highest 28, lowest 10. Average during operation, 17 plus. Highest 24, lowest 6. One hour after operation, average 16. Highest 26, lowest 4. It will be noted that the pulse fluctuated but very little during the entire period. The respiration showed a slight decrease in the number per minute. As regards anesthesia before administration of chloroform: Number of patients brought to the table partially asleep, 55; wholly asleep, 5; fully awake, 15; complete mental repose, 74; mild excitation, 1. Vomiting previous to operation, none; during operation, none; after operation, four. Awake on table after operation, 5; partially asleep, 12; wholly asleep, 5; complaining of pain, 6; stertorous respiration, 14; able to awaken easily, 66; able to awaken by loud talking or shaking, 7; unable to awaken, 2; favorable post-operative symptoms, 73; unfavorable symptoms, 2. CONCLUSIONS. 1. Morphine-hyoscine-cactin compound in the amount noted, is not an ideal, safe or rational general anesthetic, as the amount necessary to produce surgical anesthesia is dangerous. 2. Only a small per cent of minor operations can be performed by using one tablet. 3. An additional anesthetic or very strong hypnotic suggestion is required in all major surgery. 4. One tablet administered forty-five minutes before the hour set for operation, quiets the patient, relieves mental anxiety and places the patient in the best possible condition for anesthesia. 5. Thus given, the amount of chloroform required for complete anesthesia is reduced to little more than a few drops, and in a few instances no other anesthetic may be required. 6. Time occupied in producing anesthesia is lessened. 7. The pulse shows little variation throughout. 8. The respirations are slightly lowered. 9. There is no struggling or vomiting while patient is going under. 10. Post-operative conditions are much improved, the patient remains quiet, sleeps nicely, does not vomit (except in a very small per cent of cases), and no post-operative pain is felt. 11. The tablet is much more desirable than morphine alone. 12. The inhibitory effect of morphine upon intestinal peristalsis is greatly lessened by reason of the addition of hyoscine. 13. A reduction of the hyoscine to gr. 1.150, would, I belivee, produce equally good results. 14. The removal of the cactin and substituting therefor strychnine would, I believe, make a more desirable combination. 15. A tablet composed of morphine gr. 1.4, hyoscine gr. 1-150 and strychnine gr. 1-45 is recommended. 16. Two tablets should never be administered. It is noted that an additional anesthetic was given in the majority of operations reported by various surgeons who have used this compound in the two doses, hence there is no valid reason for giving it as an ideal general anesthetic, or lauding it as such, if another assistant is necessary. Rather should we recommend it as a valuable aid in anesthesia, within the limits of safety. ANTERIOR SUSPENSION OF THE UTERUS. F. B. Dorsey, M. D., Keokuk, Ia. Chief Surgeon Graham Hospital. HE unfavorable results following the old ventro-fixation operation, and also the ventro-suspension of the uterus when the attachment was made to the upper or so-called posterior-fundal region of the uterus, the continued pain in some, due to the fixation or suspension, and the untoward effects on the development of the uterus during gestation and the complications during labor, caused me to abandon them for what I have found to be, in my opinion, a more satisfactory operation. In this connection, we should have in mind that the long diameter of the uterus, in its normal position, is at about right angles with the perpendicular of the body when the woman is on her feet. If a line be drawn from the apex of the pubic arch to the tip of the coccyx, it will be noted that the former is about ten degrees below the latter, and the lower or socalled anterior surface of the uterus, from cervix to fundus, when the uterus is in its normal position, is about one inch or over above a hori. zontal line drawn across the pelvis anteriorly from the tip of the coccyx. Approximately speaking, the lower or so-called anterior surface of the uterus is. above the crest of the symphysis. In suspending the uterus, we desire to place the organ in as nearly a normal position as possible,. The plan I devised and have followed for the past fourteen years for securing approximately this position, is this: Immediately before operating, the woman is catheterized, the field of operation rendered surgically clean, and the uterus curetted when necessary. An incision two and onehalf inches in length is made to within three-fourth of an inch of the symphysis, opening the peritoneum the full length of the external wound. As soon as the relation and condition of all organs are determined, the patient's hips are elevated so that the intestines may fall out of the way. A large pad of gauze is introduced to protect them and keep clean the field of operation. After freeing all adhesions with two fingers of the left hand, as can usually by done, the uterus is brought forward to its normal position. If necessary, diseased tube or ovary is removed. In cases where it is necessary to remove both ovaries or both tubes, I do not suspend the uterus, but remove it. In a few cases I have had difficulty in dislodging the uterus from its imbedded position, but by careful manipulation this can, in most cases, be accomplished without injury. The suspension of the uterus to the abdominal wall is secured by introducing a through-and-through silk-worm gut suture, half an inch to one side and below the lower angle of the wound and bring it out at a corresponding point at the opposite side, passing it through the peritoneal covering of the uterus, at or a little above the junction of fundus and body on the lower or so-called anterior surface of the organ. The suture is passed beneath the peritoneal surface of the uterus, for a distance of one-half to three-fourths of an inch, being careful to avoid including any muscular tissues. Another through-and-through suture of silk-worm gut is then introduced just above and in like manner to the first. These two are held fast by catch forceps, the gauze is removed, the omentum drawn down and tucked behind the uterus, if long enough. The patient's hips are lowered and the wound is closed with catgut. The sutures through the uterus are then drawn upon until the organ is brought closely in contact with the peritoneal surface of the abdominal wall, a small gauze pad is placed between the sutures and they are then tied. Care should be taken to avoid strangulation of tissue in tying. The usual dressings are then applied. Dressings and sutures are removed on the tenth to the twelfth day, and fresh dressings applied. The patient should keep her bed twenty-one days. In fourteen years that I have been doing this operation, I have not observed nor had reported to me, recurrence of the displacement except in my early cases, and in these where there was recurrence, I had failed to properly repair injuries to the pelvic floor. I consider it paramount to the success of an operation of this character where the patient has had laceration of the pelvic floor, that it should be properly repaired. In some cases where the prolapsus has been of long standing, and the tissues have become greatly stretched, the utero-sacral ligaments almost obliterated or atrophied, as to be useless, the center of Douglas' pouch can be caught up with forceps and either denuded or a transverse section removed and stitched antero-posteriorly, thus lifting upward and backward the cervical portion of the uterus. When the utero-sacral ligaments are not extensively impaired, it is proper to shorten them instead. Following this plan of restoration, the irritability of the bladder so often complained of, is no more frequent than in cases operated on for other conditions. Pain in the hypogastrium is not experienced except for the first few days following operation, and then only where the uterus is large, the dragging of the uterus causes some discomfort. There are no buried sutures to give subsequent trouble. Difficulties during pregnancy and labor are usually wanting. Abortions are infrequent. The proper expansion and development of the uterus during pregnancy are less interfered with than in other methods of suspending the uterus or following intra-abdominal operations for the correction of retro-displacements either accompanied or not by prolapsus. Protracted and powerless labors are not experienced. The uterus is held in approximately its proper position. I have to report nineteen pregnancies subsequent to anterior suspension of the uterus by this method. In two instances occasion was afforded me to open the abdomen in two years after the first operation, and in one instance, three years after-all due to neglect to remove the appendix at the time of the first operation. In cases of pregnancies, there were two instrumental deliveries, necessitated by disproportion between the maternal pelvis and fetal head. Three abortions occurred, the causes I was unable to learn. No deaths. In anterior suspension of the uterus by this method, is produced what we might term a temporary drawing forward of the uterus, and no possible importance can attach to this or the restricted mobility as long as it does not interfere with conception, gestation, and the normal process of labor, and especially when it gives to the woman, freedom from her former distress and discomfort. In my experience, no disturbance, except as noted, occurred and my patients have expressed their gratitude for the relief afforded them. If extensive adhesions were produced, such results would not obtain. A Contributed Article TRACHOMA.* W. H. Minton, M. D., St. Joseph, Mo. S the above subject is familiar to every physician, whether he be general practitioner, or one doing special work; and as it is almost impossible to add anything new in the way of diagnosis and treatment, it would seem that the chapter on trachoma was closed. However, if we examine the statistics on total blindness, and find granular ophthalmia, either directly or through its many complications, responsible for at least 6 per cent of these cases, and constituting from 40 to 50 per cent of eye disease in this middle west, does it not behoove us as men of progressive medicine to acquaint ourselves more thoroughly with this disease, which is one of the chief factors in filling our blind and charitable institutions? While trachoma, generally speaking, is a self-limited disease, much can be accomplished in the way of mitigating the suffering, shortening its duration, and preventing the many complications which are liable to occur in the course of the disease. The etiology of trachoma is probably due to a micro-organism, although culture and inoculation experiments are much at variance. Satler, von Michel, and other noted ophthalmologists, have each separated an organism, which he believes is responsible for the disease; however, the greater number seem to hold the trachomacoccus as the specific germ, and the one most capable of standing the crucial tests of culture and inocula tion. The infection is undoubtedly transferred through the secretions of a trachomatous eye, by means of wash basins, towels, handkerchiefs, etc., and it is especially in the earlier stages that proper hygienic measures should be instituted. Trachoma is more prevalent in the eastern countries, particularly among the lower classes of Jews, Egyptians, Irish and Italians; and in this country, these races are the greater sufferers; however it does not seem to be limited to the lower classes in this, as in eastern countries. The disease flourishes best in our larger cities, where the population is housed and living under improper sanitation, although any cause whatsoever that will bring about a conjunctivitis, whether due to eye strain, lachrymal obstruction, or external irritations, such as wind and dust, will favor the contagiousness of the disease, and in this central west, we find the farming class particularly affected. Climate seems to play a very minor part upon the origin and spread of trachoma, although it is more prevalent in low and damp countries; and high altitudes practically guarantee immunity. The symptoms of trachoma are most conveniently considered in conjunction with its pathology, as we can clinically divide the disease into three stages: 1st. Lymphoid infiltration. 2d. Granular formation. 3d. Scarring or cicatrization. Read before Sixth District Medical Association at Bethany, Mo. |
