THE IMPORTANCE OF AN EARLY DIAGNOSIS AND IMMEDIATE OPERATION IN ECTOPIC PREGNANCY.

BY J. CAMERON ANDERSON, M. D.,

Professor of Surgery in New York School of Clinical Medicine; Attending Surgeon to West Side Dispensary; Associate Attending Surgeon to St. Francis Hospital, New York City.

[Written for the MEDICAL BRIEF.]

The purpose of this article is to call the attention of the medical practitioner to the importance of making an early diagnosis in cases of ectopic gestation. This pathological condition is greatly on the increase in our large cities, due, to a certain extent, to the frequency of malpractice in cases of abortion, midwifery, and various venereal diseases resulting in a distortion of the fallopian tubes sufficient to prevent the impregnated ovum from reaching the uterine cavity.

The symptoms here enumerated cover all those of practical value in this condition, and embody a careful study of the subject, including the writings of Kelly, Greig Smith, Park, Warren-Gould, and others.

DISTURBANCE OF MENSTRUATION.

Menstruation is nearly always delayed. The quantity of the flow varies in each case. The bloody discharge usually indicates the shedding of the decidua, and there is invariably a history of sterility.

Presence of a tumor.-A mass is usually felt laterally of doughy consistence, and accompanied by neither the acute pain nor temperature of an inflammatory condition. This mass disappears on rupture of the preg

nancy.

SYMPTOMS OF PREGNANCY.

With the foregoing there are the usual symptoms of pregnancy: nausea, changes in the breasts, softening of cervix and discoloration of the vaginal mucosa.

ENLARGEMENT OF THE UTERUS.

The uterus is found enlarged and softened. An examination with a sound is warrantable on history of hemorrhage, and the emptiness of the uterus confirms and establishes the diagnosis.

RUPTURE.

Rupture usually occurs in the latter part of the third month, but may occur as early as the sixth week. Women who have been treated for various uterine and tubal diseases are the patients who require great care in examination, as it is in this class of cases that the condition most frequently

occurs.

TREATMENT.

Vaginal section, with its usual infection upward of a sterile field, morphine injections, electric currents, and other methods a short time ago in

vogue, are only mentioned to be condemned as dangerous and useless. Vaginal section may be used in septic cases, and then only in conjunction with abdominal section. All of these cases should be treated by immediate laparotomy, except when moribund.

The supplying blood vessels should be directly ligated before any attention is paid to mass or clots. If the tube has ruptured, this ligation will at once stay the hemorrhage. Hot saline irrigation from a pitcher should be profusely resorted to after testing on the bare arm of the operator, to ascertain whether it is too hot; flushing out all the clots that will be found in the lumbar depressions and up under liver and diaphragm should be practiced.

In some cases it may be necessary to give a direct infusion of saline solution into the veins during the operation. Should the case be a septic one, drainage by a tube running from the abdominal wound out through the vagina should be employed. In infected cases drainage should not be used, as it will cause infection through the gauze, or tube, by capillarity, and predispose to ventral hernia and formation of adhesions, which may distress the patient the rest of her life.

This is the one operation that should be done immediately, and especially if rupture has occurred. The operator must work with speed, and thus conserve the strength of the patient and the vitality of the peritoneum, upon which we depend for absorption and rapid recovery.

A tight binder, covering a firm dressing, will aid materially in equalizing the abdominal blood pressure, and hasten convalescence. The results following the treatment herein suggested are very gratifying. 53 East 51st St.

PHLEBITIS FOLLOWING APPENDECTOMY.

BY EDWARD Wallace Lee, M. D.,

Formerly Professor of Surgery in Creighton Medical College, Omaha, Neb.

[Written for the MEDICAL BRIEF.]

One of the complications following appendectomy, regardless of the conditions demanding the operation, is phlebitis. This condition-a swelling of the right leg-has been observed by me a number of times following operation for appendicitis in my own practice, and in the practice of other well-known surgeons.

It is not the province of this paper to delve into the etiology of this condition, but simply to call attention to the fact that this complication prevents the immediate recovery of many cases which otherwise could be considered cured. In the "interval" operation of appendectomy the idea is to prevent recurrent attacks, and to place the individual beyond the possibility of appendicitis. So many of these cases have come under my observation that I feel justified in giving expression regarding the cause of this complication as a sequel of appendectomy.

I believe the best way to impress the "occasional" surgeon is to call attention to the complications that arise in the practice of the surgeon who operates every day. I do not wish to criticise the "occasional" surgeon; he is a man who should be prepared to meet any emergency, but it is in the practice of the "occasional" operator that I have met most. cases of post-operative phlebitis. The operation in these cases was usually perfectly satisfactory, but the complication was permanent in the majority of them. The "occasional" surgeon does not operate in cases of appendicitis when the true indications present themselves; he waits until his patient is in a more receptive condition. He then undertakes what he calls the "interval" operation. He makes his incision according to his anatomical knowledge, and, I am sorry to say, regardless of the technique laid down by those men who have studied and made a perfect "interval” operation. The outside operator may have certain ideas regarding his procedure, but the moment he has transversed the integument, he seems to forget everything but the location of the appendix. His one object is to reach this organ quickly. Is there a bleeding vessel? Is there oozing? Is there hemorrrhage from some uncertain point? Yes, there is! He has within his hands the means of controlling the hemorrhage, and he resorts to the measure in a physical way, regardless of anatomical, pathological or physiological conditions.

The fact that he has controlled this hemorrhage in his energetic manner, is often the cause of phlebitis. He crushes arterioles, small arteries. and large arteries. His one object is to stop immediate hemorrhage. His object primarily having been accomplished, he is in perfect ignorance of the after effects.

Ordinarily the operation of appendectomy in the hands of a man who knows pathological anatomy, is a simple operation, but the man who undertakes an "interval" operation, without sufficient knowledge of the existing conditions, is likely to have his patient present themselves a few weeks later suffering from phlebitis.

The ordinary surgeon, or practitioner, is more justified in operating on a case of appendicitis where he can positively diagnose abscess with the accompanying septicæmia than on the so-called "interval" case. In the former, every surgical procedure is indicated by the physical signs as they present themselves. In the latter, there are many fine and delicate manipulations of surgery which only the expert should attempt.

Phlebitis is a complication which follows appendectomy more often than has been recorded. This knowledge I have gained from the examinations of patients that had been reported as absolutely recovered from the operation, but who afterwards found it necessary to consult a surgeon in reference to the swelling of the right leg. The first evidence of this condition has been described as an "inconvenience" in walking, then "heaviness of the foot;" later, swelling of the foot, the ankle; finally swell

ing of the leg and thigh, and great difficulty in locomotion. On examination we find, in addition to the swelling, great tenderness along the veins; sometimes along the saphenous vein; sometimes along the femoral, all indicating that a septic process has interfered with the functions of these vessels.

I have observed this complication at periods ranging from six months to a year and a half following operation.

TREATMENT.

So far as the treatment is concerned, I advise absolute rest in bed, with elevation of the affected limb; proper massage, bandaging, and mechanical supports to prevent further complications which would necessarily follow if the diagnosis had not been properly made.

616 Madison Ave.

PRINCIPLES OF PRACTICE IN THE TREATMENT OF
GENITO-URINARY DISEASES.

BY T. W. WILLIAMS, M. D., Milwaukee, Wis.

[Written for the MEDICAL BRIEF.]

Chronic nervous, organic and functional affections of the genito-urinary system of man arise from various causes, but are all traceable to wrong modes of life and bad habits. Habitual over-excitation of the functions of the pelvic organs is responsible for those indiscretions and excesses of youth and manhood which impair the nerve centers and lay the foundation of many ills in after-life. The injury reacts long after its cause has ceased. Youthful vitality recuperates the organs for awhile, but as mid-life approaches, the symptoms indicative of presenility begin to appear. The majority of men at fifty experience a decline of natural vigor which, in the ordinary course of events, should not overtake them before sixty-five or seventy.

Most cases of this kind can be remedied; at least I have not found them difficult to remedy, and I attribute the indifferent success of others to the fact that the routine treatment laid down in the books, and followed by physicians who have had little or no experience of their own to guide them, is radically wrong in theory and practice. There is, in reality, no reason why weakening and premature decline of the genesiac functions should not yield to appropriate treatment as readily as those of other organs of the body. But we will never attain this object by hackneyed prescriptions of "phosphorous, nux vomica and damiana," and other reputed aphrodisiacs and nerve tonics. The practice is predicated on error, and fails because it does not reach the cause of the trouble, which must be sought in the central plexus from which genetic innervation is derived.

If I am right, and I believe I am sustained by physiology and neurology-the malpractice of stimulating a flagging function with mere nerve-irritants is apparent. That remedies of this class are capable of inducing temporary erethism of the hypogastric and sacral plexus which is reflexed to the genitalia, must be admitted. But the subsequent reaction leaves the functions in a weaker condition than before, necessitating increased dosage, until the nerve center no longer responds to excitants. Phosphorus, the type of this class of stimuli, owes whatever virtue it possesses as an aphrodisiac simply to its irritative action upon the cells. It is never assimilated, according to Robin, and may be recovered from the urine. The cerebral congestion produced by most reputed aphrodisiacs. can not be repeatedly induced with impunity, particularly in cases of elderly men-most frequently subjected to such experiments, on account of the tendency to sclerosis and brittleness of the cerebral arteries.

The train of evils usually included under the popular term, "Seminal Weakness," can not be wholly ignored. If we seek the causes of this prevalent vice of youth, we must include all those circumstances concerned in the merging of childhood into pubescense, which ushers a new element into life, seeking expansion and proliferation, and struggling to extend and engraft itself upon other processes for the transmission of life..

The premature excitation of the functions of sex hastens the formation. and evacuation of the life-giving principle, and, once established, it continues independently of habit and volition, and becomes a physical and mental menace to the undeveloped frame of youth and early manhood. That it leads to dementia in thousands of cases, indirectly, we have indubitable proof, but I believe that mental alienation in these cases is not so much the direct offspring of the vice as that destruction of hope and courage in these despondent sufferers by the misrepresentations of pernicious quackery which poisons the mind of youth, paralyzes the energies of promising young life and plunges it into the depths of despair.

What can we do for this unfortunate class of sufferers? It will not do to chuck them under the chin and say, "That's all right, my boy; don't you worry-just let it alone, correct your habits, take care of yourself, and live right, and nothing will come of it." Their sufferings are too vivid, and their fears and anxiety too real, for the time being, to be "piffed" away in this manner, and must be recognized and treated by the physician, or they will fall into the hands of the fraternity of quacks who are largely responsible for their condition; and we had better face things as we find them, however disagreeable, instead of shutting our eyes and pretending not to see them.

Limitations of space forbid my going into details of treatment, and I will therefore content myself with a general outline of the principles which my experience approves as the most successful. I have found internal medication alone wholly unsatisfactory, and often positively harmful,