PROPOSITIONS FOR MEMBERSHIP.

Applications have been received from the following:

John H. Ohly, 12 Schermerhorn Street, L. I. C. H., 1899. Proposed by J. S. Wood; seconded by W. S. Shattuck.

Horace M. Sloat, 149 Van Buren Street, L. I. C. H., 1877. Proposed by Membership Com

mittee.

Julius C. Bierwith, 253 Henry Street, P. & S., N. Y., 1885. Proposed by Membership Committee.

ELECTION OF MEMBERS.

The following having been duly proposed and accepted by the Council was declared, by the President, elected to active membership at this meeting:

John A. Shields, P. & S., N. Y., 1898.

DECEASED MEMBERS.

The Chairman of the Historical Committee reported the death of the following members: Stanley G. Clark, N. Y. Univ., 1868; died March 5, 1904; member, 1889 to 1904.

Frank L. Tetamore, L. I. C. H., 1882; died February 9, 1904; member, 1882 to 1892.

SCIENTIFIC PROGRAM.

1. Paper: Medical School Inspection in Greater New York," by Dr. Florence Emerson.

2. Paper: "The Relation of the General Practitioner to the Quarantine of Contagion," by Dr. Henry N. Read.

Discussed (both papers) by Dr. James N. Gaston, of Atlanta, Ga., and Drs. Hoople, Ingalls and Raymond. Closed by Dr. Emerson.

EXECUTIVE SESSION.

Reports of Committees.

On behalf of the Committee on Public Health Dr. Raymond reported that the resolutions adopted at the last meeting relative to the Advisory Board of the Department of Health and a Visiting Staff to the Kingston Avenue Hospital, were presented to Dr. Darlington, President, Department of Health, who expressed his hearty sympathy with the suggestions made and his desire to comply with them, and promised that the Society would hear from him shortly in regard to the matter.

Dr. DeLong, member of the Milk Commission, reported progress in the work of his Committee,

and stated that 20,000 quarts of certified milk were sold in the city during the past month.

Drs. Bristow and Fleming reported progress in their work in opposition to the Optometry

Bill.

A motion was made by Dr. Emery and seconded by Dr. DeLong, that a Committee be appointed by the President to investigate the water supply of Brooklyn. It was carried. The President announced that he would apopint the Committee at a later date.

The following resolutions were offered by Dr. Schirmer. A motion was made by Dr. Shirmer and duly seconded, that a copy of the resolutions be forwarded to the Mayor of New York in form as follows:

Hon. GEORGE B. MCCLELLAN,

Mayor, City of New York. Honorable and Dear Sir:

At a stated meeting of The Medical Society of the County of Kings, held this 15th day of March, 1904, the following resolutions were adopted:

Whereas, There is a Bill before the Legislature of New York to regulate and grade the salaries of Inspectors in the Department of Health in the City of New York; and

Whereas, We fully appreciate the very important services rendered by said Inspectors for the benefit of the people of New York City and the dangers to which they are exposed in the performance of their duties, and that the salaries of many professional men trained and experienced in the duties of the various branches of the service is less in many instances than is paid for ordinary labor; it is

Resolved, That we unanimously endorse the Bill referred to; and it is further

Resolved, To present a copy of these resolutions to the Hon. George B. McClellan, Mayor of New York City, and pray that he may use his personal influence and give his official support to have the said Bill incorporated in the charter of New York City as proposed.

N. Cox and Henry A. Fairbairn, the Board of Trustees has been enabled to erect a memorial tablet to the late Dr. A. J. C. Skene; it is

Moved, That a vote of thanks be extended to them.

First, with regard to fixation and suspension of the uterus. Fixation, I think, should not be done except in women past the menopause. An intended suspension is likely to become a fixation and is therefore an unsafe operation during the

W. C. WOOLSEY,

Associate Secretary.

THE BROOKLYN GYNECOLOGICAL

SOCIETY.

JANUARY, 1904.

H. C. KEENAN, M.D., Editor.

PAPER: A BRIEF REPORT OF A YEAR'S HOSPITAL (PRIVATE) WORK.

BY L. GRANT BALDWIN, M.D.

Discussion.

DR. JOHN ASPELL: I only got here at the time the Doctor spoke about his cases of pelvic abscess, and his review of the method he employs in cases of complete procidentia.

I presume, inasmuch as Dr. Baldwin and I were brought up in the same hospital, our practices are pretty much alike. In cases of complete procidentia, I pursue the different methods of pelvic work that we were instructed to do at that time, unless the case is of long standing and the connective tissue gone. Nothing absolutely unusual is claimed in these methods of operation, but it is claimed that if you cannot restore the uterus to its normal plane in the pelvis, you can turn it on its long axis so that it will not come down again. By this method you can lighten the uterus and restore it to its normal plane in the pelvis.

As far as pelvic abscesses are concerned I have learned much from Dr. Baldwin's method of drainage by means of gauze. By remaining in situ a week a canal is formed that facilitates any further drainage when the gauze is removed.

I am sorry I did not hear the full and more important parts of the paper.

DR. C. JEWETT: We are indebted to Dr. Baldwin for an interesting review of his work. There are one or two points about which I will say a word.

retro-displacements which has given me the best results, in cases likely to become pregnant, is the Webster operation. A loop of the round ligament is passed through the broad ligament close to the uterine wall and is fastened to the posterior surface of the uterus. This never lets go. The results are perfectly satisfactory and there is no danger of complications. I prefer it to most of the other intra-abdominal operations for the purpose. The use of a pessary is a valuable precaution. While I have had no failures after the Webster operation, wearing a pessary for six or eight weeks helps to prevent possible stretching of the shortened ligaments.

Procidentia I have not as a rule been able to treat with entire satisfaction by anterior and posterior colporrhaphy alone. In women past the menopause the plastic operations followed by a ventro-fixation may do, yet the cervix may again. appear at the vulva unless the plastic work is much overdone. In other cases a thoroughly effective procedure is the following: To anterior and posterior colporrhaphy add shortening of the round and the utero-sacral ligaments. The utero-sacral ligaments are very much relaxed in these cases. By carrying the cervix well up and back the uterus is held at right angles to the vaginal axis and prolapse is impossible. It is kept resting on the pubic shelf.

For shortening the utero-sacral ligaments Bishop's method is a good one. The abdomen is opened by a free incision, the fundus is drawn. well up over the pubis, an obturator pushes the posterior vaginal wall up, carrying with it the peritoneal cul-de-sac, till the utero-sacral ligaments are brought within reach. They are shortened by seizing a fold of the ligament, carrying it high up on the sacral wall and fastening it there. The loop is denuded of its peritoneum and the adhesion between cellular tissue and peritoneum is extremely firm. Boveé folds the ligament by a vaginal operation, but this is more difficult.

I can subscribe to all that Dr. Baldwin has said about the value of the Wight clamp. I have used it frequently in vaginal hysterectomy. It is practically impossible for a vessel to slip out of its grasp.

One clamp answers for each ligament. In

simple cases the operation may easily be done in ten minutes. The peritoneum opened back and front, a blunt hook is passed up behind one broad ligament and the ligament pulled down till the finger can be substituted for the hook. A clamp is applied, the ligament cut, the uterus delivered through the vulva and the remaining ligament cut and clamped.

A point that interested me is the Doctor's habit of opening the bowels early. I have never seen any harm from it. The temperature drops, tympanites subsides and the patient feels better. Early stimulation of peristalsis, too, tends to prevent adhesions and intestinal paresis.

The Doctor's objection to the gauze pack for isolation are obviated if a sheet of rubber tissue

is first spread over the intestines and the gauze pads placed over this. The smooth, moist surface of the rubber tissue is much kinder to the peritoneum than gauze. When septic material is likely to be encountered in the pelvis, the pack is indispensable.

Six or eight glasses of boiled water daily for several days before operation, a glass immediately

before anesthesia and the free use of hot water afterward from the moment the patient can swallow is better than hypercatharsis, and it lessens vomiting and allays thirst.

DR. J. O. POLAK: Dr. Baldwin has supplied

such a wealth of material for discussion that it

is hard to begin. There is one point Dr. Jewett has already referred to that deserves commendation, and that is his calling attention to the treatment of procidentia by plastic work. I think the reason that many of us fail with restitution of the uterus to its proper plane by plastic work is that we do not give these cases sufficient preoperative treatment. If we adopt the plan frequently recommended by Emmett of keeping the patient in bed with the foot of the bed raised. and insert tampons of boroglyceride daily a week or so before operation, it will give us tissues to work upon. A high amputation of the cervix with an anterior colporrhaphy and the operation that has been devised by Reynolds, while it has not met with as enthusiastic support by some men as it will later, I think has given me very excellent

anterior walls.

The operation as devised by Reynolds, if you remember, is practically a denudation of the anterior wall in shape thus: (blackboard drawing). It gives a very firm anterior wall.

This anterior wall operation has been extremely satisfactory following an amputation of the cer

vix and supported by a posterior-perineoplasty, going up in the posterior sulcus and narrowing the vagina in that way. In complete procidentia where you have given preoperative treatment and used plastic work of that sort, then to follow that by a suspension or by a folding of the round ligament, will give very satisfactory results. These cases should be kept in bed for a very long period

four or five weeks. Then a pessary is introduced and they wear that pessary for a considerable length of time. I have yet to see a case of procidentia done with combined plastic operation and suspension that has relapsed.

In regard to the Bischoff operation, I have had no experience with it. Theoretically it is perfect, because the suspension of the uterus is dependent on the utero sacral ligaments. With a tight anterior vaginal wall, the cervix removed. and the uterus raised to its proper plane of equilibrium, you can, I think, get a very satisfactory and permanent result.

There is an operation that I have done once during the last three months, that has been suggested by Harris for the relief of very old women with complete procidentia. He does no plastic work at all, but does a supravaginal hysterectomy and sews the cervical stump into the abdominal wound. That case so far is of too short duration to report the permanent or remote results. Theoretically it would seem better than the methods suggested by some radicals of hysterectomy in procidentia.

I cannot conceive of a case of procidentia that would be benefited by hysterectomy. We have prolapsed anterior and posterior vaginal walls, and by taking out the uterus we gain nothing, unless we tie these walls to something above.

In regard to pregnancy and suspension, I reported sometime ago 123 cases of suspension with 20 pregnancies-nine labors I attended myself with no complications. I have not found, outside of two or three operations occurring in that series, any difficulty from suspension. The only class of operations for retrodeviation of the uterus that I have found difficult is the so-called vaginal fixation of the uterus.

The point that Dr. Baldwin made in regard to pelvic abscesses, and the maintenance of gauze drainage for a long time without removal after it had been placed in position, is something that I want to endorse most heartily. Where the culde-sac has been opened, it is far better to leave that gauze in situ for five to seven days, as the Doctor says, and then to withdraw it and leave it out, because we then have a drainage tube

The Doctor interested me particularly in the report of his cases of fibroid complicating pregnancy, particularly the last case that he reported, where the tumor was sessile and a large denuded area was left. It simply demonstrates to us that it is far better to operate on these cases and that with present-day surgery we can operate without fear in a large number of cases.

In three or four cases of fibroid complicating pregnancy I have done myomectomies upon them, and have yet to see a case miscarry-the same as many of you have done operations for twisted pedicle cysts during pregnancy, and very few of these cases miscarry. The only condition that I have found very difficult complicating pregnancy is appendicitis; then the uterus seems to take up all the abdomen and it is difficult to get the appendix out.

DR. W. B. CHASE: Dr. Baldwin has given us a digest, which might occupy a good deal of time in considering the various questions. There is very much in Dr. Baldwin's experience that is interesting and instructive.

At the present day we have much less dread of old pelvic abscesses than we used to, on account of the practical immunity which the patient bears, even though the peritoneum becomes soiled, and it is a recognition of this fact that I attribute very much of his success. I have seen him open abscesses of that kind and drain them through a large piece of gauze twisted in through the abdominal wall, almost as big as my wrist, and yet the facility with which the patients recovered was remarkable. The fact that when the peritoneum has become soiled by old pus, it can be washed clean and the abdomen closed is certainly an advance on the old method-the feeling that in all cases of pus in the peritoneal cavity we must drain.

I am very much interested in the experience of Dr. Baldwin in the after treatment of cases of pelvic operation by abdominal incision, and the necessity of early movement of the bowels afterward. Dr. Baldwin is entirely correct. My experience is this: that my patients suffer more from the discomfort arising from the accumulation of gas in the intestine after abdominal operation than from all other things combined. Even if you prepare the intestines carefully before the operation, yet in the majority of cases there will be gas accumulate after the operation, and accordingly as it accumulates is the discomfort of your patient, and the sooner you can rid the pa

better. I think very many patients have been sacrificed by allowing the bowels to be locked up five days.

Dr. Baldwin did not tell us regarding his method as to sutures. I infer and feel confident that in all these cases he has left no buried unabsorbable sutures. Nothing short of a suture that would last months or years would suit many men, even though the object of the ligature would be accomplished in the course of a day or a few hours. I am sure as to what the Doctor's answer will be as to unabsorbable sutures, and I think his experience will be valuable not to put patients in jeopardy by articles of doubtful advantage.

DR. H. C. KEENAN: The former speakers have so well threshed over the ground, that they have left very little for me to say. All I can do is to repeat the expressions of appreciation, which the other gentlemen have already stated.

However, there are two or three points which I should like to speak about. First, is opening the pelvic abscesses. Whether I do not make a large enough opening, I do not know, (I believe I do) but I have known a number of cases where after leaving the gauze in for a couple of days the patient experiences a rise of temperature. When they are put on the table and the gauze is pulled out there is often a gush of pus. It looks to me as though the meshes of the gauze become clogged up and act as a cork, so that I have removed the gauze in two or three days. It is, however, very difficult to reinsert it and it is painful to the patient, and I would like to know from Dr. Baldwin if he gets drainage after the third day.

There was another point I was glad to hear him speak about. He came out boldly and said he put the needle through the skin from without in. Time and time again I have seen needles used through and through the skin, taking the tissues from the peritoneum to the skin and the same needles used from the peritoeum to the skin again, under the delusion that the needles. were as sterile as used in the first instance.

Another point I would like to speak about is the use of morphine. I had quite a good deal of experience during the summer in this matter. A small amount was given the first evening. The next twenty-four hours the patients would be in very good condition, but during the second twenty-four hours they would be considerably worse than if they had no morphine at all. I think also it would be quieting to the bowel and would predispose to the formation of adhesions.

DR. A. C. BRUSH: Mr. President, I feel that I am rather out of my line in speaking before a gynecological society, but with regards to the coccyx Dr. Baldwin's paper brings this subject to my mind forcibly. Injuries to this little bone are a thing that can cause considerable trouble, and when the trouble is a local one, might be easily mistaken for the well known coccyxageal pains found in hysteria and neurasthenia.

The coccyx from its anatomical relations is of more importance than we think at first glance. Spreading over its posterior surface we have in its fibrous covering a mass of connective tissue, blood-vessels and nerves descending from the spinal cord through the open spinal canal. We are dealing then with a sensitive little organ, injury or disease of which can cause pain reflected all the way up the spinal cord and thus to every nerve in the body. I think we have all seen an immense amount of disturbance from small injuries to the part. I remember one case operated on for me by Drs. Polak and Butler where the removal of this small bone was followed by an immense amount of relief to the patient.

There is another point in operating on this part of the spine in hysterical patients: it is a question how much actual good the operation does and how much is accomplished by suggestion. In true disease of this bone there can be no question that it is better out of the way than in the patient's body.

DR. C. P. GILDERSLEEVE: I did not hear Dr. Baldwin's paper, and even if I had heard it I would not consider myself competent to discuss it, so far as procidentia is concerned, but I infer from the nature of the discussion that Dr. Baldwin advocated gauze drainage, and I also infer that there are others who believe that there is other drainage better than gauze.

We all know that no drainage is perfect, we all know that all drainage is decidedly imperfect, but my experience is that there is no material that as satisfactorily drains as thoroughly and safely as gauze drainage properly introduced. When I say properly introduced, I do not mean to pack in a lot of gauze indiscriminately as tight as you can get it, but to take a strip of gauze and twist it properly and be sure it goes down to the bottom of the cavity. I am positive that it is a great mistake to take the drain out as a rule two days after the operation. You take in those cases operated on for appendicitis with pus sac, you are dealing with a large cavity and comparatively delicate structures. You have got your incision through the abdominal wall, in which you hope

to get some primary union, and there is no doubt in my mind that if you take out the gauze drain before the second day, you are bound to interfere with your wound, and you are taking a chance when you reintroduce it to force it through the wall. At the end of four or five days you are not dealing with nearly as dangerous a surface as on the first or second day.

It is perfectly true, as Dr. Corcoran says, that when you withdraw this wedge some pus runs out. It is equally true if you use a glass tube, which is more adapted for a lamp chimney than a drainage tube, the pus stays in there. That is certainly not good drainage.

Dr. Keenan spoke of morphine. I do not know what Dr. Baldwin said. I do not believe he said to give morphine day after day. After any operation of that sort there is a certain amount of nervous disturbance and restlessness, which nothing will quiet except morphine, and as a rule you do not need it after twenty-four hours.

Dr. Brush spoke of the coccyx being so sensitive. I do not believe that. I do not know of any part of the anatomy which gets subjected to moderate violence more often than the coccyx, and I have never heard of any serious results from moderate violence to that part except in medico-legal cases, admitting, of course, that the bone can be bruised or broken exactly as any other bone if violence of sufficient force is applied.

DR. J. F. TODD: I presume it is permissible for the assistant of a gentleman to be rather enthusiastic in the work of his chief. When a student, and after graduation, when I had the honor of being associated with one of our late lamented professors of Gynecology, I was led to believe that complete procidentia was a most hopeless condition; that the arts of the surgeon whether by means of plastic operation alone or supplemented by abdominal section, were well nigh useless in the great majority of cases.

I presume in a young woman, one in whom the condition has only existed for a short time, a simple perineorrhaphy combined with a suspension of some sort will restore the uterus to its normal plane; but take the average case of a woman four or five years beyond the menopause, the uterus completely prolapsed and outside the vulva for six or seven years, this lady is in no condition to stand an abdominal operation.

The usual operation on the posterior vaginal wall and perineum will certainly be useless, but combine with these the anterior operation as spoken of by Dr. Baldwin, and the uterus will