SEQUELE OF SUPRAVAGINAL HYSTERECTOMY.*

(ORIGINAL ABSTRACT.)

RUFUS B. HALL, M.D.

DR. HALL said he thought the profession had been too hasty in approving the present methods. They had taken the stand that there was nothing more to be desired; the operation was conplete. While the doctor had no new method to offer, he hoped the discussion of his paper would suggest something to improve the technique of the present methods.

He referred to the objections to the extra-peritoneal method, and then spoke rather more in detail of total extirpation. He was one of the first to advocate and make this operation, and he attained excellent results with it. However, it did not meet his ideas of a perfect operation. The final results were good, but there was a primary difficulty that was disagreeable. Suppuration necessarily took place about the ligatures on the sixth or seventh day, causing a slight rise of temperature. To overcome the suppuration, he used specially prepared catgut for the ligatures below the peritoneum. He found the catgut unreliable on account of the danger from hemorrhage through slipping of the knots, and so abandoned its use.

After seeing Dr. Kelly of Baltimore in 1895 make the supravaginal operation with his modifications in the technique of the Baer method, Dr. Hall adopted that method. He operated according to it forty-six times, but was not pleased with his results. Eleven of the cases had post-operative sequelæ, due to the buried ligatures. All the patients made good primary recov eries, only one showing any signs of trouble earlier than the seventh week. This one had a discharge of pus from the vagina at the end of the fourth week. The discharge disappeared to return again at intervals of a few days to four or five weeks, and only ceased when the ligatures were removed. The other cases had similar histories, except that they did not have any trouble until from four to eleven months after the operation. Within a few days after the ligatures were removed, the patients were *Original abstract of paper read before the American Association of Obstetricians and Gynecologists at Niagara Falls, N. Y., August 17-19, 1897.

These two, one sixteen

well and have remained so, except two. and the other eighteen months since the operation, are still having trouble, as the ligatures have not all come away. The doctor said he knew the material was not at fault, or there would have been trouble immediately following the operation. Besides, the same material was used in other operations and no trouble resulted. He said he believed a large per cent of the patients so operated upon would certainly have this trouble. The general surgeons are abandoning the use of silk, silkworm gut and silver wire in Bassini's operation for this very reason, and he felt it only logical for the gynecologist to expect to have to do the same.. He urged the other gynecologists to tell their results with this method, and compare notes. The doctor closed his paper by saying that, in spite of the fault he had to find with total extirpation, he preferred it to supra-vaginal hysterectomy as practiced by Baer and modified by others. He felt more certain of his final results

with the former method. Cincinnati, O.

EDITORIAL.

CONSIDERATIONS ON APPENDICITIS.

THE diagnosis of appendicitis is certainly not difficult when the patient presents the classical symptoms of the affection, namely: sudden appearance of the symptoms, pain in the region of McBurney's point, rather copious vomiting, rise in temperature and tympanism. But in many cases there is good reason to hesitate as to the diagnosis and the affection has been mistaken for the commencement of a simple attack of acute indigestion, as for example in the case of a child reported by Moizard, in whom the diagnosis of perforating appendicitis was made sixty hours after the onset of the symptoms, and operation being performed showed the correctness of the diagnosis, as well as saving the little patient's life.

In other cases the mistake made in the diagnosis in the first place is prolonged and after having considered the condition as one of simple indigestion it is taken for an acute gastric catarrh. In these forms the phenomena of a slight gastro-intestinal intoxication predominate and this insidious type is all the more important to be familiar with from the fact that it may be the com

mencement of the most serious form of appendicitis, namely, that which rapidly develops into a diffuse, septic peritonitis, usually resulting in an early death.

In these insidious forms of appendicitis the physician may be put on the track of the correct diagnosis by the difference between the rapid and poor pulse and the temperature, which remains normal.

There are also cases where in the beginning the appendicitis is mistaken for a typhoid fever. This error is only possible when the symptoms of the appendicitis are marked by those of the gastro-intestinal infection which precedes it and are its cause.

An appendicitis may be mistaken for an invagination or intestinal strangulation, an error that can be avoided by considering the characters of the fever as well as the vomiting and constipation present in all these cases. Another disease that can be mistaken for an appendicitis is a pneumococcus peritonitis.

When the diagnosis of appendicitis has been made the question comes, is it a case for medical or surgical treatment? The very acute perforating forms, with progressive purulent peritonitis, as well as the septic forms, demand an immediate abdominal section, and it is the duty of the physician to impress this fact upon the family. It must, however, be remembered that these septic forms, as well as immediate generalized peritonitis, are very infrequent. Usually the initial paroxysm calms down and the treatment remains purely medical.

As to treatment, purgatives should be proscribed, and on the other hand, opium and its preparations should also be left aside. Ice-bags should be applied loco dolienti, the action of cold being very sedative. An absolute diet should be enforced untill all symptoms have disappeared.

If the patient be weak, injections of artificial serum or ether subcutaneously, should be given. Rest in bed should be insisted on until all pain on pressure has disappeared, a thing that is difficult to accomplish in young children.

When feeding can be again resumed, it should be carefully watched and milk and Vichy should be the first food taken, after which light soups may be allowed.

After the attack has passed off the rôle of a physician is at an end. The resulting induration of the tissues may often be dispelled by a small blister or the application of mercurial ointment

over the region of the appendix. In order to avoid other attacks the food must be simple, all excess of the table being avoided, and a strict attention must be given to the regular daily evacuation of the bowels.

Now, a medical cure having been obtained, the question comes: Should the physician stop here or should the removal of the appendix be advised when all the inflammatory process has passed by?

In reply to this we would say that if it is the first attack it will be better to allow the appendix to remain, as the patient may never have a return of the trouble. But if it is his second, operation should be advised, and a fortiori if it be the third or fourth, interference by the surgeon is indicated.

Removal of the appendix after the first attack only appears to us necessary if the patient is to go to some part where surgical aid will be difficult to get if another attack should occur, or in those cases which present a local tenderness months after the first attack.

PUBLISHERS' NOTICE.

THE various improvements in the style, arrangement and printing of this journal which have been manifest during the last few months, have now been completed. The efforts of the publishers have been directed toward securing greater clearness and better typography. With this issue we return to the single column style which was originally used in this journal.

They trust that the greater width of line, which is the same as that of the ordinary medical book, will be acceptable to the subscribers as it is more convenient for reprints. The size of the page remains unchanged while the number of pages has been increased one-fourth. This will entail upon the publishers considerable additional expense. But they feel confident that with the return of "good times" to the country, their subscribers will appreciate this enlargement.

They trust that the subscribers will accordingly not only speak a good word for the ANNALS to their friends and associates, but will themselves be prompted to make an immediate effort to pay up any overdue subscriptions. The publishers have realized with pain that the past four years have been hard ones, and have therefore refrained, hitherto, from urging payment of accounts

overdue.

DEPARTMENT OF PEDIATRY.

CONDUCTED BY ROBERT W. HASTINGS, A.M., M.D.

ORIGINAL COMMUNICATIONS.

THE TREATMENT OF LARYNGEAL DIPHTHERIA BY ANTITOXIN.*

WILLIAM F. WHYTE, M.D.

THE publication of Behring's experiment in 1892, setting forth the fundamental principles underlying the serum treatment of diphtheria, was undoubtedly received by the profession at large with considerable incredulity.

The extravagant and ill-advised claims made tor Koch's tuberculin had made physicians skeptical as to any new discovery of a similar nature. Nor did the first reports of the results of the treatment by antitoxin tend to create any great confidence in its therapeutic value. This was no doubt due in part to weak serum and insufficient dosage.

The type of diphtheria also, which is observed in European cities and in larger towns of our own country is much more severe than in rural communities and the death-rate with the use of the serum was not much lower than we had been accustomed to under the old treatment.

In my twenty years' experience in the treatment of diphtheria, I do not think the death-rate has been over eight to ten per cent in faucial cases. In 1880 I treated in one neighborhood, fifty cases of diphtheria. There were eight laryngeal cases, of which seven died and four deaths only occurred where the larynx was not involved. The earlier reports of the results of the serum treatment by Roux, Martin, Barginsky, Vierrodt and others,

*Read at the annual meeting of the Wisconsin State Medical Society, May 7, 1897.