Ernest Watson Cushing.

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the lower abdomen and the temperature was 39°.2 C.

Vaginal examination revealed a fluctuating tumor in the pos-
terior cul-de-sac and the diagnosis of localized pelvic peritonitis
and peri-uterine abscess was made. The patient entered the hos-
pital, and on the following day (November 13, 1896), and a pos-
terior vaginal coeliotomy was performed, which gave issue to 125
cc. of thick yellow and odorless pus.

The cavity was drained for some ten or twelve days, after
which the wound was allowed to close, as all discharge had disap-
peared and the temperature had remained normal for several

I now show you this case in order to point out how well such
patients do when they have been subjected to so slight an opera-
tion and I have, as you are aware, on many occasions told you
how adverse I am to the more radical operations under such cir-

Posterior vaginal coeliotomy is in the first place a conservative
and simple operation, and is indicated in both acute and chronic
purulent collections in the pelvis. The incision should always be
preferred and pimcture with an aspiratory needle or trocar should
nerer be resorted to.

The vagina is to be prepared in the same manner as for vaginal
hysterectomy, and after the pus has been evacuated the cavity
should always be drained. If you will take a little care there is
absolutely no danger of wounding either the uterus or the uterine
arteries. The vaginal incision is also indicated in certain cases
of pelvic peritonitis, salpingitis, and abscess of the broad liga-

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ment, but when there are several foci of suppuration, this treat-
ment is insufficient. Vaginal coeliotomy should not be resorted
to if by palpation the walls of the abscess are found thick and
rigid, because after the evacuation of the pus they do not collapse
and come in contact and consequently a large cavity remains
which keeps up an eternal suppurative process, and which is most
difficult to close.

I wish to particularly insist that in every case in which the
patient is a young woman, a vaginal incision should be resorted to
in order to leave the adnexa intact, and I have operated on a
number of women who afterwards became pregnant and have
become mothers.

And you must remember that a vaginal incision will in no man-
ner prevent a future vaginal or abdominal hysterectomy if the
condition of the patient should justify such an interference.

It is of course quite evident that suppurative processes in the
pelvis demand different treatments according to their situation,
size and number, and it is for this very reason that you should
endeavor to make as accurate a diagnosis as possible, because no
one method can be applied to each and every case. Consequently
I would say that each time, that you find a suppurating process
which may be easily reached by the posterior vaginal cul-de-sac
and which resists proper medical treatment, a free incision and
free drainage is the proper method of treatment.

Case II. — Mrs. W. B., set. 34, mother of four healthy chil-
dren, first menstruated at the age of twelve, but the menses have
always been scanty, lasting not over two or three days. About
two years ago, after the birth of her last child, the patient com-
plained of severe pain in the abdomen which lasted for a few
days, but since this time there has always been some pain in the
left iliac region which becomes more acute during the menses.

Examination shows a bilateral laceration of the cervix; the
cervix is situated far back in the vagina, the uterus being in
physiological anteversion and the fundus somewhat pushed to the
right. Nothing is to be felt in the right iliac fossa, but in the
left a round, movable tumor, about the size of an orange, can be
made out with ease.

I believe that we may make a diagnosis of ovarian cyst in this
case and the neoplasm is probably a dermoid. Dermoid cysts of
the ovary are congenital neoplasms and their pathagenesis is as

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yet unknown, but the theory of inclusion is probably the correct

The prognosis of these cysts is not without some gravity, as
serious complications, such as torsion of the pedicle, septic injec-
tion or secondary neoformation taking on the character of a pave-
ment cell, epithelioma may occur. All these possible complica-
tions are quite sufficient to justify an early operation, because a
tardy interference may compromise the result of the operation,
either on account of the difficulty in enucleating the neoplasm or
by reducing the patient's health so as to render surgical treatment

Abdominal section is the only proper treatment, and this
should be done, even if the patient be pregnant, for the pressure
of these cysts may give rise to serious complications during both
pr^^ancy and labor.

Case III. — I wish now to refer to a patient that some of you
saw with me at the commencement of this yearns term and upon
whom we removed the appendix. The operation was performed
on October 12, 1897, and when the abdomen was opened a large
juicy appendix was found, while the coecum presented three in-
durated nodules that I took at that time to be tubercular products
and my supposition has since been demonstrated to be correct.

The patient in question was a young man of twenty-seven years
of age, of slight build, but whose family and personal history
were fairly good. He gave a history of an acute attack of
appendicitis about two months previously from which he recov-
ered, but since he had been constipated, and the right iliac region
was tender and palpation revealed a doughy mass in the region
of the coecum.

The patient was apparently much benefitted by the operation,
and up to the latter part of December of last year he was feeling
quite well and had gained in weight. Suddenly he was taken
with a cough and diarrhosa and he died last week. The autopsy
demonstrated the presence of a pulmonary and intestinal tubercu-

This was a case then, of tuberculosis of the appendix and
coecum, which anatomically is present as a thickening and indu-
ration of the intestinal walls with ulcerations of the mucosa.
Microscopically we find an embryonal cell infiltration of all the
tmnics of the intestine and part of the mucosa.

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Clinically we divide two types, viz., the neoplastic and recur-
ring inflammatory type. In the first variety a tumor can be felt
in the right iliac fossa and having a cylindrical or round shape
and varying in size in different cases. The tumor may be either
movable or bound down by adhesions and is quite painful when
pressed on. Periodical attacks of pain are complained of and
there may be either diarrhoea or constipation.

In the second type we have an induration and a diffuse doughy-
ness in the region of the coecum, and if not treated, stercoral or
purulent fistulse result, while a differential diagnosis with that of
carcinoma is difficult to make either microscopically or mocro-

The treatment is entirely surgical. Total extirpation of all
the diseased parts by a resection of the intestine is a severe opera-
tion and the intestinal sutures are liable to give rise to much
trouble. Palliative operations, such as partial resection of the
walls of the coecum or entero-anastomosis are apt to give rise to
fecal fistula.

The best treatment, I believe, is to simply perform an abdomi-
nal incision, remove the appendix and expose the coecum to the
air for a few minutes and then close the abdomen a few cases have
been recorded which were most successful.

Case IV. — This little boy, four years old, came to the Tremont
Dispensary three weeks ago, for an inguinal hernia on the right
side. He had worn a truss for about two years but without any
result. Ten days ago I operated on him. The operation was
easily executed and did not last over fifteen minutes. Two days
ago I removed the skin sutures and found the incision well cica-

Today I only wish to make a few remarks regarding the contra-
indications to the operation, the after care and the possible com-
plications which may arise during convalescence.

Before operating, care should be taken to inquire carefully as
to the health of your little patient. A bronchitis or a cough fr©m
no matter what cause, any pulmonary trouble for that matter,
are contra-indications for operating. Leaving aside the dangers
from the anaesthetic in such cases, the effort caused by coughing
will compromise the ultimate result of the operation. The deep
sutures may give way from the strain put upon them, and a recur-
rence of the hernia is to be feared.

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A syphilitic or scrofulous child should not be operated on until
a proper treatment has built up his system. Weak or rachitic
subjects are likewise to be let alone until they have been general-
ly improved by a suitable treatment.

Coexisting malformations are a contra-indication for the radi-
cal cure of a hernia and the latter should only be operated on when
symptoms of strangulation occur. Very large hernia, which are
not infrequent in rachitic children should not be operated on, but
this contra-indication is only temporary because as the child
grows the disproportion in the size of the hernia and that of the
abdominal cavity becomes less marked and then the condition
may be radically cured.

Xow when we have a case of multiple hemisB what should we
do? Usually it is one of double hernia, and in such a case we are
to be guided by the geijeral condition of the child. I think it is
better, if operation is decided upon, to do one and then later the
second hernia than attempt to operate on both at the same stance.

As to multiple hemise, properly speaking, such as double in-
guinal hernia, umbilical hernia, crural hernia, etc., I think that it
is better judgment not to be in a hurry to surgically interfere.
As the child grows up an umbilical hernia will disappear sponta-
neously and the subject will only keep his double inguinal hernia
and when in good condition these may be treated.

Tuberculosis of the bones, such as Pott's disease, osteo-arthritis,
spina ventosa, etc., is a decided contra-indication to operation.
The same is true for children presenting an adenitis or a sup-
purating focus of any sort and in order to be successful we should
only operate on those children who are exempt from infective

Children support poorly rigorous antisepsis generally speaking,
especially iodoform and carbolic acid, and for my part I prefer
asepsis rather than antisepsis when dealing with little ones. I
advise you to employ subgallate of bismuth gauze as it is non-
toxic and a most efficient antiseptic.

To protect the wound from becoming soiled and thus infected,
the following adhesive paste will be found of use:

^. Zinci oxyd. 10.0

Gelatin. 30.0

Glycerini 25.0

AqusB 35.0

M. D. S. For external use.

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At tbe^ ordinary room temperature this formula is in a solid
state so when it is to be employed it is heated on a water bath to
liquify it, afterwards it is applied with a brush like collodion.
The fluid is freely applied aroimd the borders of the closed in-
cision and when the gauze is spread over the latter it adheres in-
timately to the skin. Another layer of the paste is then spread
over the gauze and thus the incision is protected by a layer of
impermeable dressing of excellent occlusive properties. Over
this a few layers of absorbent cotton are applied and a spica ban-
dage keeps them in place.

In very little children, retention of urine rarely occurs on the
day of operation, but if it does a catheter must be passed. No
elevation of the temperature will occur if your asepsis has been
complete. Constipation is not infrequent, but one or two gly-
cerine enemata will bring away the feses, and the temperature
will come down to normal if by chance it has gone up.

A milk diet should be ordered for the first few days following
the operation, and by the fifth day the child may be given its
regular diet.

The dressings are to be removed on the eighth or tenth day,
the sutures in the skin are taken out and another occlusive dress-
ing applied, but this time without a spica. The child may be
allowed to get out of bed by the end of the fourth week.

There is one post operative accident that will occur very often
but which should give you no alarm, and that is a marked edema
of the scrotum with a hydrocele of the vaginal tunic, all of which
will disappear in from three to four days. The hydrocele is not
caused by the manipulation of the vaginal tunic because it takes
place in cases in which the hernia is not scrotal. It is probably
caused by a permanent complession of the spermatic cord at the
external ring, the circulation in the spermatic veins is hindered
and we consequently get a serous collection. The fluid will dis-
appear in three or four weeks.

As to post-operative complications, they are mostly infective
and are due to carelessness on the part of the operator. A peri-
tonitis is inexcusable. Broncho-pneumonia, which is usually
fatal, is rarely met with if you will take the precautions I have
already mentioned, when you examine the child before operating.
When due to the anaesthetic it makes itself manifest on the second
or third day, rarely before.

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A septic inflammation of the stump of the mesentery will oc-
cur if your ligatures are not perfectly aseptic, its symptoms being
those of an ordinary localized peritonitis.

A collection of blood will sometimes occur after a difficult and
extensive disection of the sac, and the only means we have to
prevent this complication is to drain. And lastly an aseptic sup-
purative process may occur when the deep sutures are tied too
tightly. This process is, as you know, due to the thermogenic
products absorbed from an aseptic necrobiosis of the tissues; the
soft tissues included in the sutures become necrosed partially and
are eliminated in shreds, similar to those seen in anthorax.

For prudence sake I think it best to have the child wear a sup-
port for a year or so after the operation, but the hemise met with
in childhood are recent, the tissues are in a healthy condition,
both conditions being particularly favorable for a rapid and com-
plete repair.

A truss will sometimes alone be enough to bring about a cure
of a hernia when the canal is nearly normal and the rings mod-
erately dilated, but a radical cure can only be obtained by opera-
tion in cases in which the abdominal wall is relaxed and when the
inguinal canal is in a state of malformation, and I would add that
the best time for operating is between the second and fourth

Case V. — This patient has been under treatment for several
chancroids of the labia and a suppurating bubo in the right in-
guinal region. The other day the bubo was incised, curetted and
packed with subgallate of bismuth gauze, and on changing the
dressings today we find the wound in good condition.

Inguinal adenitis follows an ulcus molle in over fifty per cent
of cases and is usually a poly-adenitis. The bubo may become
infected by the specific bacillus of chancroid after it is opened or
even before suppuration occurs.

Before suppuration has taken place a bubo should be treated
by rest, blisters and compression.

When suppuration is established we have several operations
which are to be selected according to the condition of the ade-
nitis. When only one gland is the seat of the trouble, simple
incision with drainage is sufficient, but when there are several
infected glands incision curettement and drainage are necessary.
If after incision digital exploration reveals a large poly-adenitis,
the extirpation of the mass must be resorted to.

871 Beacon Street, Boston, Mass.

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It has been well said that "the first step in presenting a subject
is to define exactly and exhaustively the thing to be discussed."

My paper refers to the usual classification of fibroids, sub-
mucous, interstitial, or sub-peritoneal, which, from location, pro-
duce obstniction of the bowels, irritation of the bladder, ex-
haustive hemorrhages and pain, growing rapidly, irrespective of
patient's age, and become a menace to life or a source of invalid-

Many practitioners have learned that to encourage these pa-
tients to hold out until the menopause has passed, when the tumor
will disappear, is giving hope to a very small percentage. Sta-
tistics demonstrate a great tendency for these fibroids to become
much more irritable, and to exhaust the strength of the patient
at the climacteric. Aside from controlling the hemorrhage, in
a certain number of cases, and a possible diminution in size of
the tumor, electricity is not a positive curative agent. .

The intelligent practitioner will come to the surgeon asking,
''What is your successful method of treatment?" Is it by the
use of the clamp, extra-peritoneal treatment of the pedicle, by
the vaginal route, in all cases, or do you prefer supra-vaginal hys-
terectomy, leaving in the cervix? Do you operate by Dr. J. F.
Baldwin's method, or do you know of cases where this operation
was done in which silk has escaped, sometimes producing abdomi-
nal sinuses?

"Do you find Doyen's method, as improved and used by Dr.
Allen, of Cleveland, satisfactory; is Dr. Le Bee's operation most
suited to the removal of large fibroids, or do you find Dr. Riche-
lot^s abdominal hysterectomy preferable to all others, etc. ?

♦Abstract of paper read at Pittsburgh, Pa., September 20, 1898.

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**How successful has been ligation of uterine arteries, also of
ovarian vessels in these cases? What about curetting of the
cavity of the uterus, lifting up the fibroid and introducing a pes-
sary? Does the operation of salpingo-oophorectomy receive the
endorsement of the operating surgeon of to-day. Do sub-
peritoneal fibroids require removal of the entire uterus? What
about the operation of myomectomy, and what has been your
success with Dr. Baer's method?"

These, and many other questions does he ask; then, possibly, if
time permits, you touch upon the subject of medication in the
treatment of uterine fibroids. He inquires: *^ave you seen good
result from intra-uterine injections of sterilized glycerine, or
from the administration of thyroid extract? What about the use
of ergot, diet, chaAge of climate and occupation for his patient?"
In fact, much time can be pleasantly spent in discussing the par-
ticular case in hand, and yet one cannot but admit that the treat-
ment of uterine fibroids, as studied from the practitioner's stand-
point, is not yet thoroughly settled. You may say to him that
*^o drug has been discovered that has had any influence upon the
growth of uterine fibroids," — perhaps a sweeping assertion on
your part, yet sustained by recent text-books.

He has brought patients through to the menopause, by the giv-
ing of ergot, but they are exceptional cases, more often this
treatment being carried out to the extent that no chance is left
for any operation.

The subject of surgical interference is the important factor,
and as operating surgeons we must bring together, in a happier
combination, the different methods that are now being made use
of by a great variety of successful operators. The operator must
explain to the general practitioner that upon opening the peri-
toneal cavity he may find the case one in which the combined
vaginal route or pan hysterectomy is the proper way. You can
say to him most truthfully, "we must be prepared to do any one of
the operations spoken of." There are complications in all cases,
and I would emphasize, in your conversation with the intelligent
family physician, that if his patient has suffered much pain, and
the growth increased rapidly, we are almost sure to find diseased
ovaries, but, on the other hand, when we consider the nerve symp-
toms that have been brought about by the artificial meno})ause,
we must always consider the advisability of leaving behind
healthv uterine adnexa.

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I am bound to state, as the result of conversation with the
patient's physician, that this reply will be emphasized, "The great
majority of uterine fibroids do demand an early and prompt



A. P. CLAliKE, M.D.

The author says that in operating on cysts or on morbid
growths developing between the broad ligaments, it becomes nec-
essary in order to avoid injuring the ureter and some of the more
important blood vessels, to exercise as much care as is required
in cases of disease demanding hysterectomy.

In those cases in which numerous adhesions have occurred as
the result of inflammatory or of other morbid processes, a loop
of intestine may be found entangled in the mass. Such cases al-
ways necessitate the employment of special precaution lest
in the course of extensive manipulation to free the parts, undue
violence result to important structures involved.

In those cases in which the cysts or growths are only partially
intra-ligamentous, removal by enucleation can be effected more
rapidly. The cavity or bed of the tumor should be obliterated
by suturing its sides together; in cases of such a character the
author further remarks that it will rarely be necessary to ligate
previously the ovarian or other large arteries.

Drainage as far as possible should be dispensed with. Reliance
should be placed on the scrupulous care taken in the management
of the toilet of the peritoneum and on the aseptic condition of all
materials and instruments employed in the operation. Mention
is made of the occurrence of hematoma and hematocele from rup-
ture of the sac of tubal pregnancy within the structure of the
broad ligament and of the necessity of prompt surgical interfer-
ence. When suppurative processes appear or a lithopsedion or
other abnormal formation takes place within the broad ligaments,
the employment of surgical measures should not be deferred.

Varicocele of the broad ligaments is also mentioned. Ex-
cision of the parts, including portions of the ligaments with the
tube and ovary, furnishes in some cases the only safe means for a
permanent cure. Sarcomatous and other malignant neoplasms,
♦Abstract of paper read at Pittsburg, Pa., September 20, 1898.

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involving to any great extent the ligamentous structures, are rarely
overcome by extirpation, excision, or enucleation. Myomatous
and fibro-myoraatous formations originating in those parts de-
mand the early adoption of surgical procedures, on account of
the danger of such growths assuming a malignant transformation.
Cambridge, Mass.




Prior to the enucleation method of Miner, the surgical treat-
ment of these cases was crude and incomplete. Miner's method
marked a new epoch and will ever remain the foundation prin-
ciple of their surgical treatment. It was, however, attended
with so much difficulty and danger as to greatly abridge its use-
fulness. The chief danger was from hemorrhage, which was
oftentimes fearful and not infrequently fatal. Other, by no
means unimportant, dangers came from injuries to important pel-
vic structures while conducting a hurried and blind dissection.
There was a crying need for something better. The essential fac-
tors of the ideal operation are: 1, tapping, to reduce the volume
of the cyst, and to open the way for hemostasis and enucleation ;
2, ligating the supply vessels, to control hemorrhage; 3, enuclea-
tion along the line of cleavage, to insure easy, rapid and safe dis-
section. This technique was foreshadowed in a case which I
operated on the 30th of October, 1894. It was here that I dis-
covered the line of cleavage for the intra-ligamentous cyst and
reported it to the Columbus Academy of Medicine. In 1896,
Kelly announced the line of cleavage for the intra-ligamentous

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