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J. A. (Joel Asaph) Allen.

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symptoms. If those symptoms were relieved, then we may claim
that the operation was justified.

One of the great faults committed by those condemning the
removal of diseased tubes and ovaries, is that of assuming that
these patients must necessarily be completely rejuvenated. No
other surgical procedure is subjected to such a test.

In almost every chronic case, or in every case in which the
operation is a severe one, there are certain influences remaining
which retard or hinder the complete recovery. Let us consider
some of the principal disadvantages under which these operations
are performed, and which may be inseparable from the operation
itself.

1. Ventral Hernia.

Every abdominal section which necessitates the use of a drain-
age-tube, must leave a weak spot in the abdominal wall. I know
of two hernias following my operations, aside from the one which
I sewed up. In surgical procedures of great urgency, this con-
sideration is of little importance. But, in those cases in which
operation is not imperative, this danger should be given full
weight. To be sure, the closure of a small ventral opening is
neither difficult nor dangerous, but patients who have once been
through the discomforts of abdominal section, are very loath to
submit themselves again to the surgeon's knife.

2. The impossibility of leaving the pelvis in an absolutely
normal condition.

In cases in which large pus tubes or densely adherent append-
ages are removed, a more or less extensive raw surface is left
behind. The intestines themselves may be injured over consider-
able areas of their peritoneal surface. Adhesions are thus pro-
duced which drag upon or compress the surrounding viscera, and
interfere, to a greater or less degree, with the physiological func-
tions of these organs. It is surprising that more trouble does
not result from this cause when we see the extensive raw surfaces
often left in the pelvis after completing some of these operations.
There are cases reported where the abdomen has been opened a



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CROCKBTT : BBMOVAL OF DISEASED UTERINE APPENDAGES. 887

second time, in order to break ap adhesions about a stump. If we
cannot have a normal pelvis, we may at least substitute a lesser
for a greater evil.

3. Neglect of treating all the disease.

Salpingitis is almost invariably an extension of endometritis.
The roots of the trouble remain behind in the uterus. As may be
seen, several of my cases came back complaining of symptoms of
endometritis. It should be made an invariable rule to precede
salpingo-o(5phorectomy with curettement of the uterus, even if
endometrial symptoms are not prominent. Some authorities
advocate removal of the uterus in toto. Where a thoroughly
diseased organ is present, such a step seems reasonable. Why
should we expect very brilliant results when merely a portion of
the diseased structures has been removed ? The presence of a
diseased uterus will account for many of the disappointments
following salpingo-oOphorectomy.

Under this same head should be mentioned the neglect to
fasten a displaced uterus in proper position.

4. The ultimate results of this operation are influenced very
largely by the effect of long-standing tubal disease upon other
organs, particularly the nervous system.

In those cases which have been accompanied by pain, due to
irritation of the nerves radiating from the pelvis, it is reasonable
to suppose that a certain amount of neuritis is produced. Even if
we remove the irritant, we have left the more or less permanent
changes in the nerves. It is well known that headache is produced
by refractive errors in the eye, and it is often observed that after those
errors are corrected by proper glasses, the headaches may continue
for several months. Why should not the same thing occur after
operation in cases of long-standing pelvic disease ? Again, pain
is supposed to be due to wave-like impressions along the nerves.
After removal of the diseased appendages, the wind is lulled, but
the waves continue, for a time at least. Many physicians seem to
expect that a woman can suffer for years from pelvic disease, and
that if, directly after the operation, she does not walk out of the
hospital a well woman, the treatment has been a failure. Such an
idea, to my mind, is absurd, and simply shows the lack of common
sense manifested in discussing this subject.

5. Affection of other organs dependent or independent of
disease in the pelvis.

This consideration is closely allied with the preceding. If, for



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388 CROCKETT : BBMOVAL OF DISEASED UTERINE APPENDAGES.

years, natrition and excretion have been faulty, it stands to reason
that it will take time to bring our patient's health up to par. The
surgeon can very properly take the ground that the removal of
organs which are acting as a focus of irritation will allow a better
opportunity for the vital processes of the body to pursue a natural
course. These processes may have been permanently impaired,
but it is from disease and not from operation.

6. Effect of long suffering and treatment on the patient's
morale.

Women who have for years spent a portion of every day in
considering what aches or pains they have, and whether this or
that treatment does or does not relieve them, are very apt to
develop a habit of excessive introspection. Then, if a surgeon
makes the mistake of promising a miracle by an operation, he will
merit his fate. After operation in such cases, every minute sensa-
tion is magnified into a pain, multiplied by the amount of disap-
pointment experienced. I believe that a great many of those cases
reported worse after operation are cases of this kind. I believe
that the patient forgets how bad her condition was before, and
that a careful, minute interrogation will show that although not
cured, she is distinctly better. In other cases, the patient's state-
ments are absolutely untrue. Because they are not entirely well,
they will tell you that they are no better. We all see such people
outside of surgery, and their statements should not be accepted
without question.

7. Patient's subsequent occupation and condition of life.

One of my patients complains of backache. I find her occu-
pation to be that of a cook in a restaurant, hours from 7 a. ii. to
7 p. M., and work hard. I also find that this backache comes on
about 4 p. M. I think that many of us, under the same circum-
stances, would have backache much earlier in the day. And yet,
bow easy for the non-operative enthusiast to hold this patient up
as a failure, merely by omitting to state that previous to the
operation she was unable to be about her own house.

What shall we say of the patients pursuing their vocations in
the infected districts ? If such patients, six months after opera-
tion, are not entirely well, does it prove anything against the
operation ?

Almost all hospital patients go back to a life of hard work ;
work which often breaks down a healthy woman. Under these
circumstances, I can easily imagine a patient not so well at the



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CBOCKBTT : KBMOYAL OF DISEASED UTBBIMB APPENDAGES. 38V

end of two years as at the end of one year, and here again is a
splendid opportnnity for those who wish to gather evidence
against ophoro-salpingectomy. As will be seen later, it is not
my intention to make any extravagant claims in favor of opera-
tion, bat I do wish to expose some of the fallacies of the argu-
ments of the other side. It seems to me that the mere fact that
many of these patients whom I have reported are able at all to
perform their presejit occupations, is evidence speaking well for
the operative treatment.

8. Lack of skill and judgment on the part of the operator.

A few months ago I saw a patient whose abdomen had been
opened and closed again, because there were adhesions between
the ovary and rectum. This patient is not enthusiastic over surgi-
cal treatment, and the case is probably one of a large class. Again,
there are plenty of cases in which the appendages are removed
when the cause of the suffering was elsewhere. It is needless to
say that such cases go to swell the number of failures, but it is
the operator who is the failure.

In the treatment of the non-cystic form of o^phoro-salpingitis,
the electrician competes with the surgeon, and claims the most
brilliant results for electricity. Dr. Sanders, in a recent article,
reports twenty-two cures out of twenty-five cases treated. He
states that from six months to one year may be required for treat-
ment. In not one of the cases in my list could the patient afford
to spend such a length of time in treatment. We hear so much
about the eager young operator who wishes to add another victim
to his list, but I take it that, apart from a question of conscience, it
is distinctly to the physician's advantage to 6ure his patient, and
that none of us can afford to turn loose in the community a number
of << mutilated " and complaining women. The electricians never
seem to consider that the reason so many salpingo-o(5phorectomies
are performed is because most patients cannot carry out any long-
continued course of treatment. Personally, I had rather cure my
patient without an operation, and I would always use various
local methods of treatment before resorting to the knife. I have
not yet had the good fortune to cure a case of markedly diseased
uterine appendages by means of electricity or any other local
methods of treatment, where the trouble has existed as great a
length of time as in my operative cases. In eleven of my salpingo-
oOphorectomies, no other treatment except operation would have
been proper. In the other nine, outside of the fatal case, the



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390 CROCKETT : BBMOYAL OF DISEASED UTERINE APPENDAGES.

subsequent history speaks in favor of the treatment pursued. As
a rule, the most unsatisfactory results have been in those cases
which, month after month, have been subjected to local treatment ;
not only with no improvement to the diseased structures, but with
a distinct impairment of the general health due to long-continued
suffering.

It is not my intention to advocate any pet method of treat-
ment, but merely to place these clinical observations on record,
and give the general practitioners an opportunity to judge of the
question for themselves, by clearing away the smoke of the conflict,
and presenting to them the following conclusions regarding oper-
ative treatment in cases of diseased appendages :

1. Each case must be judged on its own merits and surround-
ing circumstances. There is no one form of treatment which will
guarantee a cure.

2. Salpingo-oophorectomy stands on the same level as any
other surgical procedure, and its results are influenced by a
variety of elements which may play a part after any surgical
method of treatment.

3. The results of salpingo-oOphoreotomy are sufficiently
encouraging to justify its performance after milder methods have
failed. The most serious mistakes the physician can make are :
(a), continuing local treatment after such a course has proven
worthless ; (^), making too positive assertions as to the favorable
result of the treatment.

The operation is not a guarantee against poverty or old age,
but justice to the patient requires prejudice to be put one side and
a fair chance given her to regain her health.



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uabtw^ig: prostatic disease. 897

PROSTATIC DISEASES WITH SPECIAL REFERENCE TO
THE PROSTATE OF OLD AGE.»

By MARCELL HARTWIG, M. D., Buffalo, N. Y.

The deficiency of my knowledge in regard to the subject chosen
for an introduction to the discussion of tonight has made me grasp
it with eagerness, in the hope of eliciting for myself something
worth the while in practice, by searching the literature ; but, I am
sorry to say that my somewhat sanguine hopes have been sadly
disappointed. In spite of all endeavors and surgical daring,
especially fostered and developed in the last few years, incidental
to the spread of antisepsis and asepsis, with their marvelous
advances and results, the benefits from operating in prostatic
hypertrophy have remained very limited indeed. I am jumping
in tnedias res. Let us first duly consider the rest of prostatic
diseases. We may divide them in : (1) Faults of prime formation ;
(2) cuts, bruises and hemorrhage ; (3) acute purulent prosta-
titis ; (4) chronic prostatiti» and prostatorrhea ; (5) tuberculosis ;
(6) atrophy ; (7) tumors, especially cancers ; (8) stones in the
prostata; (9) neurosis (respectively fissures of the prostate) (Home) ;
(10) hypertrophy and fibromyomata.

I. Faults of prime formation of surgical importance are
cysts, probably retentive cysts, from dilated ducts. I could not
find a case which was diagnosticated before operation, although such
diagnosis would be all important, because a very simple puncture
should suffice. Everybody ought to think of a cyst when prosta-
tic obstruction occurs in early age, and he may, by deftly feeling,
possibly discover it by bulbous bougie and rectal palpation com-
bined.

II. The prostate is very seldom the sole organ wounded,
because of its secluded position, and if it is, the other organs
which have been cut have predominant importance, still it may
happen that the prostate is Etabbed, and bleeds profusely. Pres-
sure by a rectal colpeurynter is mostly sufficient. It is not to be
forgotten that the blood may escape unseen into the bladder and
cause profound anemia before discovered, even where we operate
ourselves. So we have to remain on guard. Israel has reported a
most astounding case, a few years ago. Where doubt exists, the
bladder should be catheterized, a small stab wound in the peri-
neum enlarged, and, if danger is apparent, suprapubic incision
added, and the prostate cauterized, or tamponed from above.

1. Read before the Buffalo Academy of Medicine, December 6, 1893.



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398 HAETWIG : PBOSTATIC DI8BASB.

Trendelenburg's posture is the most advantageous for seeing from
above the pubis.

III. The causes of acute purulent prostatitis are somewhat
dark yet. This is a field where bacteriological research will earn
fiome laurels yet in coming times. Gonorrhea seems a frequent
«ause. Wound infection is another, but some cases have hitherto
defied explanation (my case). The course of the disease is varied.
In the majority of cases, the abscess ruptures into the urethra,
but sometimes into the perineum, exceptionally above the fascia
profunda, and then it may extend behind the peritoneum till to
the diaphragm, and is most likely to end in death. Fever is some-
times high, chills frequent, pain, of course, located in the perineum.
Inability to urinate appears early. Diagnosis ought to be made
as early as possible, and incision from within the urethra ditto.
Only when rectal or perineal edema exists already, I doubt whether
intraurethral incision will sufiice, as there may exist already
paraprostatic abscess, which, by all means, demands perineal inci-
sion. As a matter of fact, the majority of abscesses broke spon-
taneously into the urethra, those which the surgeons incised were
all attacked from the perineum. The proceeding needs no descrip-
tion ; it could be questioned only whether to incise in the rhaph^
or by a cut around the front of the rectal sphincter. The latter
incision gives more space, and I should prefer it, if suspecting that
the fascia profunda is broken and the retroperitoneal space
infected.

lY. Chronic prostatitis may be purulent and form an abscess
which can be detected by rectal and combined palpation, and, of
course, incised, as above described, for acute cases, but, as a rule,
this form is characterized merely by a feeling of heaviness in the
perineum, some pain in ejaculation, and prostatorrhea. Patients
with chronic prostatitis are inclined to hypochondria and neuras-
thenia. The cause is almost always gonorrhea or self-abuse.
The differential diagnosis is by no means easy, and many cases
remain forever dubious. The size and feel of the prostate show
DO distinctive feature ; the only means of diagnosis lie in the
microscopical examination. Azoospermia and urethritis posterior
are most likely mistaken for chronic prostatitis. The posterior
urethritis carries more cells resembling pus. Azoospermia is
mostly connected with want of erections. Spermatorrhea carries
the characteristic sperma. Catarrhal condition of Littre's and
Cowper's glands shows a glassy appearance of the secretion,



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uabtwig: prostatic disease. 399

t

while the prostatic jaioe is milky, has the characteristic odor (not
the sperma), and contains globules, which some call amyloid,
while Posner thinks to have it proven that they are lecithin. The
most unmistakable proof can be had by producing the Boettcher-
Oharcot crystals. One drop of the secretion is mixed with one
drop of a one per cent, solution of phosphate of ammonia, and
after standing under the coverglass for a while, shows the crystals,
the base of which is C H^ N*. The simplest way of obtaining the
prostatic juice is by expressing the prostate from the rectum
after urinating. I have found that the quantity in a case of
chronic prostatorrhea was largely diminished the day after a
night-emission. Treatment must be tonic. The best results are
obtained, where complicating stricture exists, by curing the latter.
Aside from general tonifying, strychnine and ergotine in supposi-
tory I have found useful, but I rely most on reducing sensualism,
(Bromides) and the application of electricity upon the colliculus
seminalis: the Faradic current, as a milder means ; the galvanic,
which, of course, cauterizes, as a more formidable weapon. So the
treatment is the same as for genuine spermatorrhea. E. H. Fen-
wick says liquid extract of salix nigra, 3i, three times a day,
checks involuntary emissions, if prostatitis be due to masturbation
or excess in venery.

The prostate unmistakably is an organ of the genital apparatus,
and empties itself during the orgasm. Its juice excites the



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 40 of 78)