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easily caused by retention. How should the result of the
first and second series be reconciled ? When chorionic villi
remain behind, the involution of the uterus is bad and hemor-
rha^s ccmtinue for some time ; but often the transformation
of tne decidna into endometrium proceeds with disturbances.
The shreds which depend half detached into the uterus keep
up continual hyperemia and prevent complete involution.
Tne retention of such shreds occurs most readily when the
vera tears. Still Winter had observed no disturbances in the
thirty cases because the shreds were removed. The result as
to the treatment is, the decidua vera can be left undisturbed,
only loose shreds should be removed.
FooHiEB (Lyons) exhibited


by which eflFective downward traction is made possible. He
also showed an instrument specially devised for puncture of
the posterior vaginal vault.

AuvARD (Paris) read a paper on


Tamponade of the uterus in gynecology and in obstetrics
should oe kept strictlv apart. For its performance the cer-
vix is drawn down with two bullet forceps ; the uterus, for-
nix, and vagina are completely filled. Tne tampons remain
only for a few hours. Dol^ris has employed the same procedure
At the Charit6 in Paris in two cases with good results. It is
a powerf al hemostatic measure. Auvara has used it in 67
cases, with a mortality of 6 per cent : 3 of syncope, 1 of sep-
ticemia, 1 of eclampsia.

DuEHBSSEN (Berlin). — Besides Auvard, Pasquale and Fochier
have likewise warmly advocated Duehrssen's method. In the
tamponade of the utero-vaginal canal we possess a reliable
and nannless hemostatic measure, the most certain of all in
hemorrhage from atony and laceration. Of late Daehrssen has
tamjponed with sterilized gauze. For this purpose he uses a
double box, the inner of which is filled with gauze and steril-
ized with a current of steam. Tamponade has passed
through its baptism of fire in Germany and largely in foreign
countries. In only four cases did it fail to arrest the hemor-
rhage ; in one the tamponade was too loose, the other three
were cases of placenta previa. In all cases of hemorrhage
from the lower uterine segment, the lower portion of the va-
gina should be filled with the less pervious cotton. Should

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the hemorrhage then become internal and the nteras bedoroe
distended — an accident never observed by Dnehrssen — it can
easily be overcome by pressing the uterus against the tampon
within it. Success alone sanctifies the means. In reply to
Olshausen he would state that the tamponade is recognized
as a harmless measure not only in Germany, but also in Eng-
land and elsewhere. By no means should the uterus he
inverted and constricted, as has been proposed, in cases of

VoN Bamdohb (New York) has employed the tamponade
four times after all other means had been exhausted and the
women were almoBt moribund. In ten other cases the same
experience was had. All his colleagues in New York were
fully in accord with this method.

Thirteenth Session, August 9th, 8 a.m.
Peof. Wlnckel (Munich) in the Chair.
Enostbom (Helsingfors) read a paper on


Myomata of the uterus are products of irritation. They
standi in connection with menstrual congestion. For (1) there
are no congenital myomata ; (2) they never arise after the
menopausCjbut only during sexual activity. But this is not
the only etiological factor. Engstrora believer in a certaiu
heredity. In proof he cited four cases in which two sisters
were suffering from myomata, and in two others the mother
was likewise affected.

Ephbaim Cutteb (New York) read a paper on


In October, 1877, he publislied in this Joubnal a series of
cases treated by a diet of meat and hot water according to
the Salisbury system. All of these cases are now alive and
well. The growth of myomata is caused by an imperfect ac-
tion of the normal tissue metabolism. To reraeay this the
systemic power must be improved or restored by : (a) Proper
feeding, hygiene, tonic medicine ; (b) Stopping useless expen-
diture of nerve force in work, worry, or pleasure ; (c) Confer-
renee of force by massage, horse exercise, etc. ; (<i) Inspira-
tion and hope ; (e) Galvanism in certain cases.

Eastman (Indianapolis) exhibited an instrument for the re-
moval of uterine fibroids.

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Fritsoh (Breslau) read a papej^ on


There are diflFerent methods of treating mvomata. Castra-
tion, in the first place, is indicated when the patient is too
weak to bear a graver operation, or when the myoma is still
small. However, the cure after castration is not always defini-
tive. In two cases Fritsch has been obliged to perform lap-
aro-myomotomy subsequently because the hemorrnagesdidnot

Enucleation of the myomata from the uterine parenchyma
— an operation for which we are indebted to A. Martin — is
sometimes indicated. In this operation we must seriously
consider whether the principle of the conservative method is
to be maintained. For if, owing to the extent of the ope-
ration, future impregnation of tne woman is no longer pos-
sible, it is unnecessary to preserve the organ, as it is useless.
Besides, we cannot exclude the possibility of a subsequent de-
velopment in the same patient of additional myomata from
small germs which did not manifest themselves during the
operation. For this reason Fritsch would perform enuclea-
tion only in cases in which the tumor lies close under the peri-
toneum — that is to say, where we have no longer to deal with
subperitoneal myomata sessile on a broad base.

As regards hysterectomy, the different methods of operation
are immaterial in view of the question whether the mode is
to be intraperitoneal or extraperitoneal. Fritsch looks upon
his method as an extraperitoneal one. He has thus far
performed 87 laparo-myomotomies, 60 of them according
to his method, of whom he has lost 8. Having had sucii
good results, Fritsch believes himself justified in adhering
to his method, although he admits that it needs to be perfect-
ed technically. On principle it is probably more correct to
remove the entire uterus with its cervix.

BoisLEux (Paris) read a paper on


In ten cases of supravaginal amputation of the uterus per-
formed in A. Martin's clinic at Berlin, Boisleux has examined
the mucosa both of the body and the cervix for the presence
of micro-organisms. Having found twice in the body and
seven times in the cervix microbes which proved fatal in
two instances to animals inoculated with them, he urgently
advises to cauterize the cervical stump thoroughly witli the
thermo-cautery in all cases in which the stump is to be treated

With reference to the question of asepsis and antisepsis in

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laparatomies, Boisleux advises to operate asepticallj only in
ovarian cysts and extra-uterine pregnancies, because they are
sterile jp^ se; but antiseptically — that is to say, with the use
of antiseptic drugs — in myoinata, malignant tumors, pyo^-
pinx, ovarian abscess, and pelvic abscess. In all such cases the
antiseptic fluid employed is to prevent the further develop-
ment of the germs.
Edebohls (New York) spoke on

He explained a modification devised by him of the Alexan-
der-Adams operation of shortening the round ligaments. In
nearly all cases he has observed very good results.

Arendt (Berlin) read a paper on

the contractile power of the uterus and its practical


Uterine contractions occur on the slightest touch of the or-
gan during any diagnostic examination. Daring the action of
strong irritations, such as raassaffe of the uterus or displace-
ment of the organ upward or sidewise, these contractions in-
crease to the hardness of a fibroma. At the same time the
uterus becomes strongly anteverted and smaller. The dura-
tion of the contraotion depends upon the nature of the uterine
tissue. This mechanically evoked contraction can be em-
ployed therapeutically in metritis, endometritis, subinvolu-
tion, hyperemia, and in some cases of retroflexion. When
the erection of a retroflexed uterus is rendered difficult
through softness of the isthmus, massage of the region of the
external os can be performed from the rectum and the abdomi-
nal walls ; thereby the uterus becomes hard, the isthmus fina,
and the reposition is facilitated.

L. Meyer (Copenhagen) read a paper on


The long delay caused in labor by the wrong engagement
of the small fontanelle posteriorly, and which can only be cor-
rected with great difficulty by tne corresponding application
of the forceps in the manner recommended by Lange and
Scanzoni, has induced Meyer to devise another method for
this complication. He found that by external pressure the
small fontanelle moved downward and forward, and that on
relaxing this pressure it returned to the posterior position. By
having this external pressure performea by an assistant, and
supporting it from within, he succeeded in bringing the small
fontanelle farther forward with the hand, and, at ter fixing the
head in this position by the external pressure and app^ing

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the forceps, in terminating the labor with the small fontanelle
directed forward. In this way he has happily delivered four
DoMBSowsKi (Moscow) exhibited a very large


which had caused great difficulties, during operation, by many
adhesions. After removal the cyst was found to contain a
great mass of bone formed exactly like a pelvis.
Bossi (Genoa) described


in suitable cases. It is introduced into the cervix, which it
forcibly dilates by the action of a screw.
Lb Torre (Koine) exhibited a


which he had employed with good results after all other at-
tempts had proved fruitless. The instrument consists of an
olive-shaped bulb with a handle. By the action of a screw in
the handle the bulb expands greatly and thus dilates the

The president, Prof. Winckbl, closed the sessions with a
vote of thanks to Dr. A. Martin, who had directed the ses-
sions of the section in a most careful and amiable manner.




Stated Meeting^ January nth, 1890.

Dr. J. Taber Johnson, President, in the Chair,

Dr. T. 0. Smith read the paper of the evening, entitled

oases in PRACTICE.*

In the absence of Dr. Prentiss, who had been appointed to
open the discussion, the President called upon Dr. H. L. E.

Dr. H. L. E. Johnson said he thought that the diagnosis in
the first case might be questioned as one of erysipelas ; from

^ See original article, page 1076.


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the higtory given and the rapid recovery after the evacuation
of snch a quantity of pus, it iniffht have been entirely due to
the burrowing of an abscess. This peculiar condition of the
integument is often caused by pus burrowing. The secoud
case was certainly an unusual one, if it was not one of extra-
uterine pregnancy. The treatment, considering a possible
doubt in diagnosis, he would not discuss. In the case of
hemorrhage from the vagina, he could not see how a vagina
could be so torn by any syringe. It would require consider-
able force to inflict such an injury, and the pain Decessarily
produced would have been a guide to the patient to discontinue
the force or pressure. The vagina is tough, and when we re-
member the force exerted upon it by the head during parturi-
tion, and the use of instruments without causing lacerations, he
could not believe this injury to be so inflicted. He haridly
thought the examination made by Dr. Smith was sufficient,
considering the amount of hemorrhage ; also whether a tampon
was proper treatment, especially wTieu the hemorrhage was
not in the least controlled. He should liave examined the
case thoroughly, and discovered the cause of the bleeding,
and then given the treatment indicated.

Dr. fiusBY asked Dr. Johnson what he would consider
proper treatment.

Dr. Johnson replied that a thorough examination should
have been made, and the wound should have been brought
together by a suture. He certainly would not have introduced
persulphate of iron into a wound, which might probably pro-
duce sloughing into the peritoneal cavity.

Dr. Thobcpson, being asked his opinion of the cases reported,
said he considered the first case reported undoubtedly one of
erysipelas, as diagnosed by Dr. Smith, and not due to the bur-
rowing of an abscess.

He spoke of a case, similar to the one reported, upon which
he had operated yesterday, and from which he removed large
masses of sloughing tissue. Fluctuation in these oases is not
always possible, on account of infiltration of tissue superven-
ing ; he thought it hardly probable that the pus formed in
twenty-four hours, as stated, but was not discovered before.

In reference to the second case, in general surgery he pre-
fers to evacuate large collections of blood by the aspirator,
rather than leave them to the slow process of absorption. In
hematocele (pelvic), when diagnosis is earlv made> he thinks
the plan by vaginal puncture would be pre^rable to waiting.

He thought the treatment of the case of vaginal hemor-
rhage was the one that would have been generdly followed.
Whereas ho did not generally favor astringents, he considered
it good practice in such cases as the one reported.

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He would say that one would find it extremely difficult to
apply a li^ture in such a |>osition in so deep a vagina.

Dr. H. L. E. Johnson said that the difficulty of making a
diagnosis is not an excuse for not making it, but all the more
canse for searching. When it was found that hemorrhage con«-
tinned notwithstanding the tampon, which generally checks
a much more severe hemorrhage than this, he thinks a very
careful examination should have been made at once. The
tampon will in severe cases, when properly introduced,
check all external hemorrhage, preventing all escape, and
even -cause the blood to be retamed until suflacient has escaped
to canse great distention of the uterus.

The cause for greater search was indicated, for after
the introduction of the tampon the flow was so severe that,
as Dr. Smith states, the woman was ill from loss of bloody
and so ill that he had to see her to her home. The in-
inry must have been inflicted upon some deep-seated vessely
for after quite extensive laceration there is generally very
little hemorrhage.

Db. Smith. — In answer to the criticisms of Dr. Johnson, it
may be said that the cases reported were of interest to me be-
cause of their unusual character. The report does not enter
into that painful detail of symptoms and methods of treat-
ment which would only have served for "padding." The
salient points were noted, and the reasons for considering the
matters interesting were duly given. Dr. Johnson's agnosti-
cism makes it difficult to reply to him. He doubts the cor-
rectness of the dia^osis in the first case, and says the condi-
tion of the skin might have been due to pus burrowing. I
deny the correctness of the explanation, and differ with him
in the statement that such a condition of the integument as
that described as occurring in ray jjatient " is often caused by
pus burrowing." When he can cite such a case it will be
time enough to consider the necessity for making a differ-
ential diagnosis. But Dr. Thompson has already sufficiently
answered the doctor's criticism. Then, again, the doctor,
by implication, assumes that the second caise (hematocele)
might have been one of extra-uterine pregnancy. He
gives no reason for his belief. I have already stated that
no occasion existed for making a differential examination in
order to exclude the question of ectopic gestation ; it is,
therefore, unnecessary to say anything further on that point.

Concerning the case of varinal hemorrhage the doctor is
even more at sea than -ever. He says he cannot believe the
injury to have been inflicted in the manner indicated. I an-
swer by saying that the lady's statement is entitled to entire
indorsement, notwithstanding the doctor's incredulity. He
fails to state any other manner in which the injury might

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have been iDfiicted. It was a matter of snrpriBe to me that
such a lesion, followed by so severe a hemorrnage, could have
been received without the infliction of more pain, and that
was stated as an interesting point in the case. In relation
to the sufficiency of the examinations made by me at my
office and elsewhere, it is only necessary to say that the in-
vestigations were as complete as the case seemed to call
for, and the finding of the "punched " opening in the va-
ginal fornix was unexpected, having in view the absence of
a history of traumatism sufficient to injure the vaginal wall
The patient's statement that she had only recovered from her
menstrual period during the preceding week, and that on in-
troducing the nozzle of the syringe she had experienced some
pain from the contact of the point with the vagina, induced
me to believe that the hemorrhage was only a return of the
menses, as already stated. It was believed that the tampon
would check the hemorrhage, but it failed to do so, and this
occasioned me some annoyance. The doctor questions whether
the treatment by tampon was correct, inasmuch as it had failed
to control the now. In answer I would say that the use of
the tampon was correct, whether it controlled the hemorrhage
or not. The cotton introduced before the lady left my office
was not packed tightly ; that placed in the vagina after reach-
ing her house was securely fixed. When it was found, three
hours later, that the hemorrhage had returned, further inves-
tigation revealed the cause, and the application of the Monsel's
solution, fortified by another tampon, effectually arrested the
flow. Dr. Johnson makes a remarkable statement concern-
ing the tampon. He says the tampon will in severe cases,
when properly introducea, check hemorrhage, and even cause
the blood to be retained until it causes great distention of
the uterus. It has never been ray fortune to read of a
case where the uterus was distended by retained blood after
the use of a tampon to correct a vi^nal hemorrhage, nor do I
believe any one else has ever met with such a case. I believe
the use of the iron solution in this case was proper. I do not
believe Dr. Johnson or any other physician would have
tried to suture the wound in the vagina of my patient, if the
>case had fallen into his hands.

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1. Fehling, H. : Some Rehabks on the Etiology of Myo-
MATA AND THE Method OF Myomotomy {CentrcHbl. f. Oyn.^ Jtily
19th, 1890). — The author has always contended that, contrary
to prevailing opinion, unmarried women were more subject to
myomata than those married. Of 189 cases of myomata at
the Basle clinic, 65.6 per cent were married and 34.4 per cent
single, or 2 to 1 ; in the general population there are, how-
ever, 3 married women to 1 single woman of ages varying
from 21 to 60 years ; between 30 and 50 years there are 3.4
married to 1 single. He feels certain that a similar propor-
tion obtains with other localities. It is obvious that the unin-
terrupted menstruation should favor the development of myo-
mata. As regards the operative technique, he seeks to shorten
the period of^ recovery by cutting off the stump close to the
rubber ligature between the fourteenth and twenty-first days ;
if the ligature be closely hugged on cutting there is no danger
of secondary hemorrhage. As soon as the wound is clear and
united in its lower portions, he proceeds to the secondary su-
taring of the abdommal coverings, which are left ununited at
the primary operation, avoiding the peritoneum. The wound,
after it and the surrounding skin are disinfected, is scraped out,
the borders of the skin wound freshened, and the abdominal
wound closed by deep and superfcial silver sutures. A thin
drain is placed in the cervical region. Healing is essentially
hastened. l. r.

2. SippBL, A.: Castration in Osteomalacia {CentrcMl,/.
Ch/n,^ No. 33, 1890). — The author gives the history of a case
of osteomalacia in which castration effected a cure. The pa-
tient was 36 years old, and since a miscarriage between the
fourth and fifth labors, which was accompanied by profuse
hemorrhage, suffered from osteomalacia. The vertebrae were
distorted : the pelvic bones were so greatly bent that a finger
could not be pushed between the symphysis. There were pro-
fuse menstruation and constant pains. At the operation the
conjugate was found so narrowea as to preclude the admission
of two fingers. The patient was discharged four weeks later.
The bleedings ceased ; the pains persisted during the first
weeks, but gradually subsided and eventually ceased. Patient
feels perfectly well, and is able to pursue her usual avocations.
The operation was performed mainly because of the profuse

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1174 AB8TBA0T8.

bleedings, and the author believes that the cure was probably
in soma measure due to the cessation of the loss of blood.

L. B.

3 Fai.k, E. : The Utbeine Antbophobb {CeniraJhl.f. (ryiu,
No. 33, 1890). — At the snffgestion of Dr. Landau, the author
experimented with antrophores, used for some time for the
male urethra, modified so that thej could be utilized in intra-
uterine medication. The va^a and portio were first disin-
fected, and the antrophore mtroduced by a pair of forceps
through a c;^lindrical speculum without dilating the cerviod
canal ; the instrument was left in situ for ten minutes, and
then the spiral was removed, the medicament having by this
time been thoroughly dissolved. Positive dosage may be had
with this instnunent. In fungoid endometritis antrophores
with zinc chloride (1 per cent), cupric sulphate (0.8 to 1 per
cent), resorcin (10 per cent), tannin (5 to 10 per cent), were
found the most efficacious ; while in gonorrheal endoraetritifi
sublimate (0.1 per cent), creasote (2 per cent), and espedaUj
sublimate fO.l per cent) with zinc chloride (1 per cent), were
found useiul. As zinc chloride, resorcin, and creasote pro-
duced uterine colic, the antrophores were coated with a layer
of cocaine, with which the procedure was painless. The au-
thor will report more in extenso at a later aate. l. b.

4. Brosin: Extbenax Version wrrn the Second Twin
{Cmt/ralbl. f. Oyn,, No. 36, 1890).— B. contends that internal
version can always be avoided with the second twin ; if the
membranes are intact and the pelvic normal, external version
ought never to fail. The birth of the first child has prepared
the parturient canal for the exit of the second ; if tne mem-
branes have ruptured, success may still be achieved as long as
violent pains have not wedged the shoulder into the pelvis.
External version possesses the advantage of minimizing the
danger of infection. l. r.

5. Elbino, K. : A LrraoPEDiON in the Kudhcentart Horn or
A. Uterus Bioornis oomplioated with Preonanot of the other
Horn {St. Petershvrger Med. Wochen., No. 33, 1890).— The pa-
tient, a peasant woman, had been delivered by a midwife^ but,
as the latter had diagnosticated twin pregnancy, the author was
called in consultation. Durinfi: her previous and first pr^-
nancy the abdomen was remarkably enlarged and fetal move-
ments were felt on both sides, those on the left side, however,
ceasing toward the end of pregnancy ; her labor was normaL
but the enlargement of the abdomen persisted, and was ac*
companied by Durning pains in the leftside of the abdomen,
which disappeared about seven weeks afterwards; the pain

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AB8TRA0T8. 1175

was aoeompanied by fever. The second pregnancy was nor-
mal. When the author arrived one child was bom ; the pla-
centa had not yet come away ; the abdomen was still enlarged,
fetal parts palpable in the left hypochondrium ; they felt very

Online LibrarySociété d'émulation de l'AinThe American journal of obstetrics and diseases of women and children → online text (page 116 of 146)