ble of doing so unaided, or, even if she is, it is desirable for reasons mentioned that the woman should be freed from the irritating material within the uterus, and it will be proper to consider measures for its removal. If we wait too long we may have our duty explained to us as in the following: Miss X., taken with flowing; had gone over her time, but denied any indiscretion. Gave sabina 2x and arnica 3x in hourly alternation and ordered rest in bed. After two days flow not ceasing, made examination and found something coming down to external os. Two days later, still farther down and protrudes through the os. Two days later, a young miss, a sister of the patient, called at the door and informed me that "you need not come any more, for we called in another doctor who took it away, and it ought to have been done long ago, and we will never pay you a cent." After one has had this experience thirty or forty times it grows a little monotonous, and he perhaps thinks it time to change his tactics. I have no doubt that if the patient had waited a day or two longer,there would have been no need of manual interference;but that did not help me any,the other doctor reaping all the glory and the banner of homoeopathy was trailed in the dust. I have always felt reasonably sure that when the membranes protrude through the external os, filling it up after the manner of a ball valve, that there was comparatively little danger of excessive hemorrhage, and that they might be safely trusted to themselves, especially if the discharge became offensive leading me to infer that they were sloughing off. There is, in these cases, in my opinion, but little danger of sepsis, as nature, if not hurried, has time to throw out a protecting wall. It is pretty certain that rapid dilatation of the cervix is almost invariabiy attended with laceration of the internal os, therefore it is to be avoided if possible, and in case it does become necessary, the utmost surgical cleanliness should be the rule on account of the raw surface favoring absorption. Thorough irrigation with warm water before and after manipulation, is generally sufficient. The hands i of the operator should previously have beeen thoroughly washed with soap and water, and nails filled with soap,and fingers anointed with some fatty material as vaseline, lard or sweet oil. The simplest expedient is to pass the sound, which in a certain number of cases will stimulate the uterus to the completion of its work. From this we may learn the depth of the uterus, and also by gentle manipulation be enabled to make out position and amount of softened material on the otherwise hard surface of the endometrium. If this is not successful then other measures should be instituted, or they may, if judgment dictates, be put into practice at first. If the uterus will admit of the index finger through the internal os, we may introduce the hand into the vagina if necessary, and scrape the fundus with the nail. This will demand chloroform on account of the painful distension of the vulva when the hand is passed in. If the uterus will not admit the finger, we may be able to pass a small placental forceps and remove as much as we can following with a sharp curette if we think it advisable; of course doing the work as thoroughly as possible. Still even though we do not get it all, the crushing it sustains generally results in the remainder coming away in a day or two. If it does not we can repeat the process. I prefer to have the patient chloroformed in these cases, especially if she is of a nervous temperament and sensitive to pain, for then it is possible to proceed with more deliberation. Sometimes a part comes away, and leaves a small mass of tissues, perhaps not larger than a marble, in the uterus which keep up a drizzle that is very tiresome and irritating to the patient. It is surprising what a small amount of offending material will be sufficient to keep the womans condition below par and render her life miserable. The history of these cases is many times obscure, the patient not having thought herself enceinte, only being conscious of an increased flow, the curette alone revealing the cause of the mischief. CLINICAL CASES IN GYNECOLOGY.' W. M. TROWBRIDGE, M. D. VIROQUA, WIS. Mrs. K. aged 48 years, weight 150 pounds, presented the following history: Has been married for twenty five years, never pregnant, menses were regular up to twelve years ago, when at times they were profuse, patient had received treatment for retroversion for years, but it gave her only temporary relief. Bimanual examination revealed a perineum and cervix intact, cervix being drawn high up and soft;a large globular body filling the pelvic cavity was easily outlined. An attempt was made to pass a uterine sound, but as there was complete stenosis of the internal os it was impossible. Patient complained of constant bearing down pains, obstinate constipation and no hemorrhages. The diagnosis of fibroid was made and the preparations for a laparotomy such as washing the abdomen with soap and sterilized water followed by ether, lastly absolute alcohol and an abdominal compress of five per cent carbolic was applied. Chloroform being used to complete anesthesia, an incision was made in the median line three inches long, and later was enlarged to the umbilicus. The adhesions were broken up, and the growth drawn out of the abdomen. The vessels were secured between two sets of ligatures and divided. A temporary elastic ligature was passed around the neck of uterus and a peritoneal flap made to cover the stump of the cervix. The abdominal wound was closed by interrupted silk worm gut sutures. Iodoform gauze drainage. The patient was in a good deal of pain for the first twenty-four hours, and received during that time a hypodermic of morphia and atropia. She rallied well and at the present writing is able to attend to her household duties. 1. Read before the Wisconsin Homeopathic Medical Society, 1897. REMARKS: This case was an interesting one from the standpoint of diagnosis. Three physicians having examined the case; one diagnosing it as an intra-uterine fibroid, the other two as out side of the uterus. As was stated before it was impossible to pass a sound on account of a stenosed os and on bimanual manipulations we disagreed. We all decided that an operation was indicated and upon an exploratory incision we found it an intrauterine fibroid. Mrs. B. American, age 58 years, weight 150 pounds, married at twenty-one years; menopause established at forty-eight. Patient complained of severe dysmenorrhoea prior to menopause no complaints of pain afterwards. About eight years ago she noticed some enlargement of the abdomen and complained of a dragging feeling and sense of weight in the pelvis. She was examined at that time. and informed she was pregnant. April 2nd, 1897, bimanual examinatian revealed a large tumor, filling the pelvis, and easily outlined. The diagnosis of intra-uterine fibrocystic tumor was made and as the patient suffered so much inconvenience it was deemed advisable to operate. The preliminary preparations for a laparotomy were made, patient was anesthetized and a median incision was made which extended from umbilicus to symphesis pubis, adhesions broken up, the enlarged uterus drawn out of the abdominal cavity and held by an assistant. Professor Pratt's method of removing the uterus was done, such as severing the ovaries and tubes from their attachment to the broad ligaments, continuous suture of cat gut, closing the wounded surfaces. The broad ligament severed from the uterus, its margins coapted by a continuation of the same suture and the uterus amputated at the internal os by the flap method. Tumor removed. When the ovarian arteries were encountered they were secured by a loop of the continuous suture being passed around them. There was only one suture employed that being a continuous one. of catgut. Integument closed by interrupted silk worm gut. No drainage. (Continued on page 50.) DISPLACEMENT OF THE BLADDER WITH CHESTER G. HIGBEE, M. D. ST. PAUL, MINN. It has been the fate of the writer to have charge of several patients afflicted with great urinary troubles that were not only difficult to diagnose but were cured only after months of study and treatment. It is possible that by a brief description of such cases and the treatment given will be of service to others. We will not take your time by giving a detailed account of each case, but give the conclusions after a careful review of them as noted at the time they were under treatment. Every case in the class to which we refer, was complicated with greater or less rupture of the cervix uteri and the perineum. We had treated several cases with little benefit to the patient or satisfaction to the doctor before we recognized the relation of the lesions above referred to, to the urethral and vesical symptoms. At times these symptoms would persist in spite of the most carefully chosen remedies, long after the surgical repair of the cervix and perineum. It was surmised that the tension on the uterus during the operation had been too severe,and that the pains were the result. We learned that the severity and continuance of the pains after the tears were repaired, were proportionate to the time since the injury to those parts occured, the briefer the period the sooner cured. In several old cases it has taken several months to effect a cure. Even in cases in which there was no great displacement of the uterus, if it was one of long standing it was difficult to cure. These cases presented all the symptoms attributable to the bladder and to the urethra and it was only by exclusion that we arrived at a satisfactory diagnosis. We would at times almost conclude that we had malignant disease to treat, and again all acute symptoms would subside so sud 1. Presented to Missouri Valley Hom. Med. Ass'n., Iowa City, Oct. '97. |