adhesions of the fibroid tumor to the abdominal wall and surrounding viscera are present, the patient's pulse soon goes up after they have been disturbed. I have seen the pulse rise in such cases, and the patient gradually succumb to what appeared to be shock. Perhaps in some of these cases of apparent shock both ureters may be tied. DR. HALL (closing the discussion). I assure you, gentlemen, the paper has brought out just what I wanted-a free and liberal discussion. It has interested me very much. In reply to the historical criticism made by one of the speakers in regard to the Baer operation, I will admit laxity on my part in stating the title of my paper when sending it to the secretary. The operation described, however, is not the Baer operation, and I so stated. It is the Baer operation with Kelly's modification and perfection of surgical technique in cases of hysterectomy. I have given all the facts in relation to the sequelae of the operation. This brings me to the consideration of Dr. Baldwin's case of stone in the bladder. His patient had a little uneasiness in the pelvis, a little cystitis, and a stone was found, removed, and in that stone was the thread or ligature. Take almost any of these patients upon whom a supravaginal hysterectomy has been performed, and the pedicle treated as described by Kelly and Noble, with the ligatures below the peritoneum, the peritoneum closed, and the cervix open or not closed, where silk is put underneath the peritoneum we will have a history of irritable bladder, uneasiness in the pelvis with a little lochial discharge. The patient may not complain of it all of the time; it is worse at times. She may think that it comes with the change of life. The silk ligatures come away without a knowledge of either the physician or patient in many instances. It is true, the technique is not complete as yet. One of the speakers referred to making total extirpation, cutting the ligatures short, closing the vagina, and not having any trouble subsequently from the ligatures. I grant that if he uses catgut and it becomes absorbed in every instance, he will not hear of any trouble; but if he uses silk or silkworm-gut, or similar material, he will have trouble months afterward. I want to differ from Dr. McMurtry in reference to the question just touched upon by the President in regard to the ligation of the ureters. I cannot see how in total extirpation there should be any greater difficulty in that direction than in the ordinary supravaginal hysterectomy. We ligate the uterine arteries in the same manner. As regards the question of prolonging the operation in total extirpation, as compared with the supravaginal method, I do not believe it takes any longer after the surgeon has done two or three of these oper ations. No surgeon can perform his first two or three operations by a new method as rapidly as by one he has tried many times. The element of time has no bearing whatever in the two operations, as one can be made just as quickly as the other. There is no more difficulty in making total extirpation than a supravaginal amputation, but it looks like a greater operation for the patient. Coming to the question of ligatures, it has been so thoroughly and freely discussed, that I shall not take up much of your time. I have used silk in all of my intra-abdominal operations, and with the exception of pus cases, I have never heard from a silk ligature after it has been put in the peritoneal cavity. I have only heard from the silk ligature in a small minority of pus cases, the ligature coming out weeks or months afterward Why should we discard silk for catgut? We should have a medium. In some places we should use catgut, where we expect trouble from silk. A gentleman from Buffalo (Dr. Crockett), who is not now in the room, stated that he had used catgut in six hundred cases without any secondary hemorrhage. That is about as good as we can expect silk to do. These results are a little better than most of us get with silk. I said in my paper that I was convinced catgut was not reliable to control hemorrhage. Seeing is believing, and experience is a dear teacher in not a few instances, especially in this regard. It is said that in tying catgut we are certain it will stay in a large majority of cases where we put it. I do not feel as certain that it will stay as I do the silk ligature where I use it, because it is slippery. To overcome the slippery quality of the gut I put it in resin. I have operated on thirty-two cases, doing total extirpation in this manner, and have had good results. Since we are continually changing from one method to another, it shows that we are not satisfied, and that no one method is perfect. Our object is to use that method which will yield the best results. The same applies to ligatures, as well as to the technique of the opera tion. POST-CLIMACTERIC CONDITIONS THAT SIMULATE ADVANCED UTERINE CANCER. BY M. ROSENWASSER, M.D., CLEVELAND. In our efforts to recognize the earliest symptoms of uterine cancer, that it may be eradicated while still local, we are making commendable head way. The teaching is being thoroughly disseminated that irregular hemorrhages and sero-sanguineous discharges are good and sufficient reasons to suspect malignancy, whether occurring during the parturient age, or long after the menopause. Such teaching has already saved, or prolonged, many valuable lives. We cannot, however, quite escape the imputation of loose methods in dealing with advanced malignant disease. Every now and then it occurs that apparently classical cases of advanced or late cancer are declared to be such merely on account of certain marked physical symptoms. As an illustration, let us imagine a woman some years past the menopause; of general cachectic appearance; suffering pain in the pelvis; subject to irregular hemorrhages, or profuse watery, fetid discharges; her womb enlarged, but slightly movable, with an outline somewhat nodular and uneven. Upon this evidence the case is pronounced inoperable, hopelessly incurable. She is furnished with a death-warrant and sent home. It is fortunate if she subsequently falls into the hands of a doubting Thomas, who reviews the testimony, completes the faulty examination, and restores the patient to life and friends. It were exceedingly humiliating should this woman be enticed into the parlor of a wary quack, and ere long walk out, a living witness of the incapacity of the medical profession and an undying advocate of quackery. Obst Soc "Nicht jede Fuerstenreise ist eine Odysse, 11 During the child-bearing period there are so many conditions. that remotely simulate advanced cancer that we are on our guard to carefully differentiate between them. But after the menopause cancer has until recently monopolized the pathologic field to the exclusion of all other diseases. Text-book writers are agreed that the diagnosis of cancer may be difficult in the early stages, but I know of none who has sounded a note of warning against possible errors in the late stages. To avoid mistakes, it must be remembered that the so-called classical symptoms are liable to be present in other (non-malignant) conditions of the genital tract, and that "we only acquire full certainty by scraping out particles and examining them with the microscope."1 Conditions simulating late cancer in the post-climacteric period are comparatively rare. In the majority of cases there is nothing left of the vaginal portion of the cervix, it having disappeared by senile atrophy. The seat of disease is confined to the upper cervical canal or to the uterine cavity. The diagnosis then lies between the disease thus located and corporeal cancer. The cases herein reported will serve to demonstrate that before a positive diagnosis of corporeal cancer can be made all other diseases of the uterine body must have been excluded. SENILE VAGINITIS. It is barely possible that uncomplicated senile vaginitis might be mistaken for malignant degeneration, when the vaginal portion is at the same time eroded and covered with bleeding granulations. The microscope, together with appropriate treatment in case of doubt, will definitely determine the character of the disease. FOREIGN BODY IN THE VAGINA. The symptoms of advanced cancer of the vaginal portion may be simulated by a foreign body in the vagina. An instance of this kind occurred in my experience a few years ago. A friend of mine, himself a competent physician, as had been his father before him, requested me to come by early train to visit his mother. Though for a long time aware of the condition, she had but recently mustered up the courage to take her son into her confidence. She disclosed to him the fact that she had been having an offensive, bloody, watery discharge that was sapping her strength. Her cachectic appearance intensified the doctor's gloomy forebodings. I found a sallow-looking, low-spirited old lady, long past the menopause. There was a foul, sero-purulent vaginal discharge. A soft, loose body lay high in the posterior vault. When withdrawn, it proved to be a rotten sponge. The patient remembered that her late husband had introduced a medicated sponge some time before his death, and that it had never been removed. GANGRENOUS FIBROIDS. Atrophic changes may so seriously interfere with the nutrition of old fibroid tumors of the uterus or cervix as to result in their partial or total disintegration. Clinically we can distinguish such a fibroid by the toughness of the healthy portion and by its elastic resistance to the finger or curette. Dilation of the womb, palpation of the cavity with the finger (when possible), and examination of the scrapings aid in the satisfactory solution of its identity. ATROPHIC, SENILE, OR POST-CLIMACTERIC ENDOMETRITIS. This form of endometritis, due to retrograde changes, has been described in reports of isolated cases many years before Fritsch2 published his complete monograph on the subject. More or less extensive contributions to the literature have since been published. Patru, among the French, and Skene, Sexton, and Mundé,6 in this country, have aided materially in awakening the profession to a realization of the importance of post-climacteric endometritis. Of the many text- and reference-books consulted, I have found but one in which there is any allusion to the disease. One cannot do better than follow Sexton's description: "Most striking of all is the discharge a watery, semi-purulent fluid which barely stains linen, which is different from the ordinary leucorrhea, which is profuse at times, and not infrequently shows considerable admixture of blood. Again, the discharge will become more purulent in character, will irritate the vagina and vulva, as well as the surrounding skin. A characteristic odor is present, sometimes even more offensive than that of cancer. Occasionally the discharge becomes grumous, at which time the odor is more offensive; not infrequently it will cease for an interval of varying length. When it does appear again it is usually with a sudden gush of thin sanious pus. Abdominal pain accompanies these cases, also pain in the back, progressive emaciation and invalidism; furthermore, a slow form of sepsis seems to invade the constitution, and the skin takes on a sallow appearance. These are the features presented by almost all cases." |