OBSTETRICS AND DISEASES OF WOMEN.

357 Mr. STANLEY BOYD (London) doubted the value of the posterior part of the pelvis. In such cases there is generally method unless it possessed a selective power over the a pyosalpinx or an ovarian abscess. (d) The sudden appearance of symptoms of general septic infection in a patient malignant growth; this was perhaps the case. Mr. A. NEVE (Kashmir) pointed out that in India the with a more or less definite history of pelvic inflammation death-rate from chloroform was only about 1 in 8000 at the and a localised swelling above the vaginal roof. Such cases. most and in one collection of 100,000 cases no death had urgently need surgical intervention. They will often beoccurred. This he attributed chiefly to the high temperature found to be examples of tubo-ovarian abscess. The abovein India and he especially urged the importance of not are instances of suppurative inflammation of the appendages. piling on chloroform during struggling. At his suggestion In cases of non-suppurativeinflammation gradual recovery the Section passed a resolution asking the Indian Govern- may usually be expected to take place without operation. ment to publish yearly the statistics of cases of administra- But operative interference is indicated even here if there iFreason to suspect complications such as incipient cystic tion of chloroform and the deaths therefrom. Mr. C. YELVERTON EEARSON (Cork) read the notes of a disease of the ovary, or if the circumstances of the patient case of a Large Spina Bifida (Meningomyelocele) which he being such as to render it highly important that she should. had treated successfully by the open method. The improve- be restored to health quickly, and the alternatives havingment in the paralysis which had been present was marked. been frankly explained to her, she should decide in favouiA point of importance in the operation was that the head of operation. 2. With regard to the choice of time for must be low. operation it is no doubt wise, in the majority of cases, tc, In the afternoon Mr. MITCHELL BANKS gave a lantern defer operation until acute symptoms of localised peritonitis. have subsided. This has been adopted as a general rule ofdemonstration on Surgery, Ancient and Modern. practice in the surgery of the appendix vermiformis and iFequally applicable in the surgery of inflamed uterineOBSTETRICS AND DISEASES OF WOMEN. appendages. Exceptions to this rule frequently occur, as, for example, where a rapidly increasing elastic swelling in. WEDNESDAY, JULY 27TH. Douglas’s pouch or in the lower part of the abdomen Dr. CULLINGWORTH opened a discussion on indicates acute suppuration and again where the symptoms The SU’rginal Treatment of Pelvic Inflammation. point to septic absorption. Dr. E. DOYEN (Paris) laid down the following rules as a. Referring to his address in Obstetrics and Gynaecology at the meeting of the Association held in Newcastle in 1893 Dr. guide to intervention in the different varieties of pelvicCulling worth considered that it was no longer necessary to suppuration. First (extra-peritoneal suppuration), phlegmon adduce arguments in favour of a method of treatment which, of the broad ligament: (a) by iliac evolution-classical iliacalthough for a time vigorously opposed, has now been incision ; (b) abscess of the inferior portion of the broa(,71 Secondly (intra-peritoneal generally accepted. The following points having been ligament-lateral colpotomy. selected for discussion debate could be confined within suppuration) : (a) the inflammatory mass remains intrauseful and manageable limits-viz., (1) the indications for pelvic and does not reach the brim-vaginal operationY (b) the suppurating tumours pass the brim of the pelvis and operative interference in pelvic inflammation ; and (2) the reach the level of the umbilicus-laparotomy. By each onechoice of time for operation. 1. Adopting the usual classification of pelvic inflammation into pelvic cellulitis and pelvic of the above methods, vaginal or abdominal, three distinct : (1) simple incision of theperitonitis the former class of cases is first dealt with. In operations may be performed focus; (2) ablation of the annexa, leaving thepelvic cellulitis when the inflammation is unattended with purulentand ; (3) total castration. suppuration no operative interference is necessary. When uterus Dr. JACOBS (Brussels) made some observations based on an abscess is formed the ordinary rule of surgery should be In cases of bilateral followed and the pus let out as soon as it is discovered and an experience of 713 operations. is within reach. The opening of a cellulitic abscess should disease of the appendages he thought that the vaginal routeshould be chosen in cases of old-standing pelvic suppuration, always be performed without opening the peritoneal cavity. with whilst thefistula adhesions, peri-uterine abscess, &c., These abscesses in the great majority of cases point on the external surface of the body. More rarely they point in abdominal way was preferable in relatively recent cases in the vagina. Sometimes they are formed at the back of which there was no evidence of injury to surrounding organs.the pelvis beneath the posterior parietal peritoneum. In Operating on these lines he had had the following results :that case the pus does not easily make its way to a surface vaginal route-432 cases, 424 cures..and 8 deaths ; abdominal and is apt to burrow. It thus may become necessary, even route-98 cases, 95 cures, and 3 deaths. Although all supwhen the presence of pus is as yet only a matter of inference, purative inflammations were of infectious origin it was. to dissect down in the direction in which the supposed seldom that the pus was very virulent at the time of operaabscess is situated, commencing with an incision similar tion and it was of less virulence in proportion as the caseto that employed in the operation for tying the external was of longer standing. Dr. LANDAU (Berlin) contributed to the discussioni. iliac artery and carrying on the dissection from without inwards along the floor of the iliac fossa, lifting up paper on the reflexion of peritoneum and dissecting beneath it. Vaginal C’eliotom Circumscribed abscesses limited to the upper part of the based on 58 cases operated on during the last three and broad ligament must be of extreme rarity, if they exist at all. half years. All the patients recovered. He concluded from, Most of the cases so described have probably been examples his experience that those patients who were operated upon. of pyosalpinx or suppurating ovary in which the broad Ega- by vaginal cosliotomy for true. genuine-not inflammatoryment has been drawn over the inflamed organs in the form of tumours and for extra-uterine pregnancy without severea hood. The indications in pelvic peritonitis cannot be inflammatory symptoms had been permanently cured. Ocj The personal experience of Dr. the other hand, of the patients in whom inflammatory con-stated so categorically. Cullingworth has led him to regard the following signs and ditions led to the operation only 20 per cent. at best had symptoms as being strongly suggestive of the need for opera- been cured. This was generally clue to the operation beingtive interference. (a) The presence of a definite, more or performed when the indications were against it and in most less fixed, irregular swelling in one or both posterior fossse cases the vaginal radical operation should have been per-of the pelvis, larger in size than would be accounted for by formed. As regards the choice between the vaginal and the matting together of a merely thickened tube and a abdominal route there was much in favour of the former. normal or slightly oedematous ovary, and accompanied with He dwelt briefly on the technique involved, but for full’ pain and fever. If such a swelling is found to be increasing particulars he referred his hearers to the translation, in size in spite of rest and the local application of warmth by Dr. Eastman and Dr. Arthur Giles, of 1, The History the suspicion that pus is present in appreciable and and Technique of the Vaginal Itidical Operation." Thedangerous quantity almost gives way to certainty. (b) The points he further discussed were : (1) when is theoccurrence during an attack of acute inflammation of the anterior or the posterior incision to be chosen ? when theuterine appendages of a tense globular cystic swelling combination of both(2) which anterior section is better, in the pouch of Douglas. Whether this to be an the longitudinal or the transverse ? (3) how is the uterus tcf intra-peritoneal abscess or a tense encysted collection of be luxated ? (4) shall and must the peritoneum be specially serum the indications for surgical relief are equally positive. closed ? and (5) shall the uterus after vaginal cceliotomy be(c) The outbreak of recurrent attacks of pelvic peritonitis fixed to the vagina or not ?7 He could not advocate the exin a patient known to have had an acute salpingitis, in whom tirpation of inflamed adnexa, unilateral or bilateral, by there has remained a quiescent but obvious swelling in the means of vaginal co-liotcmy ; even if the operation were-

proves

358 ’.successful the majority of cases were not benefited. When examination. Removal of the uterus should be practised performed for certain precise and clearly-defined indications only in cases of bilateral suppuration and destruction of the vaginal ceeliotomy gave excellent results but on account of adnexa. In the others simple incision might first be tried, as even if unsuccessful it would not interfere with future its relatively small danger it had a tendency to be overdone. Professor FEHLING (Halle) agreed with Dr. Cullingworth operation. But conservatism was not to be carried too far; a ’that they had to separate pelvic suppurations into those partially destroyed uterus was of no use after both the adnexa ’arising in the parametrium and pelvic peritoneum and those had been removed. The question to keep in mind was the of the adnexa. In many cases of tubal suppuration the patient’s ultimate condition and from this point of view 7history and temperature gave no indication of the presence he thought the best results were obtained by the vaginal of pus, yet it was found on operation. As to the vaginal route. - or abdominal route he agreed with Dr. Doyen that there Dr. LAPTHORNE SMITH (Montreal) endorsed the remarks of Dr. Cullingworth as to the immunity which the peritoneum was no fixed rule ; every case must be dealt with on its Tnerits. When the diagnosis was uncertain and when the acquired after one or more attacks of pelvic peritonitis. His disease was unilateral he preferred the abdominal route. experience was that these cases had a much smaller deathDr. A. MARTIN (Berlin) said that, like Dr. Cullingworth, rate than those operated upon during a first attack. As to le laid great stress on the anamnesis, for in cases of gonor- the route to be employed he had come to the conclusion that Thoea an expectant treatment was indicated, since in many the abdominal plan was the best for all cases of large tumours ’instances such patients recovered without operation ; but in of any kind, for pus tubes, hydrosalpinx, tubo-ovarian septic cases operation was almost always required ; and, abscess, and tubal pregnancy ; he would, on the contrary, ’indeed, these were the cases in which an operation might employ the vaginal route for growths and collections situated ’bave to be performed even while an acute feverish condition low down in the pelvis. The advantages of the vaginal route ’was present. A difficulty often arose in the differentiation were inestimable-no scar, no bugbear of hernia, and no of these cases from extra-uterine gestation ; often this was buried sutures, while the mortality was almost nil. He was the condition found when gonococci or streptococci had been strongly in favour of removing the uterus when the tubes ’thought to be the cause of the illness. There was a cause were full of pus and both ovaries had to be removed. This f pelvic inflammation which had not obtained sufficient should usually be done through the abdomen and Trendelenrecognition, viz., the presence of the bacillus coli. This was burg’s position was of great value. Dr. AMAND ROUTH (London) agreed with Dr. Cullingworth responsible for many cases in quite young women ; and the ’0nset of menstruation not infrequently marked the commence- that cases of perimetritis should not usually be dealt with ment of the pelvic trouble, whilst a few years later definite during the acute stage, but this was not the case with swellings were found, and then, on operation, adhesions puerperal septic parametritic abscess, which should be ’were generally present uniting the appendages to the intesopened and drained through the vagina as soon as pus was tines. In his earlier cases he sometimes regretted not having suspected, and not be allowed to drift on till pus pointed ’taken away the uterus as well as the appendages, but experience above Poupart’s ligament, as it only did in neglected or long ’had taught him that in the long run those patients were standing cases. Dr. HANDFIELD-JONES (London) agreed with Dr. Culling- generally the best off in whom the uterus was left. Dr. MACAN (Dublin) thought that the two special points worth that (1) large size of the pelvic tumour, and (2) recurraised by Dr. Cullingworth had been rather lost sight of. rence of pelvic inflammation were the principal indications The indications for operation depended almost entirely on in deciding in favour of operation. In making a diagnosis it -accuracy of diagnosis, and this again on the knowledge of the was most important to examine under full anaesthesia, since bimanual examination. To carry this out properly the patient in cases of pus collections high up and situated posteriorly it ’should be examined in the dorsal position, the right hand being was often impossible to map out the mass with certainty used for the right side and the left hand for the left side. As until the muscular parietes were fully relaxed. There could .to the time of operation, he would put this off as long as be no doubt as to the wisdom of waiting to operate until ’possible so as to get all possible advantage from the efforts the acute svmptoms had subsided. He failed to see the -of nature. He thought that when the vaginal route was ’, antagonism between the vaginal and abdominal methods : - employed for operation an estimation of the difficulties to be ’, both were useful and suitable under different conditions. Dr. AUST LAWRENCE (Bristol) remarked that when the --met with was much greater than by the abdominal method, since in the former the sense of touch had to be almost vaginal swelling was most marked it was often wise to aspirate through the vagina, as some cases got well by this exclusively relied on. Professor BYERS (Belfast) said that many points yet means even when no pus was found. Dr. E. T. DAVIES (Liverpool) said that as to the route of ’required to be cleared up. The greater one’s experience the "fewer no doubt were one’s mistakes in diagnosis, but they operation the abdominal was generally the safer, as hmmor-all came across cases where it was impossible to determine rhage and adhesions were more under control. Delay till before operation the locale of the pus. As to the method the acute stage was often wise, but it was possible to delay ’to be employed they had had the advantage of hearing the too long, for if dense adhesions formed they made a subThe use of the views of French and German experts ; perhaps they in the sequent operation much more difficult. British islands were apt to be too conservative in keeping to aspirator as a means of diagnosis was a dangerous procedure he abdominal route and there were cases better managed by and should never be employed unless immediately followed a vaginal incision, as a palliative measure or as a means of by operation. After a few remarks by the PRESIDENT Dr. CULLIXGaiding a very exhausted patient over a time until her strength was equal to an abdominal operation. What they wanted WORTH replied. rwas more explicit information as to the indications for the Dr. F. J. MCCANN (London) read a paper on Clamp and Tespective methods. Ligature in Vaginal Hysterectomy for Malignant Disease, Dr. HEYWOOD SMITH (London) related a case illustrating which was discussed by Dr. HEYWOOD SMITH, Dr. E. T. the two points on which Dr. Cullingworth had mainly dwelt. DAVIES, and the PRESIDENT. ’He thought the term "laparotomy" was philologically THURSDAY, JULY 28TH. incorrect and scientifically misleading and ought to be the more correct term " The second replaced by coeliotomy." day’s session was opened by a discussion on Dr. WARD COUSINS (Portsmouth) observed that the various The Use and Abuse of the Midwifery Forceps, forms of pelvic inflammation ran so much into one another ’that a correct diagnosis of these complex disorders could introduced by Dr. MILNE MURRAY (Edinburgh), who said seldom be made in the early stages, but all of them could be that the selection of this subject arose out of the able vraced to some infective process. Many got well with very address of Dr. Japp Sinclair at the Montreal meeting. He simple treatment, whilst in acute cases of suppuration the began by asking : 11 What is the special value of the forceps dangerous stage might often be relieved by simple incision as a surgical instrument?" and his reply to this was that it The position of the incision must enabled them to shorten the suffering and diminish the risk nnd careful drainage. be determined by the special features of each case. When of childbirth. As to the indications for its use he condistinct swellings were found and the organs were clearly sidered that this was found whenever and only whenever diseased he thought the abdominal route was generally the they were assured that the danger of interference had become less than that of leaving the patient alone ; this, of - best for dealing properly with them. Dr. TAYLOR YourrG (Sydney) agreed with Dr. Macan course, implied that the use of the forceps was in practically vthat British gynaecologists often handicapped themselves in every case a matter of individual judgment and definite rules tBiaking a diagnosis by adhering to the lateral method of could not be laid down. A fcetal head and an ovarian -