Extracts from Current Medical Literature.

OBSTETRICS-DISEASES OF WOMEN.

10. Advantages of Tapping in the Treatment of Ovarian Tumors. By GEORGE SOUTHAM, Esq., Manchester. (British Medical Association, Surgical Section.)

[British Medical Journal, Aug. 28, 1869.]

The author remarked that ovariotomy was now considered a legitimate operation; but, as the mortality was still very high, it ought not to be resorted to so long as the disease for which it was undertaken could be kept in check by other means, provided they did not impair the patient's general health and interfere with the success of ovariotomy. This, he believed, could be frequently effected by tapping. He gave the particulars of three cases, showing that it was sometimes followed by such favorable results that it might be regarded almost in the light of a curative agent. One patient was tapped in 1843, and again in 1846. On each occasion, upwards of twenty quarts of fluid were removed. After the second operation, there was no return of the disease for nineteen years. Another was tapped in the same year, six quarts of fluid being removed; she has remained in perfect health up to the present time. A third was tapped in 1865, when upwards of twenty quarts of fluid were extracted; and she also continues free from any return of the swelling. The cases were all unilocular cysts; and, as a fair proportion of ovarian tumors were of this character, he considered that, by resorting to tapping, the risk of ovariotomy might occasionally be avoided. Should tapping not prove successful, he considered that it generally placed the patient in a more favorable condition for ovariotomy. He referred to seven cases where he had performed ovariotomy subsequently to tapping, only one of which was fatal. He considered that patients submitted to ovariotomy in any early stage of the disease did not recover so favorably as those where the affection had been of longer duration; and, as tapping enabled the surgeon to delay the extirpation, he advised that it should be first resorted to, except under especial circumstances. He had found that ovariotomy in recent cases was frequently fatal from peritonitis. This, he considered, arose from the extreme sensitiveness of the peritoneum, which was lessened by the continual friction of the walls of the tumor against that membrane. He did not recommend a repetition of tappings, having found the second

and third operations to be not unfrequently followed by suppuration of the cyst. He concluded by comparing tapping, as performed in former days, when it was attended with considerable danger, with the plan now adopted, which had rendered it comparatively free from risk.

II. Scarification of the Cervix Uteri in Inflammatory Affections of the Womb. By R. H. MEADE, F.R.C.S., Consulting Surgeon to the Bradford Infirmary.

[London Lancet, January, 1869.]

The management of some of the diseases of the uterus often occasions much trouble and considerable disappointment to the surgeon engaged in general practice. I shall, therefore, make no apology for offering a few observations on the mode of treatment which I have found most successful in a class of cases which is perhaps more frequently met with than any other among these affections.

The forms of uterine disease to which I particularly wish to direct attention are those inflammatory states of the organ in which congestion, inflammation, and ulceration of the cervix play so prominent a part. The causes and varieties of these affections are very numerous. We often find the cervix swollen and red; sometimes it is partly denuded of epithelium, and assumes a granular appearance, having a velvety feel to the touch; and sometimes it is decidedly ulcerated. With regard to the causes, anything that produces determination of blood to the uterus, or excites inflammatory irritation of the organ, may bring on inflammation or ulceration of the cervix.

These complaints are, as might be expected, much more common among married than single women, and in many instances follow miscarriage, or labor at the full period of gestation. They often accompany menorrhagia and dysmenorrhoea. In most of these cases, as Dr. WEST has pointed out, the visible state of disease in the cervix is only an indication of a more deeply seated but hidden inflammatory condition of the body of the womb; the treatment, therefore, should be such as will relieve the whole organ.

These complaints are sometimes connected with, and apparently produced by, general constitutional disorder, and require appropriate general treatment. Still, many of them are in a great measure local, owing to the physiological peculiarities of the uterine organs. During the periodical determination of blood natural to the menstrual period, the uterus is exposed to increased danger from accidental causes, as exposure to cold, violent exertion, etc.; and marriage, pregnancy, abortion, and delivery are still more fruitful causes of local mischief. Our treatment, therefore, must be chiefly directed to the uterus itself.

Where true ulceration exists, great benefit will doubtless accrue from the use of caustics, the nitrate of silver appearing to me to be the one most generally applicable; but when the neck of the womb is enlarged and normally vascular, showing that the walls and lining membrane of

the body of the organ are similarly affected, what will relieve the patient so speedily or effectually as the local abstraction of blood?—and the point to which I wish to direct attention is as to the best mode of effecting that object.

Local bleeding has been prominently brought forward as one of our most powerful means of relief in the treatment of these cases, by all our best writers on uterine diseases; but the agents which they have principally recommended are leeches, which may be applied either to the cervix itself, the margin of the anus, or the vulva. Leeches applied to the lips of the uterus are very efficacious, but give a great deal of trouble. In London and other large cities nurses can be obtained who have been taught to put them on; but in the country, if used in this way, they must be applied by the surgeon himself, and the loss of time necessarily entailed by the personal performance of this operation will often cause it to be deferred or neglected altogether. I was formerly in the habit of ordering leeches to the anus, but not feeling satisfied with the relief thus afforded, and finding a dislike to the application of leeches among many patients, I was induced to try the plan which I now beg to recommend— namely, the direct abstraction of blood from the neck of the womb, by making incisions, or rather punctures, into its substance. Quite as much blood can thus be obtained as by means of leeches, and in a much more easy and rapid manner. The whole operation may be completed in two or three minutes, without any fuss or preparation, at the same time as the necessity for its performance is ascertained by an examination with the speculum.

In advocating this method of treatment, I do not bring it forward as any novelty, for I am aware that scarification of the lips of the womb has been recommended by many authors for the relief of congestion and inflammation of the cervix; but I cannot find, in the works which I have consulted, any precise directions as to the method of its performance. It has been compared to scarification of the palpebral conjunctiva, and I presume is therefore expected to be performed in a similar manner— namely, by drawing the edge of a sharp lancet lightly across the inflamed surface. Very little blood could be thus obtained, and I am not surprised at leeches being recommended in preference to scarification, in cases where much depletion is desired.

The plan I adopt is to make a number of punctures or stabs with a straight lancet-pointed bistoury, having a long handle, which stabs I make more or less deeply and more or less numerous, in proportion as I think it necessary to take away more or little blood. From one to two or three ounces may be easily thus procured. Of course, a speculum must be used, and the one which I prefer is a bivalve one, with wide flat blades. I think it is called TYLER SMITH'S speculum by the instrument makers. The blades are not very long, and, being wide at their extremities, when fully expanded they stretch and shorten the walls of the vagina, so that the cervix uteri readily falls between them, and is easily seen and reached. Another advantage of this speculum is that when closed it is very easy of introduction.

In this mode of abstracting blood it is seldom necessary to puncture or cut very deeply; but incisions in the lips or neck of the womb seem to heal very readily. I have never seen the slightest inconvenience follow, however deeply I have made them, with the exception of the bleeding being rather profuse.

12. Injections of Warm Water in the Treatment of Uterine Inflammations and of Dysmenorrhea. By Dr. A. Desprès, Surgeon to the Lourcine Hospital.

[Bulletin Général de Thérapeutique, May 30, 1869.]

Injections of water at the ordinary temperature, cold douches, douches of mineral waters at a temperature nearly cold, have been vaunted in the treatment of chronic uterine inflammations, and even of acute. Cold injections have been recommended in dysmenorrhea. The employment of cold under these conditions. was one application of a more general method of treatment very much used at the present day, viz: hydropathy. During my service at the Lourcine Hospital I have been able to examine the effects of cold vaginal injections in all the uterine diseases, and I have not hesitated to substitute heat for cold, which latter I believe to be useless or injurious when a uterine inflammation exists.

The hospital has a system for injections that is invariable. A reservoir filled with water, in which alum has been dissolved, communicates by a pipe, running to the injection room, with a stationary faucet. The patients apply their canulas to the faucet and give themselves an injection. It will be seen that this constitutes a system of injections which are always cold.

I have remarked that at certain times the patients who, notwithstanding the cold, did not intermit their daily injections, had uterine discharges, sudden inflammations of the uterus, or even pelvic peritonitis. Three or four patients were taken at a time. With those who had a uterine discharge that had improved, it was seen to reappear, with new uterine pains. I was very careful with all these patients to learn whether they went to the injections, and whether it was not at the period of their menses that some pains had come on, as is quite frequent when the patients take cold. Struck with these facts, I had warm water injections substituted for cold injections for the patients afflicted with uterine inflammation, and I have not observed these relapses. Cold water has the property of causing anæmia of the tissues

and of making the capillary vessels contract; after this phenomenon has taken place, the vessels dilate, the blood circulates in abundance in these canals, congestion occurs, and this is called the reaction. To the anæmia thus occasioned corresponds a painful sensation, and a sensation of heat afterward takes the place of the painful impression. In therapeutics, what is sought for when cold is employed? Is it the painful impression or the reaction? For uterine disorders, in particular, it can only be the reaction. Anæmia a frigore is too fugitive for us to take into account its action, but we must take into account the reaction that follows. If we seek for the reaction, that is to say the congestion, why make the uterus previously pass through a chilling process when by another agent we can obtain the congestion at once? In dysmenorrhoea it is the congestion that we seek to obtain, and we obtain it by employing cold water. But the uterus is chilled, and this is a cause of uterine inflammation, which is admitted by all physiologists, and which may be also the cause of a new arrest of the menses that are upon the point of appearing.

In view of the above considerations, I have come to the conclusion to have recourse to warm water for vaginal injections in all uterine inflammations. I have also established myself upon experience: warm lotions, warm cataplasms, have an incontestable effect in phlegmonous inflammation; warm water lotions for inflamed eyes, praised by LAURENCE, have an indisputable antiphlogistic property.

The theory of this action of warm water is easy to seize. According to my individual researches, inflammation appears to me to be a sort of drying up of a part, due to a loss of the water in the blood contained in a capillary mesh and in the neighboring tissue. Now, if we can restore the water to the blood, it is certain that things will be restored to their normal state. This is seen very well by the aid of the microscope in the frog's foot; when the interdigital membrane begins to dry, the blood stops in the vessels; if we moisten the membrane at this moment, the circulation is seen to re-establish itself. Water can be absorbed by imbibition of the epidermis, and the more the water is of a temperature near that of the body the better the water is absorbed. Everybody knows that in the warm bath man absorbs more water than in the cold bath.

In another point of view, warm water causes congestion of