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more than one in fifty confinements. He agreed with the author that it was not very easy to diagnose this position, and that ordinarily it was not done until the unusual behavior of the case led one to suspect it. There were many positions made out as posterior at the brim which, if the case were let alone, would become right or left occipito-posterior. He would prefer to resort to version rather than to high forceps.

DR. BROOKS H. WELLS said his experience with regard to diagnosis coincided with that of Dr. Tucker, that the occipitoposterior position could always be determined by careful, systematic abdominal and vaginal palpation. If the case was seen early, while the head was still movable, he preferred to rotate the child, as just described by Dr. Grandin; if the head was already wedged into the pelvis in an oblique diameter he would try to increase flexion, but would not apply forceps unless urgently indicated, as spontaneous rotation to an anterior position so often occurred as the head descended. With the occiput directly posterior, however, prompt interference was always required.

DR. G. W. JARMAN testified to the success of the method described by Dr. Grandin. Within a year he had seen three cases of occipito posterior position which he corrected by rotation of the head and body anteriorly and maintaining them in that position until fixed by uterine contractions. He had not been called to a case at the City Maternity by the house staff for three months on account of occipito-posterior position above the brim, as the staff always succeeded without aid in correcting the position by rotating with the hand.

THE CHAIRMAN (Dr. McLean) said that a few years ago he had made the statement that no teacher of obstetrics could positively diagnose the occipito-posterior position in all cases by simple vaginal examination, and the statement passed unchallenged. By abdominal and vaginal palpation, with the history of the case, the diagnosis could be made. If the ear could be felt, as he had found it possible to do, this alone would tell the position of the occiput. Regarding management, Dr. Grandin had expressed his views precisely, the important point being to rotate the head and hold it in the corrected position until fixed by a pain. He thought Dr. Tucker had misunderstood the question, for it related to cases of occipito-posterior position causing trouble, and there, of course, interference was indicated.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF CINCINNATI.

Meeting of February 8th, 1894.

The President, WM. H. TAYLOR, M.D., in the Chair.

DR. A. W. JOHNSTONE read a paper entitled

WHY IS A SUCCESSFUL LAPARATOMY SOMETIMES A FAILURE?

My answer is, because we do not follow up our cases closely enough, or are not careful enough in our original diagnosis. The wholesale removal of ovaries which our country saw some five years ago I am now happy to say has almost passed, and a more careful overhauling of the case is now the rule rather than the exception, and my experience is that it is very seldom now that an unnecessary laparatomy is done. Our greatest shortcoming at the present time is in not following up our cases after laparatomy is over. In my experience, in about ten per cent of our cases the laparatomy is only the first step toward the cure of a case. Given a successful laparatomy-that is, that the patient has recovered from the operation and is out of the bed if we fail to produce the menopause she is little better off than she was before the operation. The Stephenson wave returns in its full force every twenty-eight days, the nervous reflexes are in no way abated, and the indigestion and gaseous formations are, if anything, exaggerated. The reason for the failure to produce the menopause is twofold: first, because of conditions in the uterus itself; second, from failure to destroy the whole nervous plexus embedded in the broad ligament on either side of the uterus.

The uterine causes are of two kinds. First, when polypi in the interior of the uterus have been overlooked and cause recurring hemorrhages. Removal of these succeeds very frequently in curing the case. Next, a chronic metritis. In a case where we have had pyosalpinx or hydrosalpinx, which has been removed by the laparatomy, the patient's menopause may or may not have been brought on, but the infection continuing and the uterus not undergoing secondary atrophy, all the nervous phenomena are kept going by the same old stimulant which existed there before the operation. In my experience not less than ten per cent of all laparatomies require attention to the endometrium after the laparatomy has been successfully done.

As for my second heading, that of the failure to isolate completely the uterus from its nerve supply, I am happy to say the percentages, taken from large numbers of cases, are very small. This subject we talked over pretty thoroughly at the November meeting of this body, and I have very little now to add on the subject. The discussion that night turned on the report of one case in which a member of this Society removed the appendages, from which I afterward had to remove a large piece of tube. The woman had the most marked reflexes from the uterus; so much so that she had once been lectured upon, as a typical case of ulcer of the stomach, before one of the classes of the city. These reflexes seem now to be entirely cured and the woman is apparently well, but it is too soon yet to tell whether the menopause has been produced or not. She has had one slight red discharge from the uterus in four months. As I stated at the last meeting, I now repeat, that it is my belief that the whole of the nervous plexus of the broad ligament should be included in the ligature, and that your guide in so doing is to be sure that you have removed every particle of the ovary, and of the tube up to the horn of the uterus, and then to so peel them out of the broad ligament as to leave a rounded button of the tissue over which it is impossible for your ligature to slip. Do not ever use a knife to cut away the broad ligament; and do not do it with one snip of the scissors, but do it piecemeal, and so round your button that an inverted cauliflower-shaped piece of broad ligament is left on the distal side of the ligature. If time permitted I would be glad to go further into the nervous origin of menstruation than the limits of this paper will allow; but you all know that it is my belief that the centre which presides over it lies somewhere in the spinal cord, and that it gets various reinforcements from the solar plexus and the ganglia lying in the broad ligament, until it reaches the endometrium through the path I have so often described.

But this I know, as the practical part of it, that, if the whole of this nervous tissue is thoroughly destroyed, the percentage of failures to bring on the menopause in all cases, save fibroids which go beyond the umbilicus, is extremely small; my experience would place it at a fraction of one per cent. In speaking of fibroids, when we operate for the menopause, my views have in no way changed since our last discussion. I have never met a case of multiple fibroid which did not reach the umbilicus that could not be cured by the removal of the appendages. My experience embraces some twenty or thirty cases. I know some of my friends claim to have met them, and my experience may be unique, but I cannot help thinking they have been tempted to operate upon edematous fibroids, which we all know are nothing but lymphadenoma, over which nothing but excision has any control; not even the normal menopause seems to have any influence over them, for once started they unfailingly go on

to the production of the cystic myoma, which you all know means death or excision.

So much, then, for cases in which the menopause has failed to be produced; and whenever we have a laparatomy which does not accomplish the desired end, we cannot expect much until it is brought about, and we must get down to work to find why it failed. The days of great generalizations in laparatomy are past, and, like the astronomers, our advances must be only in the more careful calculations of small angles and in the more diligent, careful study of each individual case; and if we have a case which still menstruates or has the Stephenson pressure return, it is our duty to hunt carefully for the cause and stop it, and not let the case get out of our hands until this end has been accomplished. It is true that in ninety per cent of laparatomies which are done for infections which came from the uterus, the laparatomy, which puts out the fire in a dangerous region, starves out the inflammation by the stopping of the return congestion of the Stephenson wave. But we must also remember, as I have already intimated, that there is still a residuum of ten per cent in which this inflammation persists. In other words, the chronic metritis which started the pyosalpinx, the ovarian abscess, or whatever it might be, is not cured by the laparatomy, even though the Stephenson wave has been stopped. My experience shows that these cases are almost entirely cured by a thorough curetting and tamponing, the methods of which you all understand. Pozzi claims that every case of inflamed appendages ought to have the uterus curetted within thirty days after laparatomy. I think this is entirely too high, for in my experience not more than one in ten requires it; but that tenth case needs it very badly, and if it is not done the patient will be in very little better condition than she was before you touched her. It is true her life will be saved, but as a fact or in society, as a human being, she would be a failure. I have not had to go so far as to do trachelorrhaphy in these cases, yet I would not be surprised at some time or other to be forced to it, but so far I have found a thorough curetting all that they need. During the last year I have had a unique experience in what the older authorities call vascular degeneration of the vagina, and have been intending to give a special paper on it; but, as several of these cases bear specially on the sexual relation in laparatomy, I cannot do better than to give a foreshadowing of that paper here. One of the most striking cases, in which I removed the appendages more than two years ago for an infection of the whole genital tract, recovered nicely from the laparatomy and I thought would soon be well. At the end of a year, however, she came back to me with a decided vaginitis and metritis, although she had menstruated but once after the operation. I curetted and tamponed the uterus and sent her home, thinking that she would soon be as well as ever. Her metritis was

entirely relieved; there was a vaginitis still persisting, but I thought it was caused by the irritation of the discharges from above, and that their absence would soon allow the vagina to heal. This, however, was not the case. In the course of seven or eight months afterward she came back to me, almost desperate, with a well-marked case of vaginismus and a most decided vaginitis and vulvitis. It was a typical picture of what Tait describes, in his first work on "Diseases of Women," as vascular degeneration of the vagina. The little granulation plugs were standing up all over the surface, and the enlarged vessels were ramifying in the bases of the carunculæ myrtiformes and running around up to the edge of the urethra, and the whole thing looking as though the next step would be the formation. of cicatricial tissue and permanent narrowing and contraction of the vagina. The condition reminded me exactly of that found with granulated lids. Little adenoid lumps were standing up in the same way, and sero-purulent fluid in small quantities was bathing the whole surface. In some places the epithelium was lost and the lightest touch produced a slight hemorrhage. In these abrasions the cicatrices start, and by their secondary contraction the great deformities which this disease is noted for are accomplished. Fortunately in this case, though, no deformity had occurred, although the slightest touch produced a typical vaginismus. The case had been treated with douches and ointments, ichthyol, and all the new-fashioned disinfectants, until the patient was thoroughly worn out. No results whatever had been produced, and the case was marching steadily on to what would ultimately have been a closure of the vagina. The sexual appetite had become entirely extinguished, as might have been supposed from the condition, and the patient showed both the mental and physical distress which always accompanies such conditions. Some months before, while watching the recovery of a slight stellate tear which did not seem to warrant a trachelorrhaphy, I was impressed with the similarity of the physical condition to that of the conjunctiva in trachoma, and was seriously tempted to use the old stand-by in that condition, the yellow oxide of mercury. But, as the patient's condition was such that a salivation would have been a sad catastrophe, I postponed its use until some other time. As soon as I saw this case, though, I determined to employ it at once. In the first case I would have had to use pencils of the yellow oxide placed up in the cervix, which you know is quite a good absorbing surface; but in the latter case it was the vagina and vulva, which you know is the most non-absorbing of all mucous membranes. So I determined to try a weak ointment of the yellow oxide of mercury. I began on eight grains to the ounce, but I found the irritation from its use was too great, and weakened it down one-half. Under this latter ointment the inflammation disappeared like snow before a hot sun; the patient has gained flesh, and

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