TRANSACTIONS OF THE NEW YORK OBSTETRICAL SOCIETY. REPORTED BY CHAS. S. WARD, M.D., SECRETARY. STATED MEETING OF OCTOBER 2, 1872. DR. J C. NOTT, PRESIDENT, IN THE CHAIR. RUPTURE OF OVARIAN CYST AS A CAUSE OF DEATH. DR. POOLEY presented an ovarian cyst which was removed from a child aged three years and two months, who died from peritonitis, the result of rupture of the cyst. The specimen was referred to Dr. Peaslee for examination and report. DR. PEASLEE remarked that ovarian tumors may exist in the new-born child. A case of ovariotomy at the age of three years has been reported; the operation, however, was followed by death of the child. The youngest reported successful case was upon a child aged six years and eight months; the first being a patient of Mr. Alcott (The Lancet, Feb. 1872), and the second, of Dr. W. B. Barker (Phil. Med. Times, November 1, 1871). CONGENITAL IMPERFORATE COLON. DR. B. F. DAWSON exhibited the colon of a child who died of collapse, the result of perforation occurring on the fourth day after birth. The child was healthy and vigorous at birth, and did well until the second day, when it was noticed that there had been no evacuation of meconium. The physician thereupon ordered a dose of castor-oil, the only effect of which was to occasion much pain and some vomiting; another dose then being administered was soon followed by vomiting of meconium. On the fourth day Dr. Dawson saw the child, and, from a careful examination, decided that it was a case of imperforate bowel, and proposed to operate; the child, however, became suddenly collapsed, and died three hours after. The autopsy was made a few hours later. The abdomen was tumid, and the cavity contained a large amount of meconium. The transverse colon, which was found distended as large as the stomach, was gangrenous, and at a point at its central portion was wholly impervious. Below this point, the colon and rectum were pervious, but in a foetal state, containing nothing but mucus. On further search, a perforation was found in the transverse colon, through which the contents had escaped into the peritoneal cavity. Dr. Dawson remarked that he thought it probable that an intra-uterine peritonitis had occasioned the obliteration found, lymph having been exuded, which subsequently occasioned the imperforation by contraction. Dr. Dawson was unable to substantiate his belief, as such objection was made to the autopsy by the parents as to forbid thoroughness. DR. POOLEY remarked that children have lived two weeks with imperforation. ENUCLEATION OF UTERINE FIBROIDS. DR. THOMAS exhibited a mass the size of a cocoanut, consisting of three fibroids which he had recently removed by enucleation. The woman, who was a patient of Dr. H. Moeller, had suffered for some months from excessive menorrhagia. When seen by Dr. Thomas, the uterus was found to be as large as at the fifth month of gestation; the cervix was found well dilated, and a large fibroid presenting, which, on examination, proved to be sessile, and attached posteriorly. The patient lying upon her back upon a table, Dr. Thomas proceeded to enucleate by cutting through the capsule of the tumor with scissors, and then insinuating a grooved steel sound under the capsule, which he separated as far as possible from its attachments. Traction was then resorted to, combined with powerful expression from above, which resulted in the extrusion of a large mass in about forty minutes; another mass was felt above the one extracted, which was in like manner removed; traction then being made upon the capsule, it came away, having attached to it a still smaller tumor. There was very little hemorrhage. Opiates were given, and intra-uterine injections of carbolic acid were daily used. The patient did well for four weeks, though she now has a mild attack of phlegmasia dolens, from which she has suffered once before as a sequel to parturition. This is the sixth case in which Dr. Thomas has resorted to enucleation, in all of which the recovery has been perfect. He has, however, lost two cases in the preparatory treatment by sponge-tents. Dr. Thomas considers the operation in its results more formidable than ovariotomy. DR. PEASLEE agreed with Dr. Thomas in the operation being more dangerous than ovariotomy, though it looks so simple. It is always dangerous to operate while the tumor is in the uterus, though where danger exists from menorrhagia the operation is perfectly justifiable. DR. SIMS thought the removal would be facilitated by the patient being in the left lateral semi-prone position, and instanced a case where he had effected the removal of a tumor in twelve minutes. DR. THOMAS, in reply, said that he had removed tumors in less time than that mentioned by Dr. Sims, and he considers the dorsal position better, as expression can be so efficiently brought to bear. CAUSE OF DEATH AFTER OPERATIONS. DR. SIMS, in speaking of death resulting from the use of spongetents, and after ovariotomy, said he did not see why a little effusion of lymph into the peritoneal cavity should occasion death. DR. NOEGGERATH said, in cases where patients die from pelvic peritonitis, it is not the lymph, or the amount of lymph exuded, as many die where only a little exudation is discoverable; it is not the amount of inflammation or exudation, but the peculiar reflex irritability of the nervous system in some persons, in which the slightest amount of foreign matter in the peritoneal cavity is sufficient to occasion death. He instanced the case of a healthy young girl, who, while standing by the fire in the evening, received a fright, and was immediately seized with severe abdominal pain; the following morning she died. On postmortem examination only a superficial development of the vessels was found, and but a little bloody serum and lymph, which had escaped from the Fallopian tubes, which were found to be full of the above-mentioned product. Sometimes the exudation of enormous amounts of lymph does not occasion death. Dr. Noeggerath has lost cases from the use of sponge-tents, the initial cause being a lymphangitis which extended to the peri toneum. DR. SIMS remarked that in some cases of peritonitis following ovariotomy, large masses of lymph are exuded; but the lymph is not the dangerous element; they do not die from the lymph, but from the extravasation of bloody serum, the absorption of which results in septicemia, which may kill the patient in twelve hours after the operation. DR. NOEGGERATH did not coincide with Dr. Sims, as it is absolutely impossible for death to take place from septicemia, the result of the absorption of fluid which had been effused at the time of an operation only a few hours previously; there certainly is nothing in blood or serum which would produce septicæmia or reabsorption within so short a time. Septicemia kills only under two circumstances: first, where so much septic material is absorbed as to occasion death of itself; and, secondly, where it kills by producing secondary inflammation of import ant organs. Septicemia rarely occurs in less than four or five days, and peritonitis could not result from septicemia within twelve hours after the operation. Dr. Noeggerath thinks it will perhaps be proved that septicemia results from the entrance of bacteria into the blood, as in some cases of phlebitis. DR. SIMS said in all of the cases of death after ovariotomy in Mr. Spencer Wells's practice, there was found a sero-purulent fluid in the abdominal cavity. It is not the lymph, but probably the absorption of a little decomposed lymph, which occasions the death. He instanced the case of Mr. Spencer Wells, who pricked his finger at an autopsy, following which he had a chill and fever. Mr. Wells remarked that if the entrance of so little poison produced so much constitutional irritation in himself, the women must naturally be exposed to extraordinary risks. DR. NOEGGERATII said the cases were not parallel, as in Mr. Spencer Wells's case it was the fluid from a dead body which he introduced into his system. DR. THOMAS remarked that he was not aware that any one ever claimed that the lymph had anything to do with the death from peritonitis; it is rather the effect of the disease itself upon the nervous system. STATED MEETING OF NOVEMBER 5, 1872. DR. JAS. L. BROWN, INTUSSUSCEPTION IN A CHILD. DR. DAWSON exhibited, through permission of his friend Dr. II. T. Hanks, the entire intestinal canal of a little child, six weeks old, who had died some days previous without the real disease being recognized by the physician, except very shortly before death by Dr. Hanks. The latter having made the post-mortem, found the condition shown in the specimen, which consists of an invagination of the colon, cæcum, and a portion of the duodenum into the rectum, and which are seen bound together by exudation where the peritoneal surfaces are opposed. The invagination undoubtedly in this case had begun at the ileocæcal valve, as that portion was now located against the anal extremity of the rectum. He considered the case rare, from the great extent of the intussusception, and instructive in illustrating an almost inexcusable error in diagnosis. OVARIOTOMY UNDER BICHLORIDE OF METHYLENE. DR. NOEGGERATH reported three cases of ovariotomy. The first was a patient thirty-six years old, robust, and the mother of two children. On May 1st, 1871, she first noticed a swelling in the left side, and believed herself pregnant, as there was milk in both breasts. Menses were irregular. The first measurement in September, 1872, gave forty-three inches girth. One large cyst, with smaller ones pointing inside, diagnosticated. September 1, she was tapped, and nine quarts of greenish yellow fluid evacuated, containing albumen, coloring matter of bile, tyrosin. The tumor rapidly refilled, so that, October 21, the measurement was thirty-nine inches, and on October 24, forty-two inches. Ovariotomy was performed at the German Hospital, at three and a half P.M., under effects of the bichloride of methylene given by Dr. B. F. Dawson; during a period of one and a half hours only 3 viii. were used. The respiration was very quiet, and the pulse, which was 100 at the beginning, soon fell to 80. There were many points against good recovery. Strong health, great excitement regarding success of operation, northeasterly winds with rain, and considerable hemorrhage during the operation, from the severe and extensive adhesions. The incision was three inches long externally, and but two and a half inches through the peritoneum. The pedicle was made up of the thickened left broad ligament, and was first secured by a clamp. Attempts to exfoliate the cyst from the peritoneum entirely failed. A section below the clamp bled from many points. Liq. ferri subsulph. was of no avail, and though ligatures were passed underneath and around the bleeding points, in several places they did not succeed in controlling hemorrhage. The whole mass was then tied with silk close to the uterus, and left in the pelvis. An opening was made in the cul-de-sac of Douglas to allow of drainage. The dressing consisted of lint soaked in carbolic acid, and straps of adhesive plaster. A large bladder filled with ice was placed on the abdomen. The patient recovered from the anaesthesia fifteen minutes afterwards. There was no nausea; and she suffered no pain until late at night. Suppositories of one grain of aqu. ext. opii. gave relief. Her food consisted of barley gruel and milk. Oct. 25.-No pain until late in the evening; pulse 124; temp. 38.2 Cent. Oct. 26.-Restless and feverish; no peritonitis; pulse 160; temp. 38.2; beginning septicemia; decomposed discharge from wound; quinine gr. ij. and carbolic acid every hour. Large amount of bacterii in discharge and blood; pulse towards evening 135; temp. 38.7. Oct. 27.-Fever increased towards noon; pulse 153; temp. 39.7. Subcutaneous injection of carbolic acid, two drops every three hours; the pulse, half an hour after injection, fell to 142; temp. 38.7; evening, pulse 133; temp. 39.4. |