SOCIETY REPORTS.

SOUTHERN SURGICAL AND GYNECOLOGICAL

ASSOCIATION.

Fifth Annual Meeting, held in Louisville, Kentucky, November 15,.

16 and 17, 1892.

FIRST DAY---- MORNING SESSION.

' The Association met in the council chamber of the city hall,
and was called to order at 9 : 30 a. m. by the President, Dr. J.
McFadden Gaston, of Atlanta, Ga.
An address of welcome was delivered by Dr. L. S. McMurtry ?
of Louisville, Chairman of the Committee of Arrangements, the
response to which was made by the President.
The first paper read was by Dr. Bedford Brown, of Alexan­
dria, Va., entitled, •
PERSONAL RECOLLECTIONS OF THE LATE DR. BENJ. W. DUDLEY,
OF LEXINGTON, KY., AND HIS SURGICAL WORK.

The speaker paid an eloquent tribute to Dr. Dudley, and char­

acterized him as the greatest lithotomist that this coun­
try has ever produced and the most successful in the history of
the world. The speaker’s close relationship to Dr. Dudley as
private pupil and assistant for two years enabled him to present
.a clear and faithful sketch of his character and surgical work.
EXPERIENCES IN PELVIC SURGERY.

This was the title of a paper read by Dr. A. V. L. Brokaw, of

St. Louis, Mo. Of all the surgical problems difficult to solve, it
may be truthfully said, that those met with in the pelvis are the
most trying. The speaker knew of no surgical work which
will compare with the experiences found in the pelvis ; a di­
versity of conditions, complications and unexpected happenings
are ever presenting. In a series of many operations but few
will be alike in every particular. As his experience became
larger he was free to confess his inability to correctly diagnose
the character of abdominal and pelvic troubles. He had diag­
nosed pus tubes and found extra-uterine pregnancy ; diagnosed
extra-uterine pregnancy and found pus ; diagnosed ovarian
lesions and found the trouble located in the tubes and vice versa*
When well defined pelvic lesions exist nothing short of radical
measures succeed. The one condition above all others where
exploratory incision should be adopted was in cases of suspected
extra-uterine pregnancy. It was correct and good surgery to
open the abdomen and not wait for all the classical signs to ap­
pear. The symptoms of extra-uterine pregnancy were so fre­
quently obscure and unreliable that he was firmly convinced a
radical position should be taken. A case was cited in point.
Dr. William Warren Potter, of Buffalo, desired to in­
dorse that portion of the paper pertaining to an early exploratory
 incision in cases of suspected extra-uterine pregnancy. As regards
the use of the sound he had brought an indictment against it
some six or eight years ago, consequently he would not expatiate
upon the subject at this time.
Dr. Joseph Taber Johnson, of Washington, said that as soon
as the surgeon diagnosed something in the abdominal cavity that
ought not to be there, anatomically or physiologically, and was
histologically wrong, it should be removed. An exploratory op­
eration was justifiable in cases of suspected extra-uterine preg­
nancy, and the surgeon should base his further procedures upon
what he finds after making the exploration.
Dr. W. E. B. Davis, of Birmingham, Alabama, thought the
pendulum relative to surgical interference had swung a little too
far. He believed that a great many of the so-called “tinkerers,’’
who succeeded in relieving their patients, did not accomplish it
so much by the local treatment they used as by having patients
under their care, keeping the bowels open, giving constitutional
treatment, seeing them regularly, etc. While by so doing they
may not be cured in all cases, they were greatly benefited. Re­
garding the diagnosis, surgeons who are opening the abdomen
constantly would rarely give a positive diagnosis in the case. Dr.
Davis cited the case of a woman who had an acute attack of
peritonitis, and the history was the same as from pelvic abscess.
Dr. Brokaw, in closing the discussion, said that in every case
of suspected extra-uterine pregnancy it was good surgery to
make an exploratory incision and operate before rupture took
place.
Dr. Cornelius Kollock, of Cheraw, South Carolina, read a
paper on
CRANIOTOMY UPON THE LIVING FCETUS NOT JUSTIFIABLE.

He said this operation implied the death of the foetus and a

frightful mutilation of its body, often accompanied by serious
lacerations of the vagina and adjacent tissues of the mother. Re­
cent advances in obstetrics, gynecology and abdominal surgery
contribute largely to a demonstration of the fact that a timely
resort to Caesarean section in pelvic obstruction is the great factor
to success. In Germany, out of 149 cases of contracted pelvis,
109 mothers and 136 children were saved. If craniotomy had
been done in those cases 149 children would have been destroyed
and probably 50 women—perhaps more, making a sacrifice of at
least 199 lives. In many of these cases exhaustion had super­
vened and septic influence had already been excited. This,
added to a tardy disposition to union by first intention, caused by
contusion of the parts involved in the uterine incision, lessened
materially the woman’s chances for recovery. Ziveiffel was suc­
cessful in twenty-nine cases out of thirty ; Schauta did Cassarean
section fifteen times without a single death. Recently in eighteen
operations done in Louisiana fourteen were successful. Of eight
in Ohio six were successful. Dr. Price has done Caesarean sec­
tion a number of times successfully. Dr. Kollock is firmly con­
vinced that eighty-five or ninety-five per cent, of the cases of ob­
struction of the pelvis forbidding the delivery of the foetus in the
natural way, might be saved by a timely resort to the Caesarean
section.
Dr. W. D. Haggard, of Nashville, emphasized the position
taken by Dr. Kollock. He believes that when the profession
fullv realizes the immense difference in the number of lives saved
by Caesarean section over craniotomy there will be no doubt as
to its preference to the latter operation.
Dr. Hunter McGuire, of Richmond, favored Caesarean sec­
tion. Some time ago he saw the report of a case by Dr. Thomas
of New York, where, in doing Caesarean section, he proposed
to take the uterus out of the cavity, and then open it. He
thought this added very much to the danger of the operation,
necessitating a larger opening, exposing the cavity of the abdo­
men a long time to the atmosphere, etc. lie does not favor this
procedure.
Dr. L.S. McMurtry, of Louisville, said that a few years ago
it would have been impossible for one to have presented the views
that Dr. Kollock had without meeting with violent opposition.
Caesarean section was then regarded as an extremely heroic op­
eration, and until recent years the mortality therefrom was very
great ; but since it has been carried to the present degree of
perfection by Saenger and others it has strengthened the opinions
of abdominal surgeons, who now consider it preferable to crani­
otomy. Within the last two months symphysiotomy had been,
brought before the profession and practiced as an alternative in
certain cases for Caesarean section. What the future of the
former operation is to be, we are not prepared to say.
Dr. Arcii Dixon, of Henderson, Ky., advised Caesarean sec­
tion in a case in which he was called in consultation, but the fam­
ily physician insisted upon his doing craniotomy, which was done,,
and while every precaution was taken with regard to rendering
aseptic the Held of operation, the woman developed pelvic peri­
tonitis, and died within four days. He believed a Porro opera­
tion would have saved the life of the woman, and perhaps that of
the child.
Dr. W. D. Haggard, of Nashville, read a paper entitled
A CASE OF EXTENSIVE HEMATOCELE RESULTING FROM TUBAL
PREGNANCY RUPTURING INTO THE BROAD LIGAMENT.

Although the foetus was not found, that it was a case

of tubal pregnancy with rupture into the broad ligament
is clearly established by the clinical history and post mor­
tem appearances, summarized as follows : (i) Patient con­
fessed having had intra-pelvic trouble previously (presumably
gonorrhoea), for which she was treated locally. (2) At the time
of the accident, caused by jumping from a wagon, her menses
were past due. As to how long her statements were misleading.
(3) There was a fitful yet persistent bloody flow from the uterus
during her entire illness. (4) Paroxysmal, colicky pains in lower
abdominal and pelvic regions of frequent occurrence. (5) Ex­
istence of a tumor above the pubes, which she probably mistook
for a gravid uterus. (6) Persistent refusal to submit to a digi­
tal examination, probably fearing the detection of her pregnant
state.
Post Mortem Appearances.—(a) Enlarged and softened condi­
tion of the uterus with a patulous os, showing escape of a sero-
sanguinal, stringy fluid, (b) Enlargement of the left tube with
a well-defined cavity from which the fruit sac escaped, (c) Ex­
istence of a deciduous membrane, as revealed by the microscope,
(d) Discoloration of rectum, produced by blood dissecting
around it, producing constriction and partial death.
Dr. H. C. Hogan, of Union Springs, Ala., reported a case of
FIBROID TUMOR OF THE UTERUS—PREGNANCY: RUPTURE
ABOUT THE FOURTH MONTH---- OPERATION, SPECIMEN.

The woman, colored, was twenty-eight years of age, and

from the symptoms and history of the case, he was satis­
fied there was a rupture, and the probabilities were that it
was about the fourth month of gestation. He was also
of the opinion that the rupture did not immediately destroy
the foetus, that it continued to grow in its abnormal posi­
tion. The speaker felt sure that if he had operated on the case
immediately after rupture, the patient's life would have been
saved. In all cases of rupture he would advise Porro’s opera­
tion to be done immediately; that in all cases, where the tumor
is large or multiple, intramural or subperitoneal, with a sacciform
dilatation of the posterior segment of the uterus, and as
above the pubic bone, or inaccessible, the same operation should
be done. In all cases where the tumor is in front of the child,
or blocking the passage, it should be don$, provided the preg­
nancy has advanced to the full time, or there should be a hem­
orrhage, or rupture of the membranes, indicating that an abor­
tion or miscarriage is imminent.

FIRST DAY---- AFTERNOON SESSION.

Dr. Geo. A. Baxter, of Chattanooga, Tenn., read a paper

entitled
A NEW OPERATION FOR THE RADICAL CURE OF INGUINAL HERNIA.

Dr. Baxter presented a radically different operation in principle

from any yet given. If consists in a prolongation of the incision,
after the ordinary management of the sac and after ligation,
through the internal ring into a more or less extensive lapa­
rotomy as the exigencies of the case demand; lifting the neck of
the sac into the abdominal opening above the ring and its fixation
there by a deep suturing, cutting off the sac close above the
peritoneum and its closure by buried suture, and a final closure
of the abdominal opening by this and a more superficial set of
sutures which pass across above the closed sac and peritoneum
and underneath the deep fasciae which are intended to approxi­
mate the homologous tissues of the abdominal wall. The ring
is closed with crucial sutures dipping over cord and traversing
the tissues, and the seminal canal closed with deep sutures alone.
Points of originality claimed: A line of incision suitable for
any inguinal hernia, and by the fixation of the sac above the
peritoneum a deflection of all abdominal expulsive force from the
ring and canal, and the thickened lining of the internal ring, and
the method of closure of abdominal incision. Advantages
claimed: Quick cure with avoidance of necessity of truss, de­
flection of expulsive force from internal opening and canal to ab­
dominal parietes. Advantage in being able to approach con­
striction either from without or within. Avoidance of necessity
for traction on sac or contents. Ample room for treatment in
diseased conditions of sac or contents, including gut operations if
necessary.
Dr. Henry O. Marcy, of Boston, followed with a paper on
THE CURE OF INGUINAL HERNIA IN THE MALE,

in which he said until recently the cure of inguinal hernia in the

male had been considered at the best accidental, and when appar­
ently effected, generally doubtful, and the hernia liable to return.
The great majority of surgeons looked upon an attempt to cure as
ill-advised, and believed operative measures should not be under­
taken except in cases of strangulation. Dr. Marcy thought there
was abundant reason for such conclusion, when judged from the
earlier history of surgical procedures as attempted for cure-
The essential surgical considerations for the cure of hernia were
as follows: First—Strict aseptic conditions. These pertain
alike to all modern surgical procedures. Second—A free dissec­
tion. This is necessary in order to lay bare the internal ring,
to permit of the enucleation of the peritoneal sac, and the sepa­
ration and elevation of tbecord out of the wound. The external
epigastric artery often courses in the line of the incision. It is
not seldom that the size of this vessel is such that the operator
fears he has wounded the larger vessel. Third—The disposition
of the sac. The separation of the sac to its very base before re­
moval is to be recommended as the rule. There are times,
however, when it is not easy to free the peritoneal pouch, owing
to the adhesion to the surrounding tissues, and in large old irre­
ducible hernia a more or less intimate fusion of the contents to
the inner wall of the sac. It is generally better to open the sac
before ligating or sawing through its neck, since by so doing the
condition at the internal ring is assured, and by such knowledge
the operator is often profited, even if the sac is completely empty,
not seldom the omentum is adherent at the internal ring and
even a constriction loop of intestine may escape observation when
it is attempted to return the sac unopened.
Dr. Marcy closed his paper by saying that between three and
four millions of the people living in the United States were sub­
ject to hernia ; and, if the demonstration is complete that the
risk of life is less- than one per cent, from the operative proced­
ures instituted for cure, and that scarcely more than ten per cent,
are subject to relapses, and these almost invariably in a state
improved by the operation, the plea is a very strong one, to con­
sider favorably the advisability of operation in a very large ma­
jority of all the sufferers from hernia.
Dr. W. H. Wathen, of Louisville, read a paper entitled
THE TREATMENT OF UMBILICAL AND VENTRAL HERNIA.

He said the importance of studying carefully the best methods

of treating hernia is now especially emphasized because of the
increased frequency of the disease following laparotomy, and es­
pecially because the modern methods of surgery make the opera­
tion far less dangerous than it formerly was. The operation for
radical cure of hernia in the practice of the best surgeons, except
in extreme cases, is practically devoid of danger, and the result
may be made permanent. Modern antiseptic and aseptic precau­
tions have practically excluded the danger which formerly arose
from infective peritonitis. The author said there are many cases*
of ventral hernia that could have been prevented had the proper
treatment been carried out in the closure of the abdominal wound.
In order that there may be no hernia following laparotomy it is
necessary to get perfect union by adhesion of all the layers of
tissue forming the abdominal wall—the peritoneum, muscles, the
deep and superficial fascia, and the skin. But especially must
we get union of the layers of fascia, for unless this be done the
other layers will gradually separate and hernia will follow. This
cannot be done unless we succeed in bringing the cut edges of
the fascia in even and perfect apposition long enough for strong­
union to occur.

SECOND DAY---- MORNING SESSION.

Dr. W. O. Roberts, of Louisville, read a paper on

THE TREATMENT OF UNUNITED FRACTURES BY RESECTION.

He said the treatment of ununited fractures by resection was

more than a hundred years old, White of Manchester having done
the first operation in 1760. In consequence of the great mortality
attending the operation it was abandoned until revived by Sir Ben­
jamin Brodie. In 1805 Iloreau, after having divided the; fragments
obliquely fastened them together by tying a metallic wire around
them. Rogers, of New York, in 1838 passed the wire through
holes drilled in the wall of the fragment and then twisted it.
Since then other surgeons have used sutures of various mate­
rials in the same way. Some of them leaving the sutures in per­
manently, while others removed them after union of the frag­
ments had occurred. Some instead of drilling the bone passed,
the sutures simply through the periosteum. Screws, nails, ivory
pegs and clamps have been used for the same purpose. In the
long bones when coaptation of the fragments can be secured,
Dr. Roberts feels satisfied that resection and a fixed dressing,
will be followed by just as good results as when sutures or other
contrivances for fastening the ends of the fragments together
are used.
 “Symptoms of Fracture, their Importance and Significance.”
Dr. W. C. Dugan, of Louisville, read a paper on this subject.
(Abstract of same not received.)
Dr. Bedford Brown, of Alexandria, Va., related the case of.
a boy who sustained a compound comminuted fracture of the
skull in i860, yet he was perfectly conscious and had no symp­
toms of compression of the brain. The spiculse of bone were re­
moved, and recovery followed.
Dr. J. H, Letcher, of Henderson, Ky., advised against the too
hasty resort to the use of the trephine and chisel in injuries of
the skull.
Dr. C. Kollock, of Cheraw, S.C., had trephined in two cases-
with successful results.
Dr. J. H. McIntire, of St. Louis, reported a case of traumatic
insanity in a railroad employee in which he trephined with suc­
cess. The fracture was an extensive one and occurred in the
upper Rolandic region. He reported several other interesting
cases.
Dr. William Warren Potter, of Buffalo, called attention to
fracture of the internal table of the skull without fracture of the
external; hence the great liability to error in diagnosis.
Dr. Howard A. Kelly, of Baltimore, related the case of a man
who fell and was brought to the Presbyterian Hospital in a coma­
tose state. Careful examination revealed the fact that the maa
had diabetic cataract with fracture at the base of the skull.
Dr. William T. Briggs, of Nashville, had trephined in fifty
cases of epilepsy. Four-fifths of the cases operated on were re­
lieved temporarily but not permanently.
Dr. T. W. Reamy, of Cincinnati, mentioned the case of a man
who had fallen from the second story of a court house, sustaining
a fracture of the skull, but had never had epilepsy or any bad
symptom following the injury. He thought this case would be
some comfort to country practitioners who did not enlarge the
scalp wound in all cases.
The papers were further discussed by Drs. Vance, Lydston,
Nicolson, Greenly and Baxter, all of them favoring radical meas­
ures in the treatment of injuries of the skull.
 Dr. L. S. McMurty, of Louisville, read a paper entitled “Ova­
rian Cystoma with Twisted Pedicle and Peritonitis; Ovariotomy
in Second Week of Typhoid Fever—Recovery.” (No abstract
received of this paper.)
Dr. H. Horace Grant, of Louisville, contributed a paper on
INTESTINAL ANASTOMOSIS BY A NEW DEVICE.

For more than a year the speaker has been endeav­

oring to perfect some instrument to simplify suture, but
it has been so difficult to get just what he wanted that
time has not been allowed since the completion of the in­
strument to test it fully. It is to be used only after resec­
tions. The two blades of the clamp are oval scissors, one-fourth
of an inch in transverse and two and a half inches in longitudinal
diameter. The arms of the clamp are made long enough to
allow of introduction full five inches. After the gut is exposed,
a strand of iodoform gauze is passed through the mesentery and
•constricts the intestines fully six inches from each point of in­
tended resection. The mesentery is tied off over the portion to
be resected with fine silk, in two inch loops, cut close and dropped
in the usual way. When the resected portion is removed the gut
ends may be washed out if desired. While the two ends of the
divided intestine are held parallel, one blade is entered in each, al­
lowing at least one and one-half inches of gutbeyondthe proposed
anastomotic opening to permit of invagination of the ends. The
clamp is tightened and the two surfaces thus firmly held are rap­
idly stitched together by a continuous overhand Lembert suture
of fine silk. Two rows of parallel sutures as suggested by Abbe
may be used if desired, though it has seemed that one is enough
according to the author’s experiments. The work can be done
far more rapidly and accurately than without the clamp. When
the suturing is finished the damp is tightened if need be, and a
long bladed dressing forceps passed in the bowel and the oval
plug removed or pushed in. The scissors action of the blades,
together with the ten or fifteen minutes pressure prevents any
hemorrhage. The clamp is now withdrawn and the ends invag-
inated in the usual way.
 Dr. A. V. L. Brokaw, of St. Louis, thought the instrument
exhibited by Dr. Grant a good one, and said that anything which
materially assists the surgeon in making intestinal anastomotic op­
erations rapidly was of great value, that time was a most impor­
tant element. The use of rings, plates and mats in the past were
bad. He believes that we can suture far more rapidly with Dr.
Grant’s instrument than any other device he has thus far seen.
Dr. W. E. B. Davis, of Birmingham, Ala., believed a large
number of operators had abolished mechanical devices in doing
intestinal anastomosis. His brother, Dr. John S. Davis, had de­
vised a rubber plate and mat, but now prefers not to use the
plate. In the case of restriction of the bowel, he thought the de­
vice of Dr. Grant was an ingenious one, inasmuch as it would
facilitate the work of the surgeon and enable him to do an oper­
ation very quickly. He had conducted a series of experiments
in an effort to do away with mechanical devices, by which sur­
geons might use the end to end operation by splitting up the
bowel. While the operation was successful in some cases, the
strain on the circulation was too great, and he now condemns the
operation.
Dr. Frank G. Lydston, of Chicago, directed attention to Dr.
J. B. Murphy’s anastomosis button, a recent device by which he
says cholecysto-enterostomies can be done in from eight to
twelve minutes.
[to be concluded.]