McK. & R. Compound Stearates. COMPOUND STEARATE OF ZINC (McK. & R.) is the most satisfactory dusting powder for all purposes. It does not cake, never becomes rancid nor "sticky," resists moisture and does not soil the clothing. It is a perfect preventive of chafing in infants or adults. It can be applied to the nose, throat or other passages without causing irritation or discomfort. Supplied plain or with antiseptics, together with pamphlet containing full list of combinations and uses, on application. MCKESSON & ROBBINS = New York. Original Articles. IN THE YOUNG.1 BY MAURICE H. RICHARDSON, M.D., BOSTON. feasibility of saving ovaries in practically all cases and the possibility of saving the uterus in many have been overlooked. The tendency has been on the one hand toward REMARKS ON THE SURGERY OF UTERINE FIBROIDS, WITH ESPECIAL REFERENCE TO THE IMPORTANCE OF EARLY REMOVAL a fuller realization of the possibilities of danger in the uterine fibroid; on the other, toward extraordinary success in early intervention. The inevitable result of such observations is to make the observer THE subject of uterine fibroids has, with broaden-radical rather than conservative in the treatment of ing experience, acquired for me a renewed importance fibroids. and interest. It has seemed more important because Furthermore, with increased experience in the exI have become convinced that the gravity of the tumor ploration of supposed fibroids, one cannot but become is generally underestimated; more interesting because impressed by the frequent errors in diagnosis. The I have become impressed by the splendid results of observer is too often confounded by finding on exploearly operation under our present methods of dissec- ration that supposed fibroids have been tumors of the tion and of asepsis. The uterine fibroid is commonly most insidious and lethal nature— malignant adenoregarded as an unimportant lesion, unless it impairs mata of the uterus, dermoid cysts of the ovary, ovarian health or threatens life, or unless by its rapid growth adenocarcinomata, ovarian tumors with twisted pediit is likely soon to do so. cles, and even extra-uterine pregnancies. I have thus far relied upon hemorrhage, pain, press- Such errors in diagnosis may be uncommon, they ure or rapid growth to justify the dangers and disad- are uncommon, but no man, however experienced vantages of surgical measures, for until recent years and skilful, can always avoid them. I have already the dangers and disadvantages have been great. In-reported such errors in diagnosis in papers published tervention has been a remedy for harm already done upon extra-uterine pregnancy, upon ovarian tumors the substitution of a lesser for a greater evil. Has not the time come when, by early operation, we may avoid the one and, at the same time, diminish the other? Can we not, in a word, operate before the tumor has become a great evil· at a time when the operation is comparatively devoid of risk? Ought we not to remove from young women fibroids which cause no trouble, or very little, at a time when unimpaired vitality may permit enucleation without sacrifice of either uterus or ovaries? Though the fibroid may have given rise to neither disability nor danger, it may, nevertheless, suddenly cause symptoms of such grave importance as to demand operation at a time when the prognosis will be unfavorable. Even if the appearance of grave symptoms is gradual, the patient too often is brought to a realization of their gravity only after the loss of precious time; for she is only too much inclined to rely upon that opinion, expressed perhaps early in the history of her case, that no surgical treatment is necessary or likely to become necessary. I have seen many cases of this kind. Patients having small fibroids which, though perhaps low in the pelvis, caused no symptoms, have been advised to await later symptoms, and have not only waited for them to appear, but have waited until they have become actually threatening to life. Others, having comparatively large fibroids which, high out of the pelvis, have caused little if any trouble - they, too, have waited far beyond the period of safe extirpation. In not a few cases the symptoms seriously threatening health and life have arisen with comparative suddenness, and have demanded relief at a time when that relief was possible only at a considerable danger to life. Among the emergencies that I have seen are the sudden first occurrence of severe hemorrhage, symptoms of incarceration, of twisted pedicle, of suppuration, of localized peritonitis, of sloughing. Until recently the great success of surgical intervention has not been widely known. The dangers of the operation have been greatly overestimated, and its disadvantages greatly exaggerated. Moreover, the 1 Read before the Obstetrical Society of Boston, February 20, 1900. and upon other subjects. Though I have in many cases been mistaken as to the exact diagnosis, the symptoms have not called in vain for relief, and exploration, based upon the arguments herewith advanced, has revealed the truth in time for complete success. On the other hand, it must be said that errors in diagnosis may lead one into an unnecessary operation -the error, for instance, of calling a simple, unoffending fibroid an extra-uterine pregnancy, and of exploring the abdomen or the uterus; the error of mistaking a simple pregnancy for a fibroid uterus or an extra-uterine pregnancy, and of making an exploration which, if justifiable, is certainly untimely; the error of calling a simple pregnant uterus a diffused fibroid. A few such errors lead one to extreme care in performing operations whenever there is the least question of pregnancy. And yet the surgeon must be just as careful lest he overlook, in fear of pregnancy, a lesion which, for the safety of the patient, must be repaired at the earliest possible moment-such a lesion, for example, as a malignant adenoma of the uterine body, or even an ectopic gestation. These remarks suggest themselves to me in introducing my subject because they illustrate the extreme difficulties that sometimes arise in connection with it. They are difficulties, moreover, which can be appreciated only by those who have encountered them, and one may encounter them for the first time after so long an experience with fortunate cases that he may have been led to believe the dangers fancied rather than real. There is a time in the history of all fibroids when mistakes are the least likely to be made, and when all means of differentiation are safe. That time is when no question of pregnancy prevents examination of the uterine cavity, and when the most thorough examinations, under ether, can be made without danger of causing abortion. Even at such a time the diagnosis may be difficult, or it may be wrong. In one instance the most painstaking examination, under ether, by three men experienced in such things, resulted in the unanimous diagnosis of an unoffending uterine fibroid. A large dermoid cyst of the ovary was later removed by a the flow was not excessive, there was no discomfort more accurate diagnostician! The beauty of operations for the removal of fibroids has long impressed me. Though the operation is, in my opinion, one of the greatest in surgery, inseparable as it ever must be from possibilities of grave disaster, yet it is now one of the most successful. Its success is dependent upon rapid, accurate aud intelligent dissection, upon preliminary aseptic details, upon absolute operative asepsis, and upon perfect avoidance of wound contamination from the vagina and from the uterine canal. The results seem about as perfect as those of any operation can be. With my present methods — which I do not intend here to discuss the removal of uterine fibromata in patients not reduced by prolonged hemorrhage, and not suffering from other diseases, is attended by a success which ten or even five years ago seemed too much to hope for. Excepting such unavoidable complications as pulmonary embolism, uremia, and the like, it really seems as if the time had come when this great life-saving operation, skilfully performed upon the strong, is practically devoid of risk. Yet the experience upon which this optimistic view is based does not include only the selected and favorable cases; it includes also the cases in which the patients have been forced to operations in the face of admittedly grave dangers, operations which have been performed in many instances as a last resort-patients who by prolonged suffering have been brought to choose the lesser of two great evils. This experience has included some deplorable cases, but those cases have not been without their lesson. My mortality has been gradually reduced, by the elimination of avoidable sepsis, to a point where, excluding the complications already mentioned, it is practically nothing. With such an experience, it is perhaps but natural for one to become more radical in the treatment of fibroids, seeing as he does that the chief danger lies in the lateness of the operation, rather than in the dangers of the operation itself. One is led, therefore, to consider other questions than those of technical methods, operative skill, mortality, and the like, questions of the preservation of sex, of the possibilities of child-bearing, and of the powers of enjoying life. The preservation of these things, it must be admitted, cannot but emphasize the importance of the early treatment of uterine fibroids in the young. from pressure. It was uncertain whether the tumor was growing rapidly. The patient's circumstances permitted everything necessary. It seemed best, therefore, to watch the tumor carefully, to get an idea of the rapidity of its growth, to try the effect of rest and hygiene. The patient went south for a time, and then abroad. For six months there was no menstruation, and then a profuse flow began and lasted some six weeks. She became excessively exsanguinated; she was pale, chlorotic and "frightfully out of breath." The tumor rapidly increased in size. There was still no pain. On November 1, 1899, I found her absolutely without color. The lips were blue and the respirations rapid, though she had not flowed for some weeks. The tumor had risen to the umbilicus. It was, as before, symmetrical and smooth. The ovaries could be felt on its sides. The patient's condition was alarming; it was clear that she could not long survive the great drain from her veins. I sent her home to remain in bed as long as there should be no flowing; to be nourished and stimulated; in a word, to gain all the blood and strength possible in preparation for the operation. By December 6, 1899, she had gained enough in blood and strength to justify operation. There was no doubt as to the urgency of intervention. So severe had been the exsanguination that it would not have been surprising if she had succumbed to any additional loss of blood, small though it might be. We were ready, however, to operate at the very first appearance of hemorrhage. In the meantime she was kept in bed, absolutely quiet, and was strengthened in every possible way. On December 6th I opened the abdomen and delivered the tumor. Her condition was then much better than on November 1st, but it was not even then good enough to make the prognosis anything but serious. Though the tumor was evidently a submucous one, enucleation was technically possible. In a strong, full-blooded girl it could, I am sure, have been successfully performed. Such an operation, however, would have been a bloody one, for the venous sinuses were abundant and large, and simple incision down to the tumor could not have been accomplished without a considerable hemorrhage. Enucleation seemed so desirable in this case, and, moreover, it seemed so feasible, that I made a short incision through the uterine wall to see how it would probably work. The hemorrhage which My attention was directed particularly to this ques-immediately started from the short incision was so tion by the following case: severe that I was glad to be able to close it immediI first saw Miss March 10, 1898. There had ately by hemostatic forceps, and to go on to a bloodless always been great irregularity in the periods, four hysterectomy. None who were present doubted that months often intervening. The flow would at times enucleation no matter how rapidly performed — be excessive, though not enough to produce a lasting would have been fatal. The uterus was amputated anemia. In April, 1898, she had noticed a hardness from the cervix without loss of blood, and the patient in the abdomen. There was little if any pain, and made a most satisfactory recovery. that was of an indefinite general character. Though she was somewhat pale, her general appearance was that of a well-nourished and strong girl. There had been no loss of weight. Under ether I discovered a fibroma of the uterus about as large as a cocoanut. The tumor was smooth, spherical, symmetrical and movable. I advised her to present herself frequently to her physician for observation, with a view to operation if her symptoms should increase enough to demand it. At this time the symptoms were indefinite The possibility of myomectomy was demonstrated upon the tumor. Separation was comparatively easy, but many aud large sinuses were opened in making it. The point which I wish to emphasize in this case is that an early operation would have enabled me to remove the tumor without sacrificing the uterus. Without going into details of similar operations performed under the stress of impending death, I would mention the comparative frequency of such cases. I would at the same time lay stress upon the fact that I have shown it is among such cases that the mortality of hysterec- the tumor itself. at least to my own tomy lies. Since January 1, 1899, I have had 2 deaths satisfaction that early operations permit the enucleain my private operations for uterine fibroid; the recov- tion of small fibromata in a large percentage of cases; eries have been 26. The first fatal case was in a indeed, that this operation is often possible in large woman of forty-four, with a history of one year's fibromata. Moreover, I am convinced that the dangers tumor, accompanied by excessive flowing. The growth of the tumor was rapid, the flowing excessive, the pain and distress unbearable. The tumor was large and multiple; it was sessile and attached to everything in the pelvis and to the large intestine. The blood supply was extensive and the vessels large. I was tempted to abandon the operation when I realized its extent, dangers and difficulties, but enucleation, once begun, had to be finished, though the difficulties seemed really insurmountable. By removal of the tumor broad areas of oozing capillaries were left uncovered by peritoneum. Hemorrhage was controlled only by abundant gauze packing. The patient rallied from the operation, but died of exhaustion at the end of one week. In this case operation was undertaken at a comparatively early period, but not until the tumor was very large. There was the strongest indication for operation at the time it was performed; but there had been for many months sufficiently strong indications. Who can deny that the chances of recovery in this case were compromised by delay? Had the tumor been removed when first discovered, there is every reason to believe that the operation would have been successful. So in the case of Mrs. C., age fifty, a patient of Dr. Crocker, of Cambridge. She had had for two years excessive flowing and had been advised to submit to operation for a uterine fibroid the size of an orange. She had become white and waxy with repeated hemorrhages. She had been tamponed and curetted with temporary benefit. She finally was driven to operation by increasing flow and failing strength. The operation was bloodless, convalescence had become well established and all anxiety was over, when she died instantly from a pulmonary embolism starting from the superior vena cava. The pelvic field was perfect. of myomectomy, when it is feasible, are even less than those of hysterectomy, for all my myomectomies have recovered. Many have been for comparatively small tumors, but many have been for very large ones. In all myomectomies one important and unavoidable source of sepsis is eliminated - that of cutting across the uterine canal. The dangers of infection from this source are great, as Homans has always maintained. In at least one case of the past year cultures of the streptococcus pyogenes were obtained from the uterine canal. This danger seems to be overcome by the use of the cautery in cutting across the cervical canal, for I have had no infections since using this method. It seems also clear to me that the smaller the tumor and the easier the operation, the less the risk. The only objection to early operation in fibroids which possess little pathological significance is that they are not at the time necessary. But can it be said that even the most insignificant fibroid will not at some time assume attributes of grave significance? It certainly cannot. If the tumor can be controlled, so to speak, if it can be kept under frequent and intelligent observation, little can be said in favor of universal extirpation; but every observer knows that the patient once dismissed with the assurance that there is no need of operation is but too likely to keep her tumor to herself until perhaps the period of easy and safe extirpation is long passed. She presents herself again only when she is compelled to do so by the strongest symptoms of suffering or of danger. Even when under intelligent observation, however, the fibroid may suddenly assume grave attributes. The first hemorrhage may bring the patient to death's door, as in the first case mentioned. Such instances are by no means infrequent. Furthermore, it is by no means unheard of for fibroids to suppurate, to be associated with a pelvic peritonitis, or even with abscess, a complication of the gravest nature, which demands a heavy toll in disaster. Death from pulmonary embolism must always be considered in serious lesions, whether medical or sur- When the fibroids are extramural, with long pedigical. Yet, as I have observed it, it is more likely cles, the pedicles may become twisted. Among the to occur after extensive operations upon the blood- insidious complications must be mentioned the gradual less, in whose veins hemostatic clots are rapid of for- effect of pressure upon the ureters and consequent mation but easy of detachment. I can recall one hydronephrosis. In a word, the fibroid, though often other sudden death from this cause after hysterec-innocuous, possesses possibilities of danger to life and tomy, the patient falling dead while being fitted with health which I am convinced are underestimated. an abdominal supporter. On the other hand, the dangers of intervention must not be underestimated. Though my mortality in favorable cases has been so small, yet it is possible that the next series of cases may include some of those disasters which occur so inexplicably. Even in the class under consideration operation should not be performed without the most careful study; and it should be proposed only in those cases in which situation, size, rapidity of growth, or hemorrhage, indicate the possibility of future trouble. In all my other operations for fibroid in 1899, and so far in 1900 (26 cases), there has been a rapid and satisfactory recovery, though many have presented great technical difficulties. In the whole list there has not been a simple, easy operation. Indeed, I have not included trivial myomectomies performed during operations for other abdominal conditions. The patients, before consulting me, have in most instances waited until they were driven to it by hemorrhage, discomfort, pain, or rapid increase in the size of the If the truth of these remarks is admitted with reftumor. It seems to me safe to say that, when per-erence to fibroids in general, the importance of them formed early, myomectomy or hysterectomy has a very seems especially great with reference to young women, low mortality. for to them early operations mean not only the removal of a fibroid, which if not actually offending may become so, but the possibility of preserving the uterus itself and the power of bearing children. The chief point of my paper is the advisability of early operations in the young, in order that the uterus may be saved by limiting the operation to removal of THE USE OF THE ANGIOTRIBE.1 BY F. H. DAVENPORT, M.D., BOSTON, ANY new procedure in surgery has to pass through a period of trial before it is accepted by the profession as an advance. The angiotribe is now passing through such a critical period, and it is with the idea of giving my experience with it that I present this paper. same is then done on the other side. If the uterus is small the fundus may be turned out anteriorly, and the upper part of one broad ligament, including the tube and round ligament and the ovarian artery clamped from above, compressed for two minutes, then severed, the same done on the other side, and the uterus removed. In case of a large uterus, after the uterine arteries have been compressed, the uterus may be bisected and each half removed separately. A plug of gauze is then inserted between the stumps of the broad ligaments and the operation is complete. The angiotribe, as its name implies, is an instrument devised to control hemorrhage by powerfully The operation as done with the aid of this instrucompressing the blood-vessels, and its chief object is ment is very satisfactory. It is as near bloodless as to do away with the use of clamps and ligatures for it can be made. The use of the cautery limits bleedthis purpose. Its use was first advocated, as far as I ing from the edges of the vaginal opening, and there can learn, by Doyen, of Paris, and was followed by is practically no loss of blood from the stumps of the Thumin, of Berlin, who modified Doyen's original in- broad ligament. The necessary manipulation during strument. Later Tuffier, of Paris, brought out a new the later stages of the operation does not start up instrument, which is the one I show here to-night. A any oozing. It also shortens the time of the operalittle more than a year ago it began to be used in New tion. I had long ago given up ligatures, both from the York by Cleveland, and independently by Newman, difficulty of applying them and because if silk is used of Chicago, and it has since then found a wider field they become infected and keep up a discharge until in the hands of a good many surgeons. At the meet- they come away, often only after an interval of ing of the American Gynecological Society in Phila-months. delphia in May, 1899, Cleveland reported 26 cases, Leaving a number of clamps from twenty-four to Newman 16, and Stone, of Washington, 11, where forty-eight hours is very painful for the patient, as is this instrument had been used most satisfactorily. also their removal. Following the use of the angiotribe there is almost no pain, practically no bleeding, and the convalescence is easy and rapid. It is essentially a powerful clamp, consisting of two heavy blades, which are approximated by pressure produced by means of a screw which is worked by a wheel. With this instrument it is claimed that a pressure of three thousand pounds to the square inch can be obtained. The broad surfaces of the blades are roughened, and there is a longitudinal groove down the centre of each. A small pin at the end of one blade fits into a corresponding depression in the other, as an additional guard against any possible slipping. In vaginal hysterectomy, the operation in which the use of this instrument seems peculiarly indicated, my mode of procedure is as follows: Having seized the cervix with the vulsellum I divide the tissues in the posterior cul-de-sac at the junction of the vaginal wall with the cervix, with the Paquelin cautery heated to a red heat. The point of the blade is kept close to the tissues, and the whole breadth of the culde-sac is divided. The same is done on the anterior surface of the cervix, and the vagina is divided in the lateral cul-de-sacs as well, but to a moderate depth only. The tissues are then pushed up front and back with the fingers, separating the attachments between the uterus, and the bladder and rectum, until the peritoneum is reached. If there are no adhesions and the uterus is small, the peritoneum is then opened and the anterior and posterior surfaces of the uterus freed. In abdominal operations the results are equally satisfactory, though the advantages from using the angiotribe are less obvious. It can with perfect safety be used for clamping off the appendages. In two classes of cases it seems to me indicated: first, in septic cases where there is danger of any ligatures becoming infected, and for cases of secondary operation where there have been disturbances from the stump left after a primary operation. Here it would seem me to lessen the chance of subsequent irritation if no ligatures were used. to From my experience in 5 cases (a limited number to be sure, but embracing both abdominal and vaginal), I consider the angiotribe an advance in technique. Some objection has been made to the size of the instrument and its apparent clumsiness, but I have not found that a practical objection. It can be adjusted in a narrow vagina, and after having been used is removed, and the field of operation is not obstructed, as is the case when clamps are left on. I understand a somewhat lighter instrument has been devised by Dr. Bissell, of New York, which is giving satisfaction. If sufficient pressure can be secured with a smaller instrument, it might be an advantage in the way of being more easily kept absolutely still while exerting the pressure. Dragging on, or twisting the angiotribe while it is clamped, might possibly interfere with perfect hemostasis. The blades of the angiotribe are then introduced on the left side under the guidance of the fingers, including as much of the broad ligament as they will grasp The compressed tissues are not devitalized. The and close to the uterus. Care should be taken that course of the convalescence in the abdominal cases is the ends of the blades do not include bowel or omen- uneventful, and in the vaginal cases there is comparatum. The blades are then screwed together tightly, tively little discharge. The effect upon the tissues and the clamp allowed to remain for two minutes. has been studied microscopically by Thumin, of Berlin, The tissues are then divided on the uterine side, leav- who says: "The result was, that, contrary to what ing a little margin of tissue on the outside of the might have been expected from such a complete thinclamp. When the clamp is carefully removed the ning out, the tissues were by no means bruised out of edge of the broad ligament will be seen to be a flat shape. The effect of the instrument is nothing more ribbon as thin as paper, which is completely dry. The than a complete compression of the interstitial connec1 Read before the Obstetrical Society of Boston, February 20, 1900. | tive tissue, with all its lymph spaces. All the other |