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still open or nearly so, and makes the point a very weak one where hernia may occur.

DR. F. A. DUNSMOOR-Once there was a hanging bee in Minneapolis, and Dr. Wheaton was present when the man went out on a tie. That was the point Dr. Stewart made about cheating the insurance company. I do not think it is necessary to do that manipulation, to sew a man up for the sake of hoodwinking the insurance company. When a man gets a policy in that way he should accept the contract, and I do not believe it is our province to disguise under any other name the work we do. I am sure the company would not uphold him even if the agent should ask a man to break his contract. We ought to stand up for our professional reputation. I do not believe that is the thing to do when a man comes to us with hernia, to sew it up whether it is recent or old.

DR. L. C. BACON-While I heartily approve of Dr. Stewart's method of procedure in acute hernia, a thing occurred to me which came into my practice two years ago. A man presented himself with acute inguinal hernia. He was lifting a barrel of sugar when the injury occurred, and after consultation a truss was applied. The man was so well satisfied with the appliance that he continued to wear it. The man came to me once a month and after two or three

months the rupture was no longer apparent, and at the end of about six months he removed the truss and is no longer wearing it. He is able to lift weights and perform all kinds of labor.

DR. V. J. HAWKINS-I think it is very opportune that Dr. Stewart brings up this subject at this time, as the profession is continually neglecting to do its duty in these cases because they have got in the habit of doing so. There is no doubt about the fact of curing them by operation, and that is what we are for, and if we can only impress on the medical fraternity the fact that we must do it in that way we are soon going to get the laity where they are going to submit to operation, as at present the greatest drawback seems to be in getting their consent. I think most of us have had experience in the matter of some of our patients going to some one for operation and being advised to wear a truss when they might have been cured by operation. I believe in operation, and I am not as ready to advise the use of the truss as I was twenty years ago. I think Dr. Dunsmoor has misconstrued Dr. Stewart's statement in regard to the insurance feature of his paper. I do not think Dr. Stewart means to cheat the insurance company. It did not strike me that way at all. It seems to me Dr. Stewart's course was perfectly honorable. It seems to me he was paid to aid the patient in getting his just dues. I do not believe anybody in this society would aid a patient in getting that he was not entitled to. It is our duty to assist our patients in getting what they are justly entitled to. That is certainly the position I should take with a patient of mine. If he became suddenly disabled with hernia

or any other lesion or rupture I think it would be our duty to take just the position taken by Dr. Stewart.

DR. J. CLARK STEWART (Essayist)-I am very much obliged to the gentlemen for the attention they have given me. In regard to the remark by Dr. Dugan, there was nothing exceptional about the technic. I stated that in those cases I used the Halstead method. In regard to children, I would not advise the inguinal operation, because children are cured by the use of the truss in certain cases. I am sorry to have offended the high moral sense of certain gentlemen in regard to the insurance feature. The insurance company will not accept a man with a hernia. I do not think there is any intention to prevent a man getting indemnity for a recent injury. The wording of the policy is bad and it is avoided by my statement of facts. The statement that the contract is evaded is not so. There is no reason why a man should not get his indemnity the same as if he had a broken head. There is certainly no misstatement of facts. The insurance company understands the matter perfectly, and gives them the indemnity where they can pay the claim without violating the contract. In regard to Dr. Bacon's remark about occasional cure by the use of the truss, all those patients are left in the condition usual to congenital hernia, left with the sac coming down. Those adhesions will be torn by exertion and will be in a good position for strangulation. I wish to bring up the question of truss fitting. The profession takes a wrong attitude in regard to truss fitting. I do not think that people who have recent hernias, I do not think that even a small per cent. of people suffering with recent hernias, are advised to have early operation, but they are advised to use a truss. I do not believe they would accept a truss in place of operation if they were properly advised.

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THE OPERATIVE TREATMENT OF UTERINE
DISPLACEMENTS.

C. A. STEWART, M.D., DULUTH.

Uterine displacement as met with in practice is associated with other pathologic conditions which serve to give the patient so much discomfort or suffering that its logical treatment indicates that all these complications, which, of course, vary in different cases, must be considered and their treatment included in our plans for its relief, and it follows that the essential preliminary in the management of every case is a perfect and complete diagnosis of the patient's condition in order that every feature which exerts an unfavorable influence on the health of the patient may be found and overcome and the cure thus made more certain and permanent.

The complicating conditions may be either causative, coincident with or they may follow as a result of the displacement. By far the greater number are of a character which tend to act as causes, the displacement occurring in the sequence of events which follow and depend on some lesion or injury, and it often happens that the effects of the former are so overshadowed by the more severe symptoms of the original trouble, that unless sought for its existence is overlooked.

For instance, laceration of the pelvic floor is often followed by retroversion and prolapse, and with these there is likely to be a considerable degree of rectocele and vesicocele, with so much disturbance of function on the part of these organs as to completely eclipse the symptoms due to uterine displacement. In such a case repair of the laceration will likely relieve the rectal and vesical symptoms, but if the displacement is not remedied at the same time the symptoms due to it, which were obscured by the greater degree of suffering induced by the other condition, will begin to assert themselves and as a result the patient is not cured.

The causative factors of uterine displacement may be divided into two classes, one class being those in which the normal supports of the organ have been destroyed or impaired, and the other comprising those in which the womb is drawn out of its normal position by adhesions which have formed as a result of inflammatory action. Added to these are other influences which tend to promote and maintain displacement, such as a relaxed state of the abdominal muscles, enteroptosis and its associated disorders, which tend to increase the pressure from above on the pelvic viscera. Constitutional weakness or debility is also likely to be attended by relaxation of the uterine ligaments and renders them incapable of maintaining the organ in position, even if there are no other influences at work or if all other causes have been removed. It is not my purpose to more than briefly allude to some of the more common forms of complication in order to illustrate the different character of the problems which present themselves for solution and to mention their mutual interdependence in order to emphasize the importance of studying and mastering all the facts at issue in a given case before presuming to undertake its cure, for it is not sufficient to cure the displacement, it is the patient who must be cured, and to do this all the existing complications must be overcome.

Some of these patients can be much relieved by palliative treatment, such as the use of pessaries and the like, but little can be done that is of permanent benefit except by the use of surgical measures, and of these there have been so many different operations proposed and practiced that the very diversity of procedure gives rise to the suspicion that perfect cures have not always been the result of the operation, and as it is not logical to assume that a certain operation will succeed in one instance and fail in another that is similar in character, · the technic being equally good in both instances, we are forced to the conclusion that the failure was the result of an incomplete diagnosis and consequent resort to a form of operation that was either incomplete or that was not adapted to the condition.

The different methods of operation for the relief of this condition are all dependent on one or two basic principles, one being some method of shortening the round ligaments, while the other consists of an attachment or suspension of the uterus to some adjacent structure after replacement. Neither of these therapeutic principles will prove equally applicable in all cases. Shortening the ligaments is theoretically an ideal operation where these supports are so stretched and inclastic that they afford little or no help in holding the organ in place, provided no adhesions exist, and practically the results are very good. In these cases the Alexander method of effecting the shortening in the inguinal canal is very satisfactory, as it is simple in principle, not too difficult of execution and it is free from danger to life. The greater number of appropriate cases will be found to be those in which the displacement has followed as the result of injury to the pelvic floor and long continuance of the condition has stretched the ligaments until they are of no use in sustaining the organ. In these cases there is small likelihood that adhesions exist and repair of the laceration with shortening the ligaments in this way will meet the indications fully.

If, however, there be any feature in the symptoms or history of the case which excites suspicion that there may be adhesions, it is wiser, in my judgment, to open the peritoneal cavity and explore carefully in order to learn the precise condition before deciding what steps should be taken to retain the womb in position, because if adhesions exist they must be released in order to make a successful operation; if, however, they should not be found, intraabdominal shortening of the ligaments can be done as quickly, as successfully and with no greater danger than would be incurred in making a subsequent operation to complete the work. In case doubt exists as to the presence of adhesions it is better, in my judgment, to proceed as if there were no question about the matter, for the increase in danger is trivial in comparison with the advantage of knowing definitely what there is to overcome and that the proper steps are being taken to make a cure. If ad

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