^n^ 
 
 ^. 
 
 ^> 
 
 A^ 
 
 
 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 /. 
 
 l^ 
 
 
 ^, 
 
 
 
 1.0 
 
 I.I 
 
 11.25 
 
 2.5 
 
 |50 ™^ 
 
 t lis 12.0 
 
 1.8 
 
 lA IIIIII.6 
 
 <^ 
 
 % 
 
 /^ 
 
 ^; 
 
 
 
 0/7//// 
 
 M 
 
 Photographic 
 
 Sciences 
 Corporation 
 
 23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 873-4503 
 
 -b 
 
 ,\ 
 
 iV 
 
 ^\^ 
 
 A 
 
 \ 
 
 
 v^ 
 
 > 
 
 R>^ 
 
^ J^^> 
 
 
 .^ 
 
 ^ 
 
 fee 
 
 CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
 CIHM/ICMH 
 Collection de 
 microfiches. 
 
 Canadian Institute for Historical Microreproductions / Institut canadien de microreproductions historiques 
 
Technical and Bibliographic Notes/Notes techniques et bibliographiques 
 
 The Institute has attempted to obtain the best 
 original copy available for filming. Features of this 
 copy which may be bibliographically unique, 
 which may alter any of the images in the 
 reproduction, or which may significantly change 
 the usual method of filming, are checked below. 
 
 D 
 
 D 
 
 D 
 D 
 
 D 
 D 
 
 D 
 
 D 
 
 Coloured covers/ 
 Couverture de couleur 
 
 I I Covers damaged/ 
 
 Couverture endommagde 
 
 Covers restored and/or laminated/ 
 Couverture restaurde et/ou pelliculde 
 
 I I Cover title missing/ 
 
 Le titre de couverture manque 
 
 I I Coloured maps/ 
 
 Cartes gdographiques en couleur 
 
 Coloured ink (i.e. other than blue or black)/ 
 Encre de couleur (i.e. autre que bleue ou noire) 
 
 Coloured plates and/o' illustrations/ 
 Planches et/ou illustrations en couleuir 
 
 Bound with other material/ 
 Relid avec d'autres documents 
 
 Tight binding may cause shadows or distortion 
 along interior margin/ 
 
 Lareliure serrd"! peut causer de I'ombre ou de la 
 distortion le long de la marge int^rieure 
 
 Blank leaves added during restoration may 
 appear within the text. Whenever possible, these 
 have been omitted from filming/ 
 II se peut que certaines pcges blanches ajouties 
 lors d'une restauration apparaissent dans le texte, 
 mais, lorsque cela 6tait possible, ces pages n'ont 
 pas 6t4 filmi&es. 
 
 Additional comments:/ 
 Commentaires supplimentaires; 
 
 L'Institut a microfilm^ le meilleur exemplaire 
 qu'il lui a 6t6 possible de se procurer. Les details 
 de cet exemplaire qui sont peut-dtre uniques du 
 point de vue bibliographique, qui peuvent modifier 
 une image reproduite, ou qui peuvent exiger une 
 modification dans la m^thode normale de filmage 
 sont indiquds ci-dessous. 
 
 □ Coloured pages/ 
 Pages de couleur 
 
 □ Pages damaged/ 
 Pages endommag^es 
 
 □ Pages restored and/or laminatgd/ 
 Pages restaurdes et/ou pellicul^es 
 
 ~y] Pages discoloured, stained or foxed/ 
 ' Pages d^colordes, tachetdes ou piqu^es 
 
 □ Pages detached/ 
 Pages d6tachdes 
 
 V 
 
 n 
 
 Showthrough/ 
 Transparence 
 
 I I Quality of print varies/ 
 
 Quality inigale de I'impression 
 
 Includes supplementary material/ 
 Comprend du materiel supplementaire 
 
 Only edition available/ 
 Seule Edition disponible 
 
 Tl 
 tc 
 
 Tl 
 
 P 
 o 
 fl 
 
 
 b 
 t> 
 
 si 
 o 
 f! 
 si 
 o 
 
 T 
 si 
 T 
 
 V( 
 
 IV 
 di 
 
 SI 
 
 b 
 ri 
 r( 
 nr 
 
 Pages wholly or partially obscured by errata 
 slips, tissues, etc., have been refilmed to 
 ensure the best possible image/ 
 Les pages totalement ou partiellement 
 obscurcies par un feuillet d'errata, une pelure, 
 etc., ont kxk film^es k nouveau de facon k 
 obtenir la meilleure image possible. 
 
 This item is filmed at the reduction ratio checked belcw/ 
 
 Ce document est filmd au taux de reduction indiqud ci-dessous. 
 
 10X 
 
 
 
 
 4 A\# 
 
 
 
 
 1SX 
 
 
 
 
 22X 
 
 
 
 
 26X 
 
 
 
 
 SOX 
 
 
 
 r" 
 
 
 
 
 
 
 
 
 
 
 
 4 
 
 
 
 
 
 
 
 
 
 
 
 
 12X 
 
 16X 
 
 20X 
 
 24X 
 
 28X 
 
 32X 
 
The copy filmed here hae been reproduced thanks 
 to the generc.'ty of: 
 
 Medical Library 
 McGill University 
 Montreal 
 
 The images appearing here are the best quality 
 possible considering the condition and legibility 
 of the original copy and in keeping with the 
 filming contract specifications. 
 
 L'exemplaire fiimi f ut reproduit grAce A la 
 ginirositi de: 
 
 Medical Library 
 McGill University 
 Montreal 
 
 Les images suivantes ont At6 reproduites avec le 
 plus grand soin, compte tenu de la condition at 
 de la nettetA de I'axemplaire f ilmi, et en 
 conformity avec les conditions du contrat de 
 filmage. 
 
 Original copies in printed paper covers are filmed 
 beginning with the front cover anci ending on 
 the last page with a printed or illustrated impres- 
 sion, or the back cover when appropriate. Ail 
 other original copies are filmed beginning on the 
 first page with a printed or illustrated impres- 
 sion, and nnding on the last page with a printed 
 or illustrated impression. 
 
 Les exemplaires originaux dont la couverture en 
 papier est imprimte sont filmto en commenpant 
 par le premier plat et en terminant soit par la 
 derniire page qui comporte une j^Ttpreinte 
 d'impression ou d'illustration. soit par le second 
 plat, selon le cas. Tous les autres exemplaires 
 originaux sont filmte en commen^ant par la 
 premidre page qui comporte une empreinte 
 d'impression ou d'illustration et en terminant par 
 la derniire page qui comporte une telle 
 empreinte. 
 
 The last recorded frame on each microfiche 
 shall contain the symbol —^(meaning "CON- 
 TINUED"), or the symbol V (meaning "END"), 
 whichever applies. 
 
 Un des symboles suivants apparaitra sur la 
 derniire image de cheque microfiche, selon le 
 cas: le symbols —»• signifie "A SUIVRE", la 
 symbols V signifie "FIN". 
 
 Maps, plates, charts, etc., may be filmed at 
 different reduction ratios. Those too large to be 
 entirely included in one exposure are filmed 
 beginning in the upper left hand corner, left to 
 right and top to bottom, as many frames as 
 required. The following diagrams illustrate the 
 method: 
 
 Les cartes, planches, tableaux, etc., peuvent dtre 
 filmAs it des taux de reduction diffirents. 
 Lorsque le document est trop grand pour dtre 
 reproduit en un seul clichA, 11 est fiimi i partir 
 de I'angle supdrieur gauche, de gauche it droite, 
 et de haut en bas, en prenant le nombre 
 d'images nicessaire. Les diagrammes suivants 
 iilustrent la mithode. 
 
 32X 
 
 1 
 
 2 
 
 3 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
cp. 
 
 JU- 
 
 ^W^ 
 
 \h^(k 
 
 \ 
 
 .-T.-r 
 
 ^-<Mv2A-e.<JI. 
 
 ^v-^?Aa//?A?/^i 
 
 QUARTERLY RETROSPECT OF GYNJICOLOGY 
 
 PRBPARED BY 
 
 T. JOHNSON-ALLOWAY, M.D., 
 
 Instructor in Gynaecology, McGill University. 
 
 Reprinted from the Montreal Medical Journal, Nov'r, 1892. 
 
I( 
 
 (I 
 
 QUARTERLY RETROSPECT OF GYNiECOLOOY. 
 
 Prhpauhi) by T. Johnson-Alloway, M.D., 
 Instructor in Gyniucology, McQill Univoraity. 
 
 Compress left in Abdominal Cavity and passed afterwards at 
 Stool. — Pir.ATE of Orleans {Union Medical, March, 1892) relutes 
 a cuse where a tarlatan sponge compress used in an abdominal 
 section was left behind. On the evening of the operation thoro 
 was voMiiting and pain in the right iliac region. Phlebitis of 
 the right leg set in. These symptoms soon disappeared and 
 the patient made a complete recovery. Six months later pains 
 in the region of the liver occurred ; they became ditfused over 
 the abdomen, and vomiting and t3'mpanites set in. At length 
 there was a rise of tompei-ature and a swelling in the pelvis was 
 noticed. An operation was about to be performed when she 
 passed the compress in a mass of hardened faeces. The patient 
 recovered. Quenu relates a case where a compress was left 
 in by accident. The patient died and the compress was found 
 rolled up in a coil of intestine. Teriillow observed a case 
 where pressure forceps remained eight months in the abdomen 
 and came out close to the. umbilicus. 
 
 i^uhperitonml Hysterectomy. — Dr. Ileywood Smith read a 
 long paper before the British Clyniccological Society recently 
 upon this subject. In summing up Dr. Smith concluded that 
 the following lessons might be learned fi'om the cases cited and 
 discussion which would ensue. 
 
 (1) No two cases are alike. We cannot therefore lay down 
 any hard-and-fast rule for the treatment of the stump ; the 
 fibroid invading the uterus in so many ways and situations, a 
 certain choice must ever bo left to the operator, but that we 
 are to boar in mind that, where it is possible of application t'.o 
 sub-peritoneal method holds out as good a prospect of success 
 as any othei-, and leaves the othei- pelvic organs free and un- 
 fettered by any constriction or adhesion. 
 
 (2) That Dr. Byford's method does not commend itself be- 
 cause of the length of time the operation takes, and it is open 
 to the grave objection of manipulation being required both 
 in the abdomen and vagina in the course of the same opera- 
 tion. 
 
(3) That Dr. Sk-oiio'H HUf^gestioii of dihitinj; and iiivortiiig 
 the cervical canal is voiy difficult pniclical'y, and lias the 
 same objection against it of aHsociated vaginal and abdominal 
 manipulation. 
 
 (4) The liest methods, it appears to mo, arc those of Dr. 
 Gotfe and Mr. Milton and so far can'ied out in a moditicd way 
 by mystjlf. 
 
 The main points in t lie operation seem to be: — 
 
 (1) Make the pei-itoneal flaps sufficiently large, as they can 
 be reduced, but not added to. 
 
 (2) Secure absolutely evei-y bleeding branch o^ the uterine 
 arteries, if possible, separately. 
 
 (3) Lace the whole pelvic peritoneal wound across with an 
 uninterrupted suture of chromicised catgut, taking care that 
 Lambert's stitches are used over the uterine stump, so that it 
 is entirely sealed with peritoneal covering. 
 
 It is recommended that the cervical stump be divided as 
 low down as possible, for the proportion of connective tissue 
 to contractile tissue is greater than in the upper part of the 
 uterus, where a contractile tissue prevails; there wi'.l thei-e- 
 fore be less shrinking the more the amputation is carried 
 through the cervix proper. 
 
 I would also point out the great advantage of using tinc- 
 ture of matico as a styptic where there is any oozing — it is 
 very etfectual and seems to do much less harm than others. 
 
 There remain three points for discussion : 
 
 (1) Shall we use a drainage tube? I think where there 
 have been any adhesions and consequent oozing, a drainage 
 tube should be used, for at all events fortj'^-eight hours; but 
 where, after the pelvic wound is laced across, the pelvis re- 
 mains quite dry after sponging, there is no necessity for any 
 drainage. 
 
 (2) Shall the cervical canal be destroyed by the actual 
 cautery, or any other caustic ? This is an important point 
 and had better be discussed in connection with the question — 
 
 (3) Shall the cervix be transfixed and tied like the pedicle 
 in ovariotomy, inside the peritoneal flaps? 
 
 Dr. Granvillk Bantock exhibited specimens of fibroid 
 tumours of the uterus, illustrating the vai-ious methods of deal- 
 
 . * 
 
 i 
 
 I 
 
i 
 
 inj^ with llioso ^rowlhs hy nbdominal section. Tho methods 
 arc as ibllowH: — 
 
 (1) l']imcloati()ii of tumour and oblitoriition of l)ed of tumour 
 by means of buried and other sutures. AppoiKbiifeH also re- 
 moved. 
 
 (2) A ])p]\ct\iion of sene-nn'ud to pedunculated fibroid, leav- 
 ing uterine body, ovaries and tubes intact, and securing the 
 pedicle in lower single of wound. 
 
 (3) Application of serre-ncKMci around the uterus about level 
 of internal oh, and including both ovaries and tubes ; amputa- 
 tion above or external to serre-nwwl, and securing the stump 
 in lower angle of wound (parietal). 
 
 (4) Application of elustic ligature, circular division of 
 uterine envelope, pai'tial enucleation of uterine body with its 
 contained tumour or tumours, so as to lessen strain on broad 
 ligaments, iip))li(atioM oi' serre-nceud on peritoneal aspect, ampu- 
 tation of uteius, and seeming stump in lower angle of wound. 
 In this form, the appendages may be included in serre nceud, 
 ligatured sepaiatel}' or even left intact, according to circum- 
 stances. 
 
 (5) Division of broad ligaments to allow tumour to be lifted 
 out of the pelvis, elastic ligature, enucleation of tumour, ap- 
 plication oi sene-wmd so as to include the appendages, and 
 secuiing the stump in lower angle of parietal wound. 
 
 (ti) Klastic ligatuj'c, enucleation of tumour and uterine 
 bod}'', after circulardivision of uterine peritoneum, application 
 of serre-noeud to uterine body thus enucleated, separate ligature, 
 and removal of appendages, and securing the peritoneal en- 
 velope to parietes. 
 
 The tii'st is an example of the intra-peritoneal method ; the 
 otheis are examples of the extraperitoneal method. 
 
 Dr. Bantock i-ecited tho history of the cases from which the 
 specimens were obtained. 
 
 Abdominal Section for Diaijnostic purposes. — Dr. Clinton Gush- 
 ing, of San Francisco, writes a short paper in defence of this 
 Hubjoct. Dr. Cushing is unquestionably correct in his views 
 and deductions, and it should be the duty of every surgeon to 
 impress upon the physician the great necessity of having the 
 abdominal cavity explored as soon as possible after being 
 called to the case and he feels in doubt. Many lives will 
 
6 
 
 certainly be saved, and the public will become iniprosucd with 
 tiio UHcfulnosH of it. To Htiind witli Ibldcd hniulH for days or 
 wocUb, and Hpccuhite as to what nii<5ht bo the caime of Hutfer- 
 ing in a given patient, is certainly not sciontitic niediciiie of 
 the present day, and will surely tend to brini? upon our heads 
 a feeling of disd:iin and want of confidence on the part of those 
 to whom we should loolc for admiration and respect. I do not, 
 however, agree witii J)r. Cashing when he criticizes .Mr. (xreig 
 Smith on the i-eniaik made in the latter's book, "No incision 
 ought to be merely exploratory." ''The exploratory incision 
 of the skilled surgeon is widely different from that of the 
 tyro." No man should make an exploratory incision unless ho 
 is prepared to complete an operation for i-enioval of diseased 
 parts found, provided, by doing so successfully, he ensures to the 
 patient material benefit; therefore exploratory incisions should 
 be made only by abdominal surgeons who have been careful to 
 provide themselves against all emcigencies, and thus increase 
 to the highest possible degree the patient's chances for I'ocovery. 
 
 Dr. C.'ushing mentions cases of ectopic pregnancy, of obstruc- 
 tion of the liowels. disease of the appondi.x, affections of the 
 liver and gall bladder, of the kidneys and of pus collections 
 in any part of the abdominal cavity, which surgeons equally 
 skilled disagree upon in regard to a positive diagnosis without 
 an e.xploratory incision. 
 
 Dr. Gushing describes minutely in his paper some interest- 
 ing cases. One where he and other surgeons in consultation 
 expected to find pus tubes, but instead found a distended gall 
 bladder containing gall stones and pus. In another case cited 
 he expected pus tubes again, but found as well an appendix 
 abscess associated with a pyosalpinx of the i-ight side. 
 
 In another case pelvic abscess was diagnosed which would 
 have been treated, some years ago, by lamcturc through the 
 vagina [or by some at the present day by electi'icity]. When 
 the abdomen was opened a double pyosal])inx was found, and 
 on further exploration a sccondaiy foul smelling omental ab. 
 scess with gangrenous walls was discovered. 
 
 In another case described the patient had experienced a 
 miscarriage of six weeks pregnancy a few days previously. 
 There was gj-eat distension of the abdomen, a large tumor felt 
 in the pelvis and a temperature of 104.5°. An offensive uterine 
 discharge, and the uterine cavity measured six inches. The 
 
 i 
 
f 
 
 i 
 
 nbdoinon wra im mod lately openod ; a largo sloii/jching uterine 
 fibroid and jfonorul punilonr perittdiitirt vvua found, pun was Hoen 
 UHcaping iiilo tlio (Mivlty from tiio Fallopian tubo-t. The broad 
 lij^aincnts and tlio utorino artei-ios woi-o tied off and tho utorino 
 tumour witli ai>pend:ii,'o.s vvcro removed and tho Hlnmp cdosed 
 by Schrtiodor's molliod with cati^ut sutures. The temperature 
 at once dropped to 100'^ and patient eventually recovered. 
 
 Another case aged 20, temperature 102°, pulHo 130, one 
 child two years ago, had an attack of pelvic peritonitis eight 
 months previously, since which time has been suffering great 
 pelvic pain, progressive emaciation accotnj)anied by fever and 
 perspiration. Examination showed pelvic organs fixed and 
 tender, abdomen not distended; when tho abdomen was 
 opened a groat gush of fcutid pus, in quantity about throe 
 quarts, took place. This pus cavity extended from Douglas 
 pouch to the ensiform cai'tilage. No pelvic or abdominal 
 organs were in sight, being pushed away in every direction 
 and bui'ied in Ij'mph. At time of writing this patient was 
 convalescent, and her chance-t were favorable foi* recovery. 
 
 Dr. Gushing remarks that if tentative measures had boon 
 adopted hero, the c(jnse(iuencos would have been disastrous. 
 There was no way of learning from extei-nal examination of 
 the great extent of the disease, luid tho wonder was that she 
 could have lived under such circumstances. 
 
 These cases of Dr. Gushing are of groat value in point of 
 insti'uction to the gonei-al practicing physician, upon whom 
 80 much responsibility in such casci rests. Ke should act 
 promptly and give these poor patients a chance for their 
 lives. 
 
 Dr, Fancouit Barnes reports in the British (Ti/naecological 
 Journal for August, a case of ovariotomy in a patient 72 years 
 of age. The i)alient on tho thii-d day developed a parotitis — 
 non-8uppurativc — which subsided in a few days. This inter- 
 cuiTont condition was supposed to be due to injury to tho 
 pelvic organs and not to infection. Dr. Barnes drew attention 
 to the fact that ovariotomy is not by an}'' means common at that 
 advanced age. Dr. Bland Sutton, in his recent work on "Sur- 
 gical Diseases of the Ovaries and Fallopian Tubes," shows a 
 list of 22 cases of ovariotomy in patients over 70 years of age. 
 
 Carcinoma of the Cervix in the Negress. — D. J. W. Williams, 
 of tho Johns Hopkins Hospital, reports a case of this kind, 
 
8 
 
 pi-obiildy tlio fii'Ht on(» lopoiMdil. 'I'lio pntiotit was a darU, I'lill- 
 blooilod iio^rcHs, .'iS yoiirH ol' ai^'o, rnun'iod lor Hixfooii yoars ; 
 hud olovon (diildron, all laboiii.s l>oiny tioi-miil, and niiiHod all 
 of hor childi'oii. On oxaniiiiation, oxtonsivo iiitiltralion was 
 found involvinjr the utortis and broad li^ainiMitH. 'IMio miero- 
 Bcopo corilinnod (ht^ clinical dia^n()>iH. 
 
 Dr. \y. ('ha])inan <iri^^^ in his vahMJictoiy address as retir- 
 ing Prosidont of the British Gyiiii'cological Society, May, 18!)2, 
 made the following remai'ks : — "I feel very strongly that if 
 gynojcOlogy is to accomplish all the good of which it is cap- 
 able, the progress which is being ett'ectod must be brought 
 homo to the general pi-actilioner, upon whom, in the majority 
 of instances, falls the burden of the preliminary diagnosis, 
 without which the resources of our art must to a Itirgo extent 
 prove unavailing. We may fairly say that we have taUen 
 no mean part in breaking down many of the barriers 
 which conservatism in scioiico had i-aised to hinder the 
 free evolution of our branch of medicine. ({yniecology, 
 which not long since was practically terra incoijnita to iho gen- 
 eral practitionei', is last becoming part and ])arcel of his 
 education, and in proportion a^ this special knowledge be- 
 comes generalized, we find that the old idea as to the fre- 
 quency of this or that disease re(piire8 to be modilied." Dr. 
 (rrigg then refers more especially to the advance made in the 
 surgical treatment of ectopic pi-egnancy, a condition which 
 was regarded, until quite recently only as a pathological 
 curiosity. In this and other morbid conditions he points out 
 the great necessity foi* the family physician to be capable of 
 making an early diagnosis, and to attain this end he should 
 avail himself of every opportunity atforded in the examiiuition 
 of the female pelvic oi-gans. 
 
 Extra Uterine Pregnancij. — Prof. Maur of Stockholm, reports 
 two cases of interest {Anah of Gyn. and Ptvd., Sept. 1892.) 
 First case aged 20, last birth eight years ago. She became 
 pregnant in February, 18D0. In May she had a hoeraorrhage 
 which lasted for 14 days continuously. It then became inter- 
 mittant. 
 
 June 6th. — She became seriously ill. Severe abdominal 
 cramp and vomiting with symptoms of collapse. Abdomen 
 distended ; vaginal examination found cervix pushed to right, 
 neither softened nor enlarged, the corpus over to left and 
 
 ! 
 
9 
 
 f 
 I 
 
 mobile. To ri^dit, (if utcnis u loiiiul, Hli^htly oliisJic rcNiHtiiiico, 
 till) upper linrdor of vvliicli rcichtMl ultoiit ono inch ahovo 
 Hynipli3si>4. It oxtonded hack to the spino. It Hiirroiindod 
 the cervix uiid luy close to tho iiloniH, though Hcpumtod from 
 it l»y 11 distinct fiii row. It '\n mnoolli ; it cjin bo tnoro plainly 
 f'olt /)er roctimi and <;ivos to soiiso of touch the oiillino-i of a 
 tiitnor and not, ot an inliiti-ation. It ih very lender, trjices of 
 albumen in urine. Other or<.fanH healthy. 
 
 June 18. — Seized with sovoi-e pain in opiji^asti-ium and entire 
 abdomen, vomitinv;, pulse feeble and rapid (11-). Became 
 jtale with indication ot piofoimd collapse. Hxamination re- 
 vealed little clian;j;e iti tumor. 
 
 June 2lsf.—0;>mj^<on.—Lar;^o quantity of thin fluid black 
 blood flowed thi'ough abdominal wound. Tumor composed of 
 f<etuH, and large mass of hard black coagulum occupied lower 
 right pidvis, . lii;htly adherent to sui-rounding jiartn. F(etu8 
 lay outsidi^ sac in Douglas' pouoh. Pedicle formed by right 
 broad ligament. Secured by silk and tumour removed. On 
 closing the wound a fresh hemorrhage was detected, and on 
 search being made it was found 'to be due to the slipping of the 
 ligature [showing the great uncertainty of silk in comparison 
 with large-si/.i'd catgut]. The stump was seized with diliieulty 
 and religalured. Puliciit convalescent in fourteen ilays. The 
 temporary albuminuria which existed before operation disap- 
 peared a few days after. 
 
 Conclusions. — .luno 7th — lleinorrhago into the sac, destroying 
 life of fletus (fourth month). June 18th — Rupture of sac and 
 escape of fijetus, and inlra-pcritonal bemoi-rhago. 
 
 In the above interesting ca^e Dr. Maur should undoubtedly 
 have operated tlireclly after the 7th without delay. His patient 
 would have had a much better chance of recovery than by 
 waiting until the sac ruptured and fresh and more serious 
 hemorrhage had occurred. [ would also suggest to Dr. Maur 
 the adoption of large-sized catgut for heavy ligature; it is 
 elastic and tightens with shrinking of the pedicle. 
 
 Case 2. — Aged 3+ : married fourteen years ; nullipara. Be- 
 came pregnant in April, 1890. June 1st, became suddenly 
 very ill; severe abdominal pain, pale and collapsed, followed 
 by unconsciousness for a long time. Severe vomiting all day. 
 Following day uterine hemorrhage, which continued several 
 days, with escape of blood-clots. During whole month of June 
 
10 
 
 she suffered severe cabdominal pain, and the abdomen hecamo 
 gradually enlarged. July Ist— Patient anajmic to extreme 
 degree and appears to sutter intensely, CHpccially with move- 
 ments of body. Examinaiion gave evidence of a tumour in 
 the pelvis, divided by a central sulcus into two portions. Cor 
 vix looking forwards and tixed close to pubes. 
 
 Operation. — Intestines found adhei-ent universally; a large 
 black tumo'-./ found below intestines and adherent; tirnour 
 contained a large quantity of thin black fluid and hard masses 
 of coagulated blood, also the fcx'tus. These were all removed 
 and the cavity cleansed as well as could bo done. It was th'^n 
 closed in the usual manner. Patient died on the sixth da>. 
 The pathologist, after an autopsy, gave it as his opinion that 
 the patient died from septicjemia, which had existed pi-icr to 
 the (h te of the operation. 
 
 -^elusions wore : Conception took place about April 1st. 
 Tune 1st, rupture of icetal sac occurred with escape of 
 and considerable hemorrhage, after which it became 
 encapsulated. At this time a general peritonitis developed. 
 
 [It is evident from the history of this very interesting case 
 that June 1st or thereabouts would have been the time for her 
 to have been admitted to hospital under Dr Salin's care, in- 
 stead of which she was kept under medical supervision until 
 the 27th, all ^f which valuable time was lost, and with it the 
 life of the jmtient. Had she been seen on the l>t of June by 
 Dr. Salin and operated upon she would in all probability have 
 been saved.] 
 
 Sarcoma of Cervix.— Y. Pfannenstiel {Virdiows Arcfuv., 
 vol. cxxvii, part 2, 1892, p. 305) tabulates the twelve cases 
 of this rare and very malignant disease which have been 
 authentically recorded. The series includes a new case 
 under his own observation. The patient was titty-three. A 
 sti'ucture taken for a simj)lo mucous polypus of the cervix 
 was removed. Eleven months later recurrence was dis. 
 covered ; a large racemose growth had developed. It was re- 
 moved and the cervix scraped. Six months afterward a race- 
 mose mass filled the vagina. The patient was weak and 
 cachectic. The uterus was extirpated. Symptoms of recur- 
 rence were detected five months later, yet sixteen months 
 after the removal of the uteius the patient was alive, though 
 very cachectic ; the vaginal wall was infiltrated. This was her 
 
 V 
 
 ( 
 
 <» 
 
11 
 
 i 
 
 condition when the report was publisliod. With the exception 
 of two patients lost Bight of, the disease recurn-ed in all the 
 twelve collected cases. Strungo to say, though the clinical 
 and naked eye charapters of racemose sarcoma are fairly con- 
 stant, their histology is more variable. They are peduncu- 
 lated tumors, looking like a bunch of fruit, but Ihey may be 
 adenomata, myxomata, or even tumors consisting to a great 
 extent of embryonic striped muscle cells (Pei-nice). Eai-ly 
 diagnosis is very diflScult. These tumors are much softer and 
 more friable than true mucous polypi. Eacemose sarcoma is 
 much more malignant than any kind of cf.ncer of the uterus 
 or any other variety of sarcoma of that oigan. The only 
 active treatment justifiable in cases of this disease:^ is total ex- 
 tirpation of the uterus, aivd that severe proceeding is useless 
 and not to be attempted if the incision in the vault of the 
 vagina cannot be made over two-tifths of an inch outside the 
 aiea invaded by the disease. 
 
 In'esfinil Complications from Belayed Operation in Suppura- 
 tive Disease of the Uterine Appendages.— Dv. Charles A, L. 
 Eeed, in a paper re;id before the Academy of Medicine (Cin- 
 cinnati Lancet Clinic, March 12, 1892), says : " I have from 
 time to time presented to the academy specimens illustrative 
 of complications arising from delayed operations in cases of 
 suppurative diseases of the uterine appendages. For the most 
 part the complications have consistedof pelvic adhesions which 
 have rendered the enucleation of the appendages extremely 
 difficult. In some cases a more serious accident occurs, and 
 that accident consists in rupture of the pus pockets in an effort 
 to lift out the appendages. 
 
 " In this way the pelvic cavity and the entire field of oper- 
 ation becomes contaminated. It is true that in a majority of 
 such instances recovery takes place because thorough cleanli- 
 ness is practiced bj' means of careful flushing, but it does not 
 follow that it is a good thing to contaminate fhe field of oper 
 ation with pus In the majority of all our fatal cases some 
 such complication can be truthfully assigned as the cause of 
 death, and such c( mplications can, with equal truthfulness, be 
 assigned to delay. When, therefore, the question of responsi- 
 bility for the death comes under consideration, it must, clearly, 
 and in all justice, be laid at the door of the person responsible 
 for the dolay," 
 
12 
 
 Ho reports a case, still undoi- treatment, thouirh nearly well, 
 of a woman of thirty-one years of age, who has siiffei'od more 
 or less for fourteen years from pain and tendei-ness in the 
 region of the uterus. During this time she also had three pel- 
 vic abscesses, two of which discharged through the rectum 
 and the third through the vagina. At the operation the ap. 
 pendages were most firmly bound down, and there was on the 
 i-ight side a cyst as largo as a hen's egg. This mass was most 
 Hrmly adherent to the jejunum, and in the attempt at enucle- 
 ation a rent an inch and half long was made in the gut. This 
 was closed by Czorny-Lemboi-t buture and drained, llor con- 
 dition remained good until the second day, when the belly be- 
 came very tympanitic, and (he pulse rose to IfiO. The patient 
 had passed flatus, and was having no gastric disturbance. On 
 removal of the drainage tube a largo amount of odorless gas 
 followed, the belly at once flattened out, and the pulse speedily 
 became normal. Two daj^s later more gas was permitted to 
 escape by means of a grooved director puHhed thi-oiigh the 
 recently united incision, after which no more trouble ensued, 
 and the jjatient is now well. 
 
 " There are several points in this case that are instructive. 
 
 1. The adhesion to the intestine shows the evil of delay. 
 
 2. The escape of gas into the peritoneal cavity shows the pos- 
 sibility of a pinhole Hstula which will admit of the transmis- 
 sion of gas but not of fecal matter. 3 (las from the intestine 
 as high up as the Jejunum U odorless and innocuous. 4. A 
 drainage tube may become so fenced off that it will not drain 
 the geneial peritoneal cavity even of gas." 
 
 In the discussion that followed the reading of the paper, the 
 necessity of early operation in these cases was unanimously 
 indorsed. 
 
 Sterility.— ih: Artiicjb W. Edts says {Med. Press) : It has 
 been computed that in Great Britain alone there are five hun- 
 dred thousand married females sterile, or an average of twelve 
 per cent, of marriages which are unproductive. These figures 
 convey, to those who have not studied the subject, a very in- 
 adequate idea of the amount of unhappiness caused in so many 
 households by the inability of their occupants to fulfil the in- 
 junction given to our first parents to be fruitful and multiply. 
 It has always been held as a reproach to a woman that she 
 
 f 
 
13 
 
 <l 
 
 has no ott'ttpcing, and in many instancoH the deoire for children 
 is 80 overpowering that women will consent to risk their lives 
 by submitting to an operation rather than remain sterile, or 
 endure much pain and discomfort in the way of local treat- 
 ment, if only a reasonable prospect of success can be held out 
 to them. The questionof sterility in the female has from time 
 immemorial attracted the attention and taxed the ingenuity 
 of the medical practitioner. The causes aie so manifold, and 
 the difficulties in arriving at a correct or rational explanation 
 of the defect so great, that many practitioners give up the 
 attempt to deal successfully with the subject in despair. Much 
 as we may regret it, the fashion of the passing hour exercises 
 a considerable influence on the successful treatment of ster- 
 ility. By some, nothing but misplacements, versions, and 
 flexions of the uterus are considered worthy of attention, and 
 much ingenuity is expended in adapting various forms of pes- 
 saries to remedy these ; others ignore entirely the position of 
 the uterus, contending that this has little or nothing to do 
 with the fact of impregnation, and direct their attention en. 
 tirely to the condition of the uterus, believing that congestion 
 and inflammation explain the whole difliculty. Undue acidity 
 of the vaginal mucus or increased viscidity and alkalinity of 
 the cervical mucus is looked upon by some as the all important 
 cause, and eftbrts are directed .solely to the lectification of this 
 abnormality. Then again, stenosis of the os internum or ex. 
 ternum is regarded as the all sufficient cause, and dilatation 
 by means of graduated bougies, laminaria, or sponge tents, or 
 rapid dilatation by uterine dilators resorted to. iJivision of 
 the internal os by means of metrotomes or other cutting in- 
 struments finds favor with some, while others contend that 
 complete division of the external os by Kuchenmeister's scis- 
 sors, or other means, is the only proper expedient. Intra- 
 uterine stems are largely employed by others, and are credited 
 with invariable success, though if all the cases treated by this 
 method were published, the balance would probably be con- 
 siderable against it, taking into account the risks and dangers 
 attending their employment. 
 
 Surgical Treatment for Laceration of the Cervix. — Whenever 
 a lacei-ation occurj-ing at the cervix extends through the in- 
 ternal and external muscular tissue, the mucous coat lining 
 
14 
 
 the canal suffers materially from the violence. The plicro 
 palmataj, which have been described under the term arbor 
 vittB, undergo serious disturbance in their relation to the other 
 tissues with which they are connected. This condition often 
 leads to congestion, thickening, and to induration of the parts 
 involved, and to more or less hypertrophy and malnutrition 
 of the higher uterine segment^, and to changed relation and 
 displacement of the lower cervical zone. When laceration 
 occurs at the cervix, not- only are the muscular and mucous 
 structures injured, but the mucous glands that so freely 
 abound in the cervical canal also become disturbed in their 
 normal functional activity. It is especially in the cervix uteri 
 about the arbor vitK» that the mucous follicles, which, when in 
 a healthy condition, afford only moderate moisture for the 
 maintenance of their function, pour forth an altered, per- 
 verted, or diseased secretion. The aiteries and arterioles en- 
 tering into these structures often become preternaturally 
 developed or enlai'ged ; there will often be found a greater in- 
 terlacing or anastomosing of these vascular structures. This 
 condition may lead to more or less local oedema, which the 
 venules and lymphatics will fail to overcome. The structure 
 of the uterine nerves, particularly those derived fi-om the 
 hypogastric and sacral plexuses, becomes so deeply involved 
 that not only do the pai'ts in immediate contact with the torn 
 or injured surfaces become the source of much trouble, but all 
 the tissues forming the uterine body may continue so heavily 
 congested, and become so thickened, indurated, and globular, 
 as to constitute that condition which has so aptly been termed 
 subinvolution of the uterus. The treatment best adapted for 
 the relief of the suffering that occurs in every such case, ac- 
 cording to my experience, is that afforded by sui'gical 
 measures. — Br. Clark {Med. News). 
 
 Results of Vaginal Hysterectomy in Cases of Uterine Cancer. 
 — Terrier and Hartmann (Revue de Chirur., April, 1892) 
 publish a series of eighteen cases of vaginal hysterec- 
 tomy performed for the removal of cancer of the uterus, and 
 also give the results of recent inquiries concerning eighteen 
 other cases of a like kind, which were tabulated and published 
 in 1888. In each series the immediate mortality from the 
 operation was 23.5 per cent. In the second and later series 
 
 J 
 
 
1 c 
 
 death was due in ono case to nhoelc, and in two cases to perito- 
 nitis. In ono caso the patient died on the fourteenth (hiy in 
 consequence of phlebitis of the main venous trunk of iho lower 
 limb. Of the patients refen-ed to in the first series of cases 
 who recovered from the direct etfects of hysterectomy, two 
 were living and in good health after long intervals— one after 
 six years and four months, the other after five years and four 
 months from the date of operation. In eight cases included 
 in the earlier list recurrence. occurred after intervals varying 
 from six weeks to two years. In five of the second series of 
 cases the patients when last seen were living after intervals 
 varying from three years and five months to eight months. 
 Of these five patients, however, two presented indications of 
 return of the disease in the vaginal cicatrix. The authors 
 point out that vaginal hysterectomy is a serious measure, as 
 these tables show a death rate from the operation itself of 
 about twenty-three per cent. The results of this treatment 
 are, it is held, not more serious when it is performed as a pali- 
 ative step than when it has for its object complete removal 
 of the diseased structures. It is indicated, therefore, when- 
 ever the cancerous uterus is mobile, although the vaginal cul- 
 de-sac may be involved in the disease. Eecurrence, which has 
 been noted in about seventy per cent, of the cases, although 
 usually speedy, may in some cases be postponed for a long in- 
 terval (from seventeen mouths to two years, or even longer). 
 These tables show that thirty per cent, of the patients who 
 had undergone vaginal hj sterectomy arc apparently' cured by 
 this operation, even in cases in which the malignant nature ot 
 the disease has been proved by both clinical and histological 
 observation.