well-tried facts, except the treatment of certain surgical cavities which have been mentioned by way of suggestion to those whose practice runs more in that direction and offers better opportunities for experimentation than a purely private practice like mine.

I have used the washing and irrigation in the uterus, Fallopian tubes, vagina, rectum, and bladder with great satisfaction. Gases I have used in the uterus and vagina. Powders have been very satisfactorily used in the uterus, vagina, and rectum.

A CASE OF OBSTRUCTED LABOR CAUSED BY AN
ARTIFICIALLY SHORTENED FUNIS.

BY

J. W. KALES, M.D.,
Franklinville, N. Y.

I PRESENT this as a typical case of obstructed labor caused by an artificially shortened cord, and would ask if it is possible to diagnose similar cases correctly.

I was called January 25th, 1885, to attend Mrs. J. M. S., aged 17, primipara, whose labor had commenced several hours previous to my arrival. Upon examination, the soft parts were found well dilated, the pelvis roomy, presentation vertex, position L. O. A. Presenting part well engaged in superior strait. Pains strong and frequent. Patient cheerful, and every indication of a speedy and safe delivery. The visit, of necessity, was short, as I had three obstetric engagements that day. Returning in about one hour, I was much surprised that no progress had been made. The pains had continued strong and frequent. A careful examination revealed no cause of delay. The forceps were applied. Traction was made only during pain. Then it was observed that the fundus uteri became markedly depressed. When the head was drawn outside of the vulva, the funis was found coiled three times around the neck and deeply imbedded in it. Having removed the coils, the trunk was speedily expelled. The child was cyanosed, but was quickly resuscitated. The placenta was attached to the fundus uteri. The cord measured eighteen inches in length, and was attached to the centre of the placenta This patient had danced all of the previous evening. The day following her confinement she left the bed and took up her abode on a couch. She made a speedy recovery.

In this case all the symptoms pointed out in the text-books were absent. There was no "elastic springing back of the child

with the cessation of pain," no "weakening of uterine contractions," no "hemorrhage." The depression of the fundus uteri was no positive indication of the nature of the obstruction. I distinctly recollect the case of Mrs. H. M. (whom I had previously attended), where, after many hours' delay, no cause of which being evident, the forceps were applied and strong traetion made. The fundus uteri became markedly depressed. A second effort dislodged the child from its position, and nature terminated the labor without further aid. The cause of the obstruction was found to be due to tetanoid contraction of the middle uterine segment.

How shall similar cases be treated? Cazeaux recommends the forceps. When shall they be applied? If a positive diagnosis cannot be made, each case must be left to the operator's judgment. Experience has taught me that the fetus will endure much pressure provided it is not continued too long; also that recoveries are more satisfactory when the forceps are promptly used than in protracted cases, where "nature is allowed to take her course." I am satisfied that in this case the forceps saved the child's life.

CORRESPONDENCE.

A CORRECTION.

BY

A. MARTIN,
Berlin.

BERLIN, Oct. 10th, 1886.

Dr. Paul F. Mundé.

MY DEAR DOCTOR :-Many thanks for the report of your European trip, from which I gather much of interest to me. Permit me to reply to several of your remarks concerning my methods, in which I seem to have been misunderstood.

You reproduce two cuts which are intended to represent the method of amputating the cervix devised by Hegar and practised by me. As you may see in my book (" Pathology and Therapeu tics of the Diseases of Women "), page 284, I employ neither this method nor that of Schroeder in a typical manner. The operation usually adopted by me occupies a middle ground between

these two types, as I represent it on p. 286, and as my assistant, Dr. Langner, demonstrated to you in the cases operated on by him in your presence. I can but regret that my many engagements prevented me from showing you the operation myself. I hope your next, to me most agreeable and desirable, visit will occur at a more favorable period.

Your remark on the discision of the uterus performed by me might easily be misunderstood. May I remind you that I, on that occasion, as always when I do this operation in the presence of physicians, emphasized my preference for this division of the uterine wall over rapid or gradual forcible dilatation, because by the latter method I have always seen a lacerated wound, whereas the clean, smooth incision is immediately closed by sutures, and offers a most favorable prospect of speedy union.

The objection of leaving the pool of antiseptic fluid on the floor of the laparotomy room during second and third operations has been removed for some time, by employing a second thoroughly asepticized nurse to mop up the floor, for, of course, only properly aseptic persons are admitted into this sanctum.

Perhaps you may find opportunity to utilize these remarks. The three patients whom you saw on the laparotomy table madegood recoveries. With kind regards, yours,

A. MARTIN.

[The criticism of Dr. Martin on my report of his cervix operation (see my article "A Glimpse of Laparotomy in Europe," in the last September No. of this JOURNAL) is correct. My error was. due to my having only Hegar's book, not Martin's, with me in the country after my arrival, when I revised the article. It seemed to me then that Hegar's cut answered for the operation which I had seen Martin perform. I append, for a complete comprehension of the differences between the operations of Hegar, Schroeder, and Martin, a description of all three, taken verbatim, with the cuts, from Martin's book.

As regards division of the cervix versus dilatation, I, in no sense, wished to criticise Martin's action, for his method was. certainly rapid, efficient, and safe. I merely pointed out that he preferred it to even easy, rapid dilatation. And I am not so sure but that I agree with him.

It gives me pleasure to make this reparation for an accidental error, to a man from whom I received so much courtesy as from August Martin. PAUL F. MUNDÉ.]

HEGAR'S, SCHROEDER'S, AND MARTIN'S OPERATIONS FOR ECTROPIUM, HYPERPLASIA, AND CATARRH OF THE CERVIX UTERI. (Martin's "Pathologie und Therapie der Frauenkrankheiten," 1885, pp. 284-287.)

"For the proper method of amputating the cervix we are indebted to Hegar, who, through his procedure, made possible its performance in the most perfect manner, and thereby placed under the full control of the operator the formation of the cica

trix and the prevention of secondary hemorrhage. The steps of this method are: The uterus is drawn down as far as possible, and the cervix so exposed by means of the speculum as to be easily accessible. The cervix is then incised bilaterally as far as the vaginal insertion, and, according to the demands of the case, a more or less deep conical slice of the mucous membrane is removed from the posterior lip. Union is secured by inserting the sutures deep under the denuded surface, so that the cicatrix will be formed at about the level of the upper portion of the am

putated posterior lip. The anterior lip is denuded and sutured in a similar manner, and finally the lateral commissures are united by deeply inserted sutures. The lateral commissures may be sutured either, as is represented in Fig. 141, through direct apposition of the borders, or else, as is shown in Fig. 142, through covering over with mucous membrane.

"This procedure of Hegar's would certainly be a most perfect one, had he extended his incision through the mucous membrane of the cervical canal. This very essential modification we have derived from Schröder, who, after the above-described bilateral incision, separates the divided portions of the cervix, and, at the dividing. line of healthy and diseased mucous membrane, makes a perpen

dicular incision through the cervix (Fig. 144 a). At the extremity of this incision, from the outside of the lip (from c inwards), he then removes whatever amount of tissue the pathological alterations in the individual case demand. Union is obtained through deep-lying sutures which bring together the remaining portion of the amputated lip (Fig. 145). After the anterior lip has been treated in a similar manner as regards the diseased mucous membrane, and the lateral commissures have been closed, the cicatrix resulting is of such a nature that the lower boundary of the stump is covered by the external surface of the cervix, and the lower border of the cervical mucous membrane lies quite deeply within the cone-shaped excavation, the influence of the vagina extending but little to it.