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ties every open vessel in the stumps separately. He expressed himself decidedly against the recommendation of the author to prefer vaginal hysterectomy even in such cases as permit supravaginal amputation in healthy tissue. Cancroid of the cervix is a disease of the vaginal mucosa; it spreads only into the vagina, and thence into the pelvic connective tissue, but does not extend up the cervix. Hence the vagina should rather be extirpated than the uterus.

Dr. Schroeder corrected the historical statements of the author of the paper by the remark that the supra-vaginal operation is older than vaginal hysterectomy. Whether the one or the other is more dangerous cannot be decided from the material at hand. At any rate, he holds supra-vaginal excision to be entirely sufficient for cancroid of the cervix, and indicated for that reason; while he pointed out the necessity of total extirpation in carcinoma of the mucous membrane.

DR. A. MARTIN declined to enter on the other questions at present. But he himself had in former times seen all his cases of supravaginal amputation relapse, so that, for the past few years, he had determined to perform immediate extirpation even in carcinoma of the cervix. In the course of the present year, influenced by the positive doctrines of Dr. Schroeder, he had once more, in the case of a pregnant woman with a pronouncedly cervical carcinoma, excised only the affected posterior lip, the cut being made through undoubtedly healthy tissue. The pregnancy continued uninterrupted, but relapse took place rapidly, and the disease was now inoperable.

DR. SCHROEDER admitted that he had had a similar experience with pregnant women. For the rest, we must make a distinction between cases in which the relapses arise from morbid elements left behind and those in which they do not; these latter cases are irremediable. It is the universal experience, however, that a cervical carcinoma only rarely extends to the body of the uterus.

DR. LOEHLEIN.-As regards the statements of the author of the paper in reference to the rather lukewarm reception accorded to total extirpation in foreign countries, we find indeed cause for reflection. Aside from the decided refusal Freund's operation met with at the time by French surgeons, if we bear in mind in particular what can be learned from the proceedings of English and American gynecological societies, we see that even now the operationvaginal hysterectomy-is gaining ground there very slowly. The steps are looked upon as difficult and dangerous, and the result as rather unsatisfactory. That may be due, in the main, to the fact that they are still isolated and first operations of the kind which our English and American colleagues are reporting. We as Germans, however, who must be interested in spreading the operation, conceived and perfected in its technique by German surgeons, as much as possible in foreign parts, will accomplish it the more readily when we define the indications more accurately, and recommend the procedure less in cases in which a simpler method of operating will answer every surgical requirement.

DR. HOFMEIER supplemented his remarks by recording in the minutes his compilation of the operations performed at the institute from October 1st, 1878, to October 1st, 1885.

There were performed for carcinoma: partial amputations, 118, with 10 deaths; and total extirpations, 48, with 12 deaths. As regards positive recovery, only those cases were considered which

were operated on at least two years before. There were performed until December 31st, 1883, altogether 83 supra-vaginal amputations; of these, 8 died; the result remained doubtful in 19; relapses within two years, 35; free from disease for two years or longer, 21. During the same period, there were performed for carcinoma 35 total extirpations; of these, 9 died; result unknown in 6; relapses within two years, 15; free from disease for two years or longer, 5. The results are not definitive only in so far as the investigations are being continued.

REVIEWS.

GYNÆKOLOGISCHE WANDTAFELN ZUM UNTERRICHT.-GYNECOLOGICAL CHARTS FOR PURPOSES OF INSTRUCTION. By DR. HEINRICH FRITSCH, Professor of Obstetrics and Gynecology at Breslau. Brunswick: Friedrich Wreden, 1885.

Every clinical teacher of gynecology has felt the need of charts whereby he may demonstrate to the eye of his students conditions which the unaided finger learns to appreciate but slowly. Those under review are the production of a gentleman well known through his numerous contributions to gynecological literature, and the many years he has devoted to clinical instruction have fully qualified him for the production of accurate outline diagrams of typical normal conditions, and of the variations from the normal imparted by disease. Professor Fritsch has, we think, succeeded fairly well in his object, and, even though the individual teacher may differ in certain respects from the opinions held by Fritsch and perpetuated in his charts, these will still serve the useful purpose of enabling the student to obtain an approximate idea of his teacher's views, as well as giving him a certain graphic standard with which to compare the information acquired by the finger.

These charts are accompanied by a separate text descriptive of each, and rendered into the German, French, and English languages. Of the accuracy of Fritsch's translations, sufficient the statement that, whilst the style, diction, and grammar are not worthy of high commendation, those unfamiliar with the German may gain a clear enough idea of the author's meaning from his excursions into foreign languages.

Charts I. and II. (Part 1.) aim at settling the vexed question of the normal position of the uterus. Fritsch is one of the few gynecologists who have ceased to impress upon the uterus a fixed normal position. This organ being movable within bounds, and its position at any given time being dependent, in a measure, on the state of the organs to which it lies adjacent, he grants it a range of normal positions, and, in his diagrams, depicts the extremes of these positions, Chart I. representing the uterus when bladder and rectum are empty, and Chart II. when these organs are distended. In the first instance the uterus is shown as slightly ante

flexed, its anterior surface nearly resting on the bladder, the cervix being at about the level of the sacro-coccygeal junction. This is the position which Fritsch has found to predominate in the large proportion of cases examined by him under the given conditions, and we believe that many gynecologists will herein differ with him on the ground that the uterus lies too horizontally, and, therefore, will give rise to symptoms from the side of the bladder, which fact at once makes this position pathological. It is certainly our experience that, whenever the anterior surface of the uterus could be plainly felt through the anterior cul-de-sac without depressing the fundus bi-manually, the patient has complained of symptoms which could be effectually relieved by any means whereby the uterus was elevated into a more vertical position. I am personally, therefore, inclined to consider this position an abnormal one. In the second instance it is shown how, through distention of the rectum and bladder, the uterus is lif ed up, the peritoneum being partially stripped off the anterior face of the organ, and its axis becomes nearly coincident with that of the vagina.

Chart III. (Part I.) is intended to represent a pathological anteflexion of the nulliparous organ. It is shown how, in this position of the uterus, abdominal pressure acts directly on the posterior surface; how the utero-sacral ligaments are tightened and made tense; how, as a result of narrow external os, the cervical canal becomes dilated through retained mucus; and finally how, as the result of posterior fixation, the uterus, being unable to move forward during defecation, the cervix is pressed upon and gradually assumes the mushroom shape. This is a great deal to represent in one chart, and yet these conditions largely suggest themselves. Chart IV. (Part I.) shows us the highly hypertrophied uterus of a multipara in a state of retroflexion. The heavy corpus rests upon and narrows the lumen of the rectum, the posterior lip of the cervix is elongated, the anterior short, the vagina is sub-involuted, and its normal axis is nearly reversed.

Chart V. (Part I.) represents anteversion of the uterus. The uterus is pictured as very much enlarged, lying forward on the bladder, dividing this organ, indeed, into two cavities, and, rather unnecessarily we think, Fritsch has drawn some posterior adhesions which simply complicate the diagram. It would have been wiser and less confusing to the student to have represented an anteversion alone without introducing any remnants of antecedent peritonitis-a condition figured in other charts, and the result of which, by the way, is usually to cause posterior fixation of the corpus, instead of the cervix, as represented in this chart.

In Part II., consisting of five charts, Fritsch aims at representing the mode of origin of uterine prolapse and its accompanying phenomena.

Chart I. represents the puerperal uterus at about the fourth day post partum. The organ is sharply anteflexed, the fundus reaching above the conjugata vera. A beginning cystocele is shown, and the first step towards prolapse of the uterus is depicted in that the heavy organ has sagged down and back towards the sacral excavation.

In chart II. the retroverted post-puerperal uterus is shown, together with rupture of the perineum, cystocele, and rectocele. The fundus is below the promontory of the sacrum, its axis is coin

cident with that of the vagina, and it is readily apparent with what facility the uterus may now begin to prolapse.

In chart III., although the conditions are very much exaggerated, there is represented a condition which is variously described under the names prolapsus sine descensu, hypertrophia colli, hypertrophia portionis vaginalis media, or, better still, elongation of the infra-vaginal portion of the cervix. It is not a true prolapse, for the corpus remains stationary; the cervical tissues simply have stretched out, as if," according to Emmet, "made of putty," and have become elongated. In this chart, the perineum is represented as lacking, and a marked cystocele is present.

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In chart IV. we find the same elongation of the cervix, but the fundus, instead of remaining stationary, has sunk lower, the posterior vaginal wall has prolapsed with the rectum, forming a rectocele, and the cystocele is stili larger than in the last chart. We have represented, in other words, a prolapse of the uterus with inversion of both vaginal walls.

In chart V. is represented total prolapse of the retroflexed uterus. We believe the conditions are here greatly exaggerated. The whole organ hes separated itself from the rectum, this in turn sacculating nearly two inches above the uterus, and lying within an inch of the bladder. According to Fritsch, the rectum is so loosely connected with the uterus that in case of prolapse it usually does not participate, but remains above. In our experience, it is rare for the uterus to prolapse to the third degree without coincident rectocele, and, ordinarily, with cystocele as well. Furthermore, we cannot understand on what mechanical principle the bladder has assumed the shape represented. Altogether this chart is very unsatisfactory.

The charts in part III. are designed to illustrate the action of those pessaries which Fritsch has found most frequently useful. Chief and foremost he ranks the round elastic India-rubber ring, and figures this in position on chart 1. The effect of this ring on the uterus is, to quote from the text: 1. It fixes the uterus and prevents it from easily shifting its position. 2. It lifts the corpus and forces a fixed position on the uterus. If these are its effects, then, in our opinion, this rubber ring finds therein its condemnation, for any pessary which "fixes" the uterus, "forces a fixed position" on the uterus, cannot fail to do harm. A good pessary will never check the normal range of mobility which the uterus must execute, in order not to interfere with the functions of the neighboring organs; and, further, a good pessary will never force a position on the uterus, but will rather assist the uterus to remain in good position when once placed there. As for the value of these rubber rings in prolapsus, very marked according to Fritsch, we grant them none at all. In short, our objections to these rings are: 1. They very soon become foul, and we possess more effective substitutes which do not. 2. They distend the vagina, leading to loss of tone of this organ, and, as a result of this distensile action, larger and larger sizes must be used until the capacity of the vagina is reached, and then the woman's condition is far worse than it was before the ring was first resorted to. As for the chart, the uterus is crowded forward on the bladder to such a degree that we do not believe it would be many minutes before the patient would ask to be relieved of the ring.

Charts II. and III. will be considered together. They both represent the Hodge in situ, in the first instance rightly, and in

the second badly, applied. In chart II., the posterior bar of the pessary has sufficient curve to keep the posterior cul-de-sac upward and forward, and, in consequence, the uterus lies anteverted-too much so, in our opinion, for the comfort of the patient, but then Fritsch believes, as already stated, that the anterior normal limit of motion of the uterus is greater than we can grant. In chart III., on the other hand, the pessary is insufficiently curved, and, as a result, the corpus uteri has flexed over the posterior bar, and the anterior bar bulges into the introitus vagina and becomes a source of discomfort to the patient.

Charts IV. and V., represent the action of two forms of pessary which Fritsch considers most useful in cases of retroflexion: the one Schultze's figure-of-eight, and the other Thomas' well-known bulb. With the former we have had no personal experience, and therefore refrain from criticism in the face of Fritsch's statement "that those who declare Schultze's pessary to be of little use, have not taken the pains to familiarize themselves with its efficient properties," and that "if all other pessaries cannot keep the uterus replaced" a sufficiently large Schultze will. There is one objection to it, however, which Fritsch partially grants, and this is its construction of soft rubber. Thomas' pessary is pronounced an excellent instrument, and herein we agree, although practically we have found the Mundé bulb more efficient, because of its greater breadth and consequent less liability of slipping out of the ostium qagine. The action of these pessaries are well represented in the charts, although here again, according to our belief, the uterus lies too far forward.

The fourth and last part concerns parametric and perimetric exudations, Fritsch's main object being to enable the beginner to understand the difference between exudations into the cellular tissue, and into the peritoneum. He lays special stress on the fact that his horizontal sections are, of necessity, purely schematic, for, in order to bring out the broad general facts, he was obliged, in a measure, to sacrifice detail.

Chart I. is a horizontal section of the pelvis at a level with the centre of the symphysis and of the third sacral vertebra. Herein

the ligaments of the uterus are represented, the position of the ureters and rectum noted, and the cellular tissue is colored red so that one may perceive at a glance the necessary boundaries of a cellulitis. For the sake of completeness, the round ligaments are also figured in this chart, although these lie in a higher plane.

In chart II. the effect of a small exudation in the left broad ligament is exemplified, the uterus having been pushed towards tha right. In chart III. a further stage is indicated. Here the exudation, beginning in the right broad ligament, has invaded the cellular tissue in front and behind the uterus, and has extended also into the tissue lying between the peritoneum and the abdominal wall. In chart IV. are indicated, in a vertical section, the localities where extra peritoneal exudations and abscesses are generally found, and it is evident how an abscess between the abdominal walls and the peritoneum may be incised without injury to this membrane. In chart V. an exudation into Douglas' fossa is shown-pelvic peritonitis- and its effect on the uterus is very well noted.

Such, briefly analyzed, are Fritsch's Charts. Notwithstanding certain defects and exaggerations, we believe they will prove to the teacher a means whereby he may make his meaning clear and

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