cally, tumor turned out to be a cystic adenoma, with early carcinomatous nodules here and there. Patient discharged in four weeks in good condition. From her physician the speaker had heard that six weeks after she had had a pleurisy with exudation and high fever, and that another tumor, size of a fetal head, could be felt in abdomen to the left. October 12th, death. Autopsy: tumor to left, a cyst containing pus. Recurrence of cancer in line of suture.

Case 5.-Ovariotomy on October 16th. Small, adherent, ovarian tumor of right side, size of an orange, a typical colloid cysto-adenoma. Poorly nourished woman, great pain before operation. Discharged well.

As to the removal of malignant growths, RUPRECHT spoke of a case where. Osterloh had done so. The patient remained well for nine months, and then there was recurrence in the other ovary. The patient shortly died.

Al

LEOPOLD mentioned a case where he had removed from a sixteen-year-old maiden a carcinoma the size of a man's head. though the prognosis was very bad, the patient still lived two years after operation.

GRENSER Said that he had removed a dermoid cyst within which was a hard carcinomatous nodule. He had treated the pedicle extraperitoneally, and drained through the vagina. Three weeks after operation there had been recurrence in the pedicle. After fourteen weeks, death.

In connection with the castration cases reported by S., LEOPOLD related the history of a woman, æt. 40, who for years, at the menstrual periods, suffered from intense pain, and who in months was only for a few weeks free from pain. Both ovaries were very painful on pressure, the left, in particular, enlarged, nodular, deep lying. Castration was successful; for four and one-half months was free from all pain, but in the fifth month, in concurrence with great mental distress, the paroxyms of pain recurred, lasting for one to two days. The patient's general condition was good. He would, therefore, advise guarded prognosis in such cases, and asked S. for the ultimate results in his cases.

SCHRAMM reported in regard to a castration performed in November, 1884, for ovarian neuralgia. The pains had entirely disappeared, and the patient was entirely well.

KLOTZ could also speak of cure in two cases, where he castrated, two years previously, for neuralgic symptoms.

MEINERT, on the contrary, said that in similar cases he had seen recurrence in six months.

CREDE reported a case where, on account of ovarian neuralgia, he removed both prolapsed ovaries through two lateral vaginal incisions.

LEOPOLD Said, further, that it was worthy of remembrance that, in those cases where the ovaries were prolapsed and lay between the enlarged uterus and full rectum, in addition to the regular paroxysms of pain, great and regularly recurring pain was apt to follow on defecation.

LEOPOLD reported an operation for

HYDRO-PYO-SALPINX.

The patient was aged 36, had been delivered in 1867 and 1870, had

enjoyed good health up to three years ago, and for two years had suffered from abdominal pain. The uterus was in good position. To the left, a cystic tumor the size of an apple, probably not the ovary; to the right, but deeper in the parametria, a fluctuating tumor, same size. Diagnosis of probable double pyo-salpinx. At the operation, June, 1885, the right ovary was normal, the right tube much enlarged, dilated, and impervious; it was removed with the ovary, the 5-6 cm. pedicle ligatured and cut. On the left side, both the tube and ovary were degenerated into a tumor the size of the fist. It was imposssible to remove it, since it lay close, without pedicle, in Douglas' cul-de-sac and it seemed too dangerous to attempt removal by the abdomen. The patient was still well. In case of recurrence of pain from this tumor, it could be opened by the vagina.

The same gentleman spoke in regard to parovarian cysts. He could not believe that simple puncture of such cysts would prevent recurrence. He had removed, by laparotomy, cysts which he had seen refill after puncture. The diagnosis of such cysts was difficult, as was amply proved by two cases, lately, in the Royal Lyingin Institute.

Case 1.-Patient æt. 49; puncture both in 1880 and 1882, on account of cyst of parovarium. Returned for third time, with very large cyst. Laparotomy and removal. The specimen showed that, outside of the large unilocular cyst, which constituted the greater part of the tumor and was surrounded by the greatly stretched tube, lay anteriorly the ovary, on the surface of which were a number of cysts. A simple puncture of the large cyst could not prevent refilling and further growth of the smaller cysts.

Case 2.-Parovarian cyst, with cyst in the meso-colon. Rapid growth. The uterus had been pushed entirely out of the true pelvis by the cyst; and could be readily felt, in greater part, behind and above the symphysis. Anteriorly, to left of umbilicus, the tube and ovary palpable. There was found a very large parovarian cyst to the left, to the right a smaller, and also the already diagnosticated meso-colon cyst, which, after opening the peritoneum, and pushing the ascending colon aside, was removed. The peritoneum was united by suture. The left ovary was removed, the right not touched. Good result in both cases.

The same gentleman discussed the subject of kolpo-hysterectomy in connection with twenty-six operations performed after his own method, without retroversion and turning-out of the uterus. He considered his method as the simplest yet reported; by it, no great after-hemorrhage had been noted, double ligature was not requisite. The steps are: First, separation of the vaginal insertion from the cervix; then, separation of the bladder, and afterwards lateral and posterior freeing of the uterus. Douglas' cul-de-sac is then opened, and a sponge placed within it, to prevent secretion passing into the abdominal cavity. The parametrium is then ligatured in bun

dles, and each vessel ligatured and cut. As soon as the uterus has been drawn out, the field of operation is cleansed, iodoformed, and, in the wound as well as in the vagina, from fifteen to twenty tampons of iodoform gauze are packed, and these remain untouched for from twelve to fourteen days. On their removal, the loosened ligatures are taken away, and the vagina irrigated. He does not use drainage and irrigation. The speaker had lost but two cases out of twenty-six operated on after this method. In one case, the cause of death did not depend on the method, but on the fact that the carcinoma had extended too far, and an abscess had developed in remnant, from which the patient died eight weeks after operation. In the second fatal case, kolpo-hysterectomy was not intended, but high amputation. Douglas' cul-de-sac was widely opened, however, and the entire uterus had to be removed. The patient died of sepsis.

The same gentleman, in conclusion, reported three cases where, owing to softening of the muscular structure of the cervix, and yet rigidity of the internal os, careful dilatation with Hegar's sounds had caused rupture of the cervix. In the last case, the rent was 2 cm. deep, and followed on the use of the number 16 sound. The patients, owing to careful antisepsis, made a good recovery. Notwithstanding these cases, the speaker believed that this method of dilatation was very valuable, and reported the cases only to lay stress on the necessity of caution where the cervical tissues were relaxed generally, but at internal os were rigid.

KLOTZ related a case of salpingotomy similar to the one recorded by L. Double pyo-salpinx; the right removed by laparotomy; the left, too deep in pelvis and broad-based, was incised per vaginam; and then for three months, drained. Wound healed, and no symptoms.

In regard to the parovarian cysts, MEINERT related a case of interest on account of recurrence and frequent puncture. The cyst was the size of an adult head, and could not be entirely removed by laparotomy. All was removed that was possible. Since, there had been recurrence. Then, puncture by vagina, and injection of 30 gm. Lugol's solution, well borne, but again recurrence. Again, puncture; later, a second laparotomy and removal of as much as possible; remainder burnt. Cure.

K. had removed the cancerous uterus seventeen times after L.'s method, with no death, and spoke favorably of the simplicity and other advantages of this method.

SCHRAMM said that, after kolpo-hysterectomy, he had seen fever supervene on irrigation. He recommended Hegar's method of after-treatment. Glass drainage tube surrounded by iodoform

gauze.

Both SCHUETZ and MEINERT said that they were in the habit of using Fritsch's dilators; the latter had also seen a case of cervical rupture.

KLOTZ also remembered a case of rupture, with consecutive parametritis, after Hegar's sounds. Since then, had used Ellinger's instrument.

SCHRAMM said that he had frequently used Hegar's sounds, and had never observed either cervical rupture or parametritis.

REVIEWS.

THE SO-CALLED MODIFICATION OF THE NEW EMMET OPERATION. Apropos of the now frequent discussions of the Emmet operation for the treatment of prolapse of the posterior wall of the vagina from loss of fascial or muscular support, I wish to call attention to the fact that the operation is very generally misunderstood, frequently incorrectly explained, and erroneously described under conditions in which error is inexcusable, no matter from what cause arising.

When a gentleman deems his knowledge of any particular subject sufficient to justify him in appearing in the world of letters as instructor of his professional brethren, he should have care that his teachings are true, and, above all, fair.

In the fourth volume of Pepper's System of Medicine, in the article on displacements of the uterus, is a description of the socalled Emmet operation.

The writer prefaces his exposition of the operation by the remark that it is the most "scientific" yet devised.

Following this statement with a brief description, lucid so far as it goes, except in an essential particular which fails to receive any attention whatever, he vouchsafes the following criticism:

The essential part of the operation, inside the vagina, almost always succeeds, but the external part of the rupture, at the pos

terior commissure, often fails to unite; furthermore, the operation as described by Emmet does not overcome the patulous condition of the introitus vaginæ in case of great relaxation of the vagina. The author has sought to obviate the first of these difficulties by the use of deep silver sutures instead of the superficial ones described by Emmet. They should be introduced before tightening the vaginal sutures, and should be passed far around in the posterior vaginal wall, their points of entrance and exit being the same as for the three lower, unsecured, superficial, external sutures. (Fig. 14.)

The second difficulty may be overcome by further denuding a triangular surface on each side in the vaginal sulcus, the base of the triangle corresponding to the line a b (Fig. 12), and its apex being in the vaginal sulcus at a distance corresponding to the degree of relaxation. This increases the length of the lines of union running into the sulci represented by db and e f (Fig. 14). Let us consider the first of the objections cited by Dr. Dudley, to wit, the patulous condition of the vagina, holding carefully in

FIG. 12.

mind the proposed plan for its relief. The deep perineal sutures, it will be remembered, are to be introduced before tightening the vaginal sutures, which have already been deeply introduced, so as to draw the posterior vaginal wall upwards and backwards. Now, both sets of sutures having been deeply introduced, they must infallibly be crossed, and, when tightened, draw on each other. In other words, the deep sutures recommended by Dr. Dudley can only tend to defeat the result otherwise attained by the vaginal sutures, thus sacrificing the essential portion and object of the operation by a "modification" barren of good results, and in effect only a grafting of the old trefoil operation upon the new and truly "scientific" method. The improvement is no improvement, and if it were, it is Emmet's own idea, and not Dr. Dudley's.

In the second modification the merit of improvement is equally well established as in the first, with this difference, that the writer first misunderstands the operation as described by Dr. Emmet, then explains the difficulty arising from his misconception, and,