pleteness of the operation. I am told that Dr. Emmet has made use of silver sutures in this same way during this past winter.

I consider that Dr. Dudley's article is a very valuable addition to the literature of this most valuable operation.

I am sure that Dr. Price would never have taken it upon himself to criticise Dr. Dudley's article so severely if he had remembered that "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."

Very truly yours, A. MCLAREN.

66

To the clear statement of Dr. McLaren I may add the following: By his implication that deep sutures are not needed to obviate the occasional non-union at the posterior commissure, the critic places himself at variance, not only with Dr. Dudley, but with the operators at the Woman's Hospital and with Dr. McLaren. His further remark, that their use is Emmet's own idea, and not Dr. Dudley's," is ungraceful, inasmuch as Dr. Dudley has made no claim to originality in the matter of deep perineal sutures; he simply stated that he had sought to obviate a difficulty by applying them in the new operation in place of the more superficial ones described by Dr. Emmet, which, to my personal knowledge, he did nearly two years ago, and has continued to do ever since with perfect results, at least in about one hundred of his operations which I myself have observed. Against the critic's reasoning, therefore, that the deep external sutures are useless, and that they would antagonize the vaginal sutures, I place a fact supported by observation of a hundred cases, that no such antagonism exists outside the imagination. Dr. McLaren also clearly shows that their necessity has been appreciated even at the Woman's Hospital.

Reference to page 391 of Emmet's "Principles and Practice of Gynecology" would perhaps correct a seeming misapprehension into which the critic has fallen, relative to the extent of tissue denuded in the sulci by Emmet in his new operation. So far as the vaginal surface is concerned, he will there learn that the same denudation is made as in the old trefoil operation. It is the line of union which is crescentic, and not, as many suppose, the denuded surface.

Dr. Dudley's recommendation to denude a further triangle on each side, the base of which corresponds to the line drawn taut with the tenacula between the crest of the rectocele and the caruncle, contemplates a more extensive denudation into the sulci than would be warranted by Emmet's description of the operation. Indeed, such denudation is even condemned by Emmet

himself, nor is it ever permissible except in cases of extreme relaxation of the vagina, or, more comprehensively speaking, relaxation of the pelvic floor, and for such cases only Dr. Dudley proposed it. The critic's idea that this additional denudation, designed only for exceptional cases, is a part of Emmet's operation proper, is therefore intolerable.

The article in Pepper's System contains three cuts which the critic has strangely introduced in their inverse order, and he has rendered them further unintelligible by omitting the explanatory text which, in connection with the cuts, was intended to show the action of the sutures and to indicate the manner of their introduction; but such an omission is in harmony with the critic's remark on that point that "an engraving alone affords all the information relative to the manner in which the sutures are to be introduced."

Reference to Emmet's chapters in the last edition of his "Principles and Practice of Gynecology" on the old and new operations, and to the article in Pepper's System, will show that Dr. Dudley has correctly and with the fullest appreciation described this important operation, and that if there has been "error," it is not his; if there has been " unfairness," it is not his; if there has been a "brain-born dream of evil," it is not his. WALTER H. MARBLE.

MERCY HOSPITAL, CHICAGO, May 26th, 1886.

ABSTRACTS.

1. Plenio: A Case of Traumatic Rupture of the Gravid Uterus. Laparotomy. Recovery (Centralblatt f. Gyn., No. 47, 1885).-A. K., æt. 19, at the beginning of eighth month of pregnancy fell backwards from a high wagon, striking on the back and shoulder; complained of intense abdominal pain, and lost consciousness for a few minutes. There was neither hemorrhage nor loss of liquor amnii, the only symptom on entrance into hospital being pain in abdomen and over the scapulæ. On examination, fetal parts were detected in the abdominal cavity above the contracted uterus. Auscultation as regards the fetal heart was negative. There were a few clots in the vagina, the cervix admitting the finger. The diagnosis was rupture of the uterus with escape of fetus into abdodominal cavity. Laparotomy was decided upon. Under antiseptic precautions the usual incision was made. The uterus was found contracted, the rupture site being in the mid-line, the fetus lying transversely in abdominal cavity, the placenta within uterus. No liquor amnii, and but little blood in abdominal cavity. Fetus readily removed, uterus drawn up to abdominal incision, and slight traction on cord removed the already loosened placenta. The uterine rupture site extended down the

middle of the anterior wall to about the neighborhood of internal os, the sharply deviated to the left, separating the cervix from the body for about two and a half cm. The borders of the rent were smooth, and the position of the rent was favorable for suture, and so, after careful disinfection of uterus, this was done with silk sutures passed straight through the uterine musculature. A drainage-tube was passed from inner borders of uterine rent near the fundus through cervix into vagina. Uterine cavity washed out through drain tube, abdominal incision treated as usual. With exception of attack of double cellulitis patient made good recovery.

E. H. G.

The

2. Wasseige: Extrauterine Pregnancy (abdominal); Dermoid Cyst; Gastrotomy; Death of Patient nineteen days after from Hemorrhage (Reprint from Bulletin de l'Académie Royale de Médecine de Belgique, Vol. XIX., No. 8).—The case concerns a patient, aged 20, who last menstruated the 20th of May, 1884. Up to four and a half months health good. About middle of October had typhlitis. The end of October was seized with sudden and violent abdominal pain, which yielded to antiphlogistics and lukewarm vaginal injections. Up to April, 1885, nothing noteworthy except constant pain in left side, due, it was thought, to transverse position of fetus. On April 24th, sudden pain, considered due to inflammation of ascending colon. April 27th, intermittent pains, considered due to biliary calculi. The fetal movements and heart beat ceased May 17th; the abdomen rapidly increased in size from accumulation of gas; nausea and vomiting set in. On May 28th, W. saw the case in consultation. Examination of abdomen revealed simply fluid in the peritoneal cavity. Vaginal examination: cervix posterior, external os open for the finger, in anterior cul-de-sac corpus uteri the size of two fists. Diagnosis was, of course, in doubt. The pregnancy, if it existed, was certainly not uterine. An extrauterine pregnancy without pain, without displacement of uterus was a rarity. choice lay, then, between multilocular ovarian cyst and fetal cyst of the ovary. It was determined to aspirate in order to facilitate palpation. The result was about two litres of a serous reddish fluid, and then palpation revealed two solid tumors in the flanks, but as to their nature it was impossible to give an opinion. Since the patient was rapidly failing, gastrotomy was determined on. On opening abdomen, a quantity of black. ish fluid and gas, both foul, escaped, and then the shoulder of a decomposed fetus presented. The fetus was delivered by version. The placenta was attached to the ant. and post. surface of uterus at the fundus but at least three-quarters could with ease be removed, the adherent quarter being left behind. A careful examination revealed towards the right a broken-down septum leading to a cavity wherein was a large quantity of hair. This dermoid cyst was emptied, the abdominal cavity carefully cleansed, abdominal incision united except at lower angle, where drain tube was placed. The patient convalesced well up to nineteenth day, when, against orders, she turned on her side, and died of external and internal hemorrhage. At autopsy, abdominal cavity filled with blood. (The case is particularly of interest as evidencing anew the almost infallible tendency towards erroneous diagnosis in abdominal pregnancy. The case was considered one of normal pregnancy till W. saw her in consultation, and he only reached the correct diagnosis through operation).

E. H. G.

CASE I.-In July, 1880, a child eight months old was brought to me for treatment for diarrhea. It was much reduced in flesh and strength. I saw the child one afternoon, and recommended the mother to take it to the sea-shore the next morning, and remain on the beach during the day. The same evening the mother noticed a lump in the right hypochondriac region that moved at times towards the left side.

The child passed a restless night, occasionally screaming, and the diarrheal discharges gave place to bloody passages, accompanied with tenesmus. In the morning, without seeing me or notifying me of the new symptoms, the child was taken to the sea-shore. The mother had already noticed that, after violent expulsive efforts, what she called the child's "body" came down. During the day the child had occasional attacks of screaming and straining, accompanied by the same bloody discharges. In the evening I was called in, this being about twenty-four hours after symptoms of intussusception had become prominent. Found the little patient with a rapid pulse, eyes sunken, cold, and vomiting. No tympanites.

An oblong tumor could be felt in the left iliac region. When the abdomen was manipulated, the child made expulsive efforts which forced out about two inches of the invaginated intestine.

The diagnosis was readily made. I at once attempted to remedy the difficulty. The patient was held in a reclining position, with head and shoulders lower than the hips, and attempts were made to force back the invaginated intestine by means of injections of warm water through a Davidson's syringe. The sphincter ani was so markedly relaxed that two fingers passed through without difficulty, and, owing to this relaxation, it was impossible to confine the injections in the bowel. As soon as three or four ounces had been thrown in, an expulsive effort would drive out every particle of the liquid at the side of the nozzle of the syringe, and force the intestinal tumor down upon the syringe nozzle with considerable force.

Finding my efforts unavailing, I called in a neighboring physician to assist me. The child was suspended for a few minutes with its head downwards. The assisting physician held the nozzle of the syringe in the anus and supported the relaxed sphincter with his hands, while I attempted to inject warm sweet oil. In spite of the position of the child and every endeavor on the part of my assistant to constrict the anus and retain the injection, it was expelled repeatedly. The expulsive force of the abdomen in this weak child was almost incredible. After intermittent attempts for more than two hours, we were compelled to give up these efforts and to propose the operation of abdominal section. To this the parents would by no means consent, and so, it being nearly midnight, we left the case for the night. On my way home I thought of a measure that might perhaps be of service. I stepped into a drug store, and procured an old-fashioned glass vaginal syringe, one inch in diameter and six inches in length, with a rounded end, perforated by a number of small openings. From the syringe I removed the piston and fitted a cork in the open end, with a hole in the cork just large enough to receive the nozzle of a Davidson's syringe. I removed the rubber tube with the nozzle in front of the bulb of the syringe and passed the nozzle through the hole in the cork. A little melted sealingwax dropped on the cork held the nozzle in place firmly, and made the joints air-tight. The other end of the rubber tube was then slipped over the nozzle of a siphon of Vichy water and fastened. I then made a shoulder on the glass vaginal syringe about an inch from the perforated end, by winding a roller bandage tightly around it. This bandage was wound so as to make a firm shoulder an inch in thickness all around the tube, and made slightly cone shape. My apparatus consisted, then, of a siphon of Vichy water warmed to the temperature of the body, a small rubber tube about two feet in length connecting the siphon with a glass tube one inch in diameter and six inches in length. The end of the glass tube that entered the rectum was rounded and perforated with a number of openings. One inch from this extremity was a shoulder formed by a roller bandage.

The apparatus being complete, I proceeded to put it to the test. The glass syringe was inserted in the anus until the shoulder on