acute and chronic metritis, the various forms of endometritis, erosions and laceration of the cervix, and atrophy of the uterus.

Acute metritis, apart from the puerperal state, is, in Fritsch's opinion, not an uncommon occurrence. The reason why pathologists do not describe the condition is that, if the process be limited to the uterus, the patient recovers; whilst, if the inflammation spreads to the peritoneum and the patient dies, peritonitis obscures the inflammatory changes in the uterus to such a degree that, at the autopsy, they are not especially prominent. Fritsch frequently, before the days of strict antisepsis, used to see acute metritis after sounding, injections, curetting, and minor operations on the cervix. As to gonorrhea as an etiological cause, he is inclined to question the widespread belief in the injury done to woman by this disease, whether acute or latent. Sterility and perimetritis, he says, are common in women, and so is gonorrhea in man. "But it by no means follows that the frequency of gonorrhea in the male offers a sufficient explanation for the frequency of sterility and perimetritis." For years he has been in the habit of examining, whenever possible, married men in regard to the possibility of latent gonorrhea, and to his surprise he has found that the wives of men who had had gonorrhea were as likely to bear children as they were to be sterile. The discrepancy in his findings from the prevalent view depends, he states, probably on the fact that observers do not differentiate between catarrhal urethritis in the male and gonorrhea. Whatever the case, however, if the woman be affected, it is the endometrium and perimetrium which are first diseased, and secondarily the parenchyma of the uterus. Even in severe cases, the prognosis as regards fecundity is not so very ominous. Fritsch is cognizant of three cases where, after years of treatment for gonorrheal metritis and perimetritis, conception ensued. "If such cases be rare," he says, "they still should cause us to doubt the dogma of sterility due to gonorrheal infection." We have dwelt on this subject, because the tendency to-day is spreading to lay considerable stress on gonorrhea as a cause of sterility, and it is a matter of importance that the views of such a careful observer as Fritsch should be considered. The treatment which Fritsch recommends in acute metritis is intrauterine irrigation repeated three to four times daily until the fever subsides and the discharge from the uterus becomes clean. This irrigation, of course, is based on the assumption that a septic element is at the bottom of the disorder. Even so, however, were we called upon to treat a case of acute metritis, aside from the puerperal state, we might wash out the uterine cavity once, but beyond this once hardly venture, in the belief that overmuch local interference with any organ of the body in a state of acute inflammation would be rather productive of harm than of good. Hot and copious vaginal douches, opium, and abdominal poultices-these are the measures we should rather favor.

Under the term chronic metritis are included by Fritsch what we here are accustomed to separate into subinvolution and areolar hyperplasia. We believe these latter terms are preferable, for the reason that in neither is there present an inflammatory process. Subinvolution is simply an arrest of a physiological retrograde metamorphosis, and hyperplasia is purely a later stage in this arrest. We had hoped the term "chronic metritis" had forever been buried, and are sorry to see it resuscitated by Fritsch. Whilst we find fault with this name, however, we have nothing

but admiration for the pages in which faulty involution, hyperplasia, the various forms of endometritis, and erosions are described. Having no criticism to make, we forbear detailed reference to matter of etiology and symptomatology, and pass at once to the practical side, that of treatment.

The treatment of what Fritsch terms chronic metritis is ranged under three heads: 1. Local and non-operative. 2. Operative. 3. General therapeutic. Since our author believes the pathological factor with which he is dealing to be one of inflammation, he naturally favors local venesection, either by leeches or the scarificator. He would thus begin the treatment of every "hypertrophied, chronically inflamed uterus." We do not question the utility of venesection. It frequently serves us well, but we resort to it, not in order to allay active inflammatory congestion, but in order to modify the passive venous hyperemia which necessarily is present in an organ in a state of subinvolution, or else, if we are dealing with hyperplasia, for the beneficial effect which follows on irritation of the cirrhosed tissue. Of the value of glycerin as a depletant, of iodine as an alterative, and of the prolonged hot douche as an absorbent, Fritsch is fully convinced. In regard to the operative treatment of subinvolution, Fritsch does not allow himself to be swayed by those of his countrymen who favor amputation of the cervix. The cases are few in number, he believes, where the indication for such mutilation is exact. We would congratulate him on his moderation, for we have yet to see the case of subinvolution where amputation of the cervix for the sole purpose of diminishing the size of the body was in the least called for. We question if the large majority of women subjected to the operation in Germany would not be saved the mutilation were that most frequent of all causes of subinvolution-laceration of the cervix-recognized, and we believe that, in case of what we prefer to call hyperplasia, excision of a wedge-shaped piece from the cervix will amply suffice in place of amputation. As for the drugs which Fritsch has found useful in the treatment of subinvolution; ergot and hydrastis canadensis are mentioned as of value. With electricity Fritsch has had no experience apparently, for we find no reference to an agent which we believe is in the future destined to lead all non-operative methods of treatment of subinvolution and areolar hyperplasia.

Under the subdivision Endometritis are considered the subjects of erosion and ectropium (laceration) of the cervix. In regard to the treatment of endometritis in general, Fritsch's methods are practically in accord with those which are in favor with the majority of gynecologists in this country. He resorts to general medication to favor the diminution in size of the uterus; he practises incision of the external os in cases where the pathological process is kept up by retention of secretion behind an orifice which is too narrow. Alterative intrauterine applications in mild cases, preceded by the curette in aggravated, yield him good results. In regard to lacerations of the cervix, Fritsch is not in accord with Emmet and almost every American gynecologist of any note. In the fact that he recognizes the lesion, he is far in advance of the majority of his compatriots. For admitting that the operation is justifiable and often indicated, he is entitled to high praise. But surely, at this late day, he is not justified in crediting to Emmet, and to those who follow him in his practice, the statement that

the operation is performed solely for the cure of cervical catarrh, and of an eroded everted cervical mucous membrane. After all which has been written on this subject of laceration, in works and monographs to which Fritsch bas access, it would appear unnecessary to be called upon to rehearse the many objects for which trachelorrhaphy is here performed. We do the operation, however, even as in Germany it is done according to Fritsch, to prevent habitual miscarriage, to modify the effects of uterine displacements, to relieve the reflex symptoms which in many cases apparently have their outcome from cicatricial tissue in the angle of the rent, to restore the shape to the cervix in order, frequently, to allow the proper use of a pessary. So far, we in America are in accord with our brethren in Germany. Still further, however, we perform the operation in order to reduce in size a subinvoluted uterus and soften down a hyperplastic-for which conditions many Germans preferably amputate the cervix-and lastly we resort to the operation in order to prevent the development of epithelioma. The operation having been amply proved by Emmet, Thomas, Mundé, Goodell, Wylie, Hunter, and scores of others with whose writings and names Fritsch must be familiar, as able to fulfil all of the above indications, we cannot excuse the author for the little space which he devotes to a description of the operation and its aims. We live in hope that our German brethren may yet awaken to the fact that trachelorrhaphy is a restoring and good operation, whilst amputation is a mutilating and bad procedure. Those who favor the practice of the latter should be exceedingly_careful how they criticise the performance of the former. The years which have gone by since Emmet first gave tɔ the world his beneficient, if occasionally still abused operation, have not in the least rendered untrue Emmet's words: "From my standpoint, therefore, I can but denounce an amputation, with scissors, knife, or cautery, of a so-called hypertrophy or elongation of the cervix as malpractice. . . . If this so-called hypertrophy, or this elongated cervix, should prove to be simply a laceration, the sides of which can be brought together and united, so that the integrity of the parts will be as perfect as if the accident had never occurred, then to resort to ablation or cauterization is malpractice."

The last section in this volume is devoted to a brief account of acquired-in contradistinction to congenital--atrophy of the

uterus.

By

EGBERT H. GRANDIN. ETUDE SUR L'OPERATION D'ALEXANDER.-ADEXANDER'S OPERATION (SHORTENING THE ROUND LIGAMENTS), PRECEDED BY GENERAL REMARKS ON FLEXIONS AND VERSIONS OF THE UTERUS. JUAN E. MANRIQUE. Paris: G. Steinheil, 1886, pp. 160. The operation of shortening the round ligaments for the cure of displacement of the uterus has now been performed in the neighborhood of one hundred and twenty-five times. It has been received with almost universal favor in England, rather coldly in France, and in this country only one operator, Polk, has expressed himself completely in its favor as being the most effective of all methods towards the cure of, in particular, prolapse of the uterus. Mundé grants that the operation is in theory rational, and believes that, in appropriate cases, if the ligaments be found and can be shortened, the operation holds out good hope of permanent cure, but he is far from being carried away by the zeal in favor of the

operation which characterizes Alexander and his followers. In general, then, it may be said that this operation, whilst full of promise, has yet to be subjected to severe test before being accepted as the long-sought-for panacea of the ills which accompany retroversion and descent of the uterus. The majority of operators are certainly as yet unwilling to admit that pessaries, perineorrhaphy, and elytrorrhaphy have entirely lost their usefulness, and that every woman with marked posterior and downward displacement of the uterus should at once have the round ligaments shortened-the claim made for the operation by certain of its most enthusiastic supporters. As in the case of every new operation, there exists here the danger of going to extremes.

The work under review deals with this operation in a judicial spirit. Dr. Manrique first proves that in version and prolapse of the uterus there necessarily exists a lengthening of the round ligaments; then, from personal experiments on the cadaver, satisfies himself that shortening of these round ligaments will effectually, in most instances, place the uterus in proper position; and finally analyzes the reported cases of the operation, one hundred and twenty-four in number. The conclusions reached from this careful and exhaustive study are in brief: The operation of shortening the round ligaments is perfectly rational from an anatomical and physiological standpoint. It cures deviations and displacements by placing the uterus in such a position that the current of the forces, which gravitate towards the pelvis, will converge behind the organ instead of impinging on its surface. Complete or incomplete prolapsus of the uterus may be cured by this operation, except where the displacement is complicated by peri-uterine adhesions. Where cystocele, rectocele, or prolapse of the vagina complicate the uterine displacement, elytroperineorrhaphy should be performed in addition to Alexander's operation. If the ovaries are prolapsed, provided they be not adherent, Alexander's operation will restore them to their natural position in the pelvis. Should conception ensue after the operation, neither the course of gestation nor the phenomena of labor are affected.

The mortality from this operation varies from .8 per cent to 6.4 per cent, according as we accept the statement of Dr. W. A. Duncan or not. This gentleman says he has heard of seven cases of death, but this statement is unsupported by the record of the cases, and Manrique tells us that careful search and inquiry in London failed to give him any clue to the cases or the operators. The only recorded fatal case is one occurring here in New York in the practice of Dr. Bozeman (not Alexander, as is stated in this monograph), and where the cause of death was pyemia. From an impartial standpoint, then, Alexander's operation may be said to be free from danger, rational in its aim, and probably effective, easy of performance if strict attention be paid to anatomical detail, but still an operation not always feasible, because, in certain cases, the ligaments may have atrophied or have become fattily degenerated, and because we are personally satisfied, from having witnessed certain of Mundé's cases, that there exist patients in whom these ligaments cannot be found where they normally lie, notwithstanding careful and thorough search. Such cases may be of atrophy of the ligaments, but whatever the explanation, the fact is that three of Mundé's cases, where we were present, they could not be found, and we reiterate this statement, because Manrique tells us positively, basing his assertion on his own experience as

well as on that of many others, that the round ligaments are always to be found, either as free ligament or tendinous cord, within the inguinal canal. It is assuredly rational to suppose that these ligaments, as such, may occasionally be lacking, even as there are anomalies in distribution of other ligaments in the body.

There is a historical side to this operation on which we would briefly dwell. The assertion has been made by Doleris that the operation of shortening the round ligaments, if it is to receive a qualifying name, should be known rather as Alquié's operation than Alexander's. It seems that in 1840 Alquié suggested the method, but there is absolutely no record of his ever having performed it. In 1864, Deneffe actually performed the operation, but failed to find the ligaments. In 1869, Koeberlé, of Strasburg, during a gastrotomy performed for intestinal obstruction, sewed the left broad ligament in the angle of the abdominal wound, and thus permanently cured a retroversion. Koeberlé, however, admits that his operation on the ligament was simply an epiphenomenon to the gastrotomy. Up to 1881, therefore, it is clear that no operator, with the single exception of Deneffe, designedly shortened the round ligaments with the end in view of curing prolapse of the uterus. It was in this year that Alexander operated, and in the following year he published his first four cases. It is evident, therefore, that to Alexander is due the credit of proving the operation feasible, although theoretically it had suggested itself to others, and been once unsuccessfully attempted. Such being the case, if this operation must be named, to Alexander belongs the honor, for Doleris' attempt to claim it for his compatriot clearly fails of proof.

That this operation has a future we do not doubt. It must, however, run the gauntlet of extravagant claims, and be subjected to great abuse, for such is the history of all new operations, before we will be in a position to judge as to exact indications and permanency of result. We recommend Manrique's monograph to our readers as an unbiassed exposition of the worth of the operation, in so far as, at the present, this can be stated.

EGBERT H. GRANDIN.