the abdominal incision would not thereby become excessively enlarged. The elastic tube is fastened with compression forceps, and a temporary abdominal suture inserted to guard against prolapse of the intestines. The child is not injured by the constriction. The loosening of the peritoneum is not essential. Should the wound tear during the extraction of the child, especially downwards, it is good practice to do some resecting, that is, to smoothe the wound. He sews with stout wire; the superficial sutures are of strong silk. The narcosis must be profound and undisturbed. With a view to guard against after-hemorrhages, he gives injections of ergotin. Atonic after-hemorrhages had not occurred in his cases. As he loosens the elastic ligature, he compresses the uterus with the hand, so as to excite a pain.

DR. KRUKENBERG, like Freund, had observed a profuse hemorrhage after the uterus had been sutured. The patient died. A clot the size of the fist was expressed from the uterus. At the autopsy, the anemia found was not great enough to explain the cause of death. The fatal issue may have been due to air-embolism and hemorrhage. He believed that atony of the uterus may occasionally render the employment of the elastic ligature dangerous.

DR. SCHAUTA lays the greatest weight on the rigidity of the suture material; he rejects silk, not because he fears infection, but on account of the mechanical injuries (too firm ligation, strangulation) inflicted on the tissues; he attempted to prove by a citation from Saenger's monograph that the latter had not prized the silver suture formerly as highly as at present.

DR. SAENGER replied that not only his papers, but his operations demonstrated that he prefers silver wire for the deep sutures. Schauta should not lose sight of the fact that he had at the same time employed the sero-serous silk suture. Silver wire alone also gives good results; Simon Thomas had obtained with it four recoveries out of six cases. It seemed Schauta did not dare to use the wire alone. The speaker claimed as his own merit that he had been the first to apply very numerous sutures, and to have shown that catgut-i. e., absorbable material-should be avoided; he had also laid stress on accurate coaptation.

To Krukenberg he replied that he had given in his monograph an accurate collation of cases with Cesarean cicatrices, together with an analysis of their origin.

DR. WINCKEL inquired whether anybody was able to give information regarding the state of Cesarean cicatrices and silver sutures at the repetition of the operation.

DR. SAENGER knew only of the one case by Lungren, who describes the cicatrix as uniformly smooth, and says that the silver sutures looked as if they had just been inserted.

DR. WINCKEL exhibited a rabbit which had been successfully inoculated (subcutaneously) on the ear and back with the blood from the heart of a puerpera dead of external and internal erysipelas. He also showed specimens of the erysipelas cocci bred from the blood.

(To be concluded.)

REVIEWS.

HANDBUCH DER FRAUENKRANKHEITEN.-A HANDBOOK OF DISEASES OF WOMEN. Edited by DR. TH. BILLROTH and DR. A. LUECKE. Second entirely rewritten edition. Three volumes. Stuttgart: Ferdinand Enke, 1885, 1886.

Second Volume: NEW GROWTHS OF THE UTERUS. BY PROF. GUSSEROW. THE DISEASES OF THE OVARIES. BY PROF. OLSHAUSEN. THE DISEASES OF THE TUBES, OF THE LIGAMENTS, OF THE PELVIC PERITONEUM, AND THE PELVIC CELLULAR TISSUE, INCLUDING EXTRAUTERINE PREGNANCY. BY PROF. BANDL. Professor Gusserow's contribution claims two hundred and sixty-two pages. It is complete without unnecessary diffuseness. The etiology and anatomy of the various uterine tumors are entered into at sufficient length, and in the sections on treatment the different surgical methods receive the recognition which the experience of the majority of operators of to-day justifies. Since it is the question of treatment of uterine tumors which is of geatest importance and interest to our readers, we prefer to dwell here on this theme rather than on the less unsettled subject of etiology and symptomatology.

Of the many non-surgical methods of treatment of fibro-myomata of the uterus which have from time to time been proposed, such as the various salts of potass., arsenic, phosphorus, and mercury, there is but one which may be said to have any positive evidence in its favor, and this is the use of ergot subcutaneously, as first advocated by the late Professor Hildebrandt. By this method undoubted cures, even if few in number, have been recorded. In estimating the worth of the method from an analysis of the reported cases, it must be remembered, as Gusserow justly remarks, that in many cases reported cured there may have been an error in diagnosis. Hildebrandt himself admitted that in one of his cases he may have been dealing with an exudation rather than with a myoma. Gusserow's personal experience with the method has never resulted in seeing the disappearance of the tumor. The effect seemed to be principally an occasional diminution in size, and decrease in the hemorrhages, and such we take it has been the experience of the majority of gentlemen who have resorted to the method. In this country the elder Byford alone has obtained marked results-eighteen cures out of sixty-one cases. As a method, indeed, it has fallen far short of the hopes of its originator, and must be considered as purely palliative in those cases where treatment by surgical means is impossible or contra-indicated.

The treatment of fibro-myomata by electrolysis is dismissed in a few words by Gusserow, in his belief that, owing to the great dangers it involves, it has been abandoned. We question if this method has not still its sphere of applicability-to those cases, for instance, where the tumor is small and readily accessible. Freeman, of Brooklyn, has lately reported cures of small myomata by this method. The probability is, that in the future electricity will be resorted to more frequently in case of small fibro-myomata than it is at present, not necessarily by electro-puncture, however,

but perhaps through utilization of the caustic quality of the galvanic current, as is advocated, somewhat enthusiastically it is true, by Apostoli of Paris, reference to whose labors in this direction it might not have been amiss for Gusserow to have introduced here.

Passing to the operative treatment of myo-fibromata of the uterus, the method above all others which is gaining ground is removal of the ovaries and tubes. When compared with the more radical operation of extirpation of the growth, the figures are certainly in its favor. A very complete statistical analysis in this article shows a constant diminution in the mortality rate of castration from twenty-five per cent to ten per cent, whilst the lowest rate from hysterectomy is nearly thirty per cent. In considering the worth of the two operations, however, it is Gusserow's opinion that, whilst castration is effective in checking the hemorrhages, it has often scarcely any effect on the other symptomschiefly mechanical-due to the tumor, whilst total extirpation, if successful, will at once eliminate every symptom. He would, therefore, extirpate the growth whenever possible, reserving castration for those cases where extirpation is either impossible or else appears too dangerous. In the light of statistical data published since the writing of Gusserow's article, we believe that he would to-day feel called upon to pronounce more strongly in favor of oophorectomy. Tait's mortality from this operation is only two per cent, whilst the best figures for hysterectomy is about twelve per cent (Keith). In considering these two operations in the light of Mr. Tait's figures, however, it is to be remembered that it is his habit to operate at as early a stage in the growth of the tumor as is possible. Unquestionably, in such an event, removal of the appendages is a simpler operation than hysterectomy when the myoma has attained vast dimentions. Until, therefore, operators are agreed as to the justifiability of interfering either by oophorectomy or by hysterectomy with myomata in a medium stage of development, statistical data must remain very fallible as pointing to the pre-eminence of one or another of these operations. The truth of this statement is evident when we oppose the opinion of Gusserow-"The ideal and correct operation should ever where possible be extirpation of the myoma with the uterus, or without if possible"-against that of Tait-" Hysterectomy is a dangerous operation. There is no choice between the operations.' The difference between Gusserow (and he may be taken as a representative of the German operators, and, in a measure, of the Americans), and Tait, is that the latter would favor removal of the appendages before the tumor has reached such a size as to make extirpation imperative, whilst the former, recognizing that, in possibly the majority of cases, fibro-myomata of the uterus may never endanger the patient's life or render existence unendurable, would counsel waiting until symptoms call for operation. Here is a wide diversity in opinion which will require time and much discussion to settle. There is always danger to-day of over-operating, and the glamour of the brilliant results of a single operator should not be allowed to swerve our opinions in favor of operating in cases where the chances are great that palliative non-surgical methods will suffice to tide our patients beyond the menopause, when nature accomplishes the same end which Mr. Tait aims at through removal of the appendages.

The section dealing with the influence of fibro-myomata on preg

nancy, labor, and the puerperium is very interesting and complete in its literature references. To the cases of labor complicated by fibroid where enucleation was necessary before delivery of the child, we would add Mundé's case, which is recorded in the ninth volume of the "American Gynecological Transactions."

In regard to carcinoma of the uterus, Gusserow, in accord with the large majority of operators, believes vaginal hysterectomy to be an eminently justifiable operation. His remarks on the indications for, and the steps of the procedure, do not differ from those which have been so frequently formulated of late years. The statistical data he offers are complete as regards European operators, but he is as silent in regard to the work of American surgeons as though with us the operation had never been performed. And the same remark holds true in reference to the results obtained here by the other less radical methods. The mortality from vaginal hysterectomy, as obtained from two hundred and fifty-three cases collected by Gusserow, is slightly lower than it has hitherto been stated by other investigators, namely, 23.3 per cent. Data in regard to recurrence are necessarily as incomplete and unsatisfactory in this as in other contributions. The time has not arrived as yet when the worth of this operation may be judged from the standpoint of radical cure, seeing that it is only of late years that the technique of performance has become settled and perfected, and that cases have been carefully selected with strict reference to suitability.

Within the space of four hundred and ninety-four pages, Prof. Olshausen offers us an admirable exposition of our knowledge in regard to diseases of the ovaries and their treatment. It would serve no useful purpose to critically analyze this contribution. Sufficient the statement that the reader will find ample information in regard to the genesis of ovarian tumors, their symptomatology, the details of operative procedure, and methods of overcoming complications. There are certain questions in connection with diseased ovaries and their treatment, however, which, being matters in dispute, we would call attention to here in the light of the opinions enunciated by such a close observer and successful operator as Olshausen.

First in regard to exploratory puncture or incision. Olshausen prefers the latter to the former, in this respect being in agreement with Lawson Tait. In case of large ovarian tumors, puncture, under strict antiseptic precautions, may be said to be as free from danger as incision; in case, however, the tumor turns out to be a dermoid cyst, or an ovarian cyst, the contents of which are purulent, then the experience of most operators justifies the assertion that puncture may be a very dangerous procedure. For these reasons Olshausen is each day inclined to resort less to puncture for diagnostic purposes, and to substitute the exploratory incision, which, if the conditions be found favorable, may at once be followed by laparotomy. With this opinion many American operators will unquestionably agree. There are others, however, of equal prominence, who still prefer exploratory puncture as a diagnostic measure, for the reason that as yet they have never happened to see any of the dangers which may follow on the procedure. În view, however, of the fact that puncture must be granted to be not free from possible untoward results, and in view of the fact that an exploratory incision is, under strict precautions, practically

free from danger, there can be little question but that before long this latter procedure will uniformly be favored over the former.

Passing to the treatment of ovarian cysts, Olshausen dismisses the non-surgical methods, in particular electrolysis, in a few pages as being of but little, if of any, value. He grants the possibility of causing, through electro-puncture, diminution in size of ovarian cysts, and, in case of unilocular cysts, he admits the chance of cure; but he is of the opinion that such cases will ever remain exceedingly rare, and would limit the applicability of the methods to cases where, for one or another reason, operative interference is impossible. The surgical treatment of these cysts is considered at length under the headings: 1, Puncture; 2, Puncture Followed by Permanent Drainage and Incision; 3, Injection of Stimulating Fluids; 4, Extirpation. As regards the operation of ovariotomy, Olshausen strongly favors the intraperitoneal treatment of the pedicle, and has entirely given up the use of drainage as being unnecessary, and even dangerous. Since 1882, he tells us, he has operated one hundred and twenty-four times without drainage, and has not lost a single case from septicemia. Even in case of an incomplete operation, in the sense that it is impossible to remove all of the cyst, he dispenses with the drainage tube, simply dropping the cyst remnant and sewing up the abdominal incision. Of eight cases of the kind, he has lost but one, and she died on the twentyfifth day from exhaustion, the result of an uncontrollable diarrhea. This whole subject of the removal of ovarian cysts, the possible complications, and the methods of overcoming them, is presented in a concise and most interesting manner. In speaking of foreign bodies left in the abdomen after laparotomy, the very few cases of which Olshausen has heard would have been considerably increased had he referred to the ninth volume of the American Gynecological Transactions," where Wilson, of Baltimore, describes fifteen unpublished cases, five in this country and ten in Europe.

66

With the exception of Hegar, German operators have not resorted to oophorectomy to the extent to which it has found favor here. Olshausen considers the subject judicially, and it seems to us that the limitations he places on the operation are very just. The indications he formulates as follows: 1, Hernia of the ovary, where reduction is impossible, and suffering great; 2, Absence of the uterus, or rudimentary condition of this organ, accompanied by amenorrhea, and yet in the presence of ovulation as evidenced by marked molimina and reflex nervous symptoms; 3, Disease of the uterus accompanied by hemorrhages or pain which endanger or make life unendurable. Under this heading are classed interstitial fibroids of the uterus, where the organ is about the size it reaches at the fourth month of pregnancy. Olshausen thinks, however, that even in such cases supravaginal amputation will gain in favor, seeing that every day, with improvement in technique, the dangers grow less, and ultimately the operation will become as safe as ovariotomy now is; 4, Cases of oophoritis and peri-oöphoritis-conditions which the tendency is growing to consider due to tubal disease. It is in these cases, particularly, that Olshausen finds it most difficult to decide as to the justifiability of the operation. He cannot go to the extremes to which Hegar does. Because an ovary is a trifle larger, or smaller, or more sensitive than normal, is no excuse for oophorectomy. Obscure ovarian pains may as well depend on a pathological pro