the whole structure of my argument when after advising strongly against the unnecessary use of the curette and expressing my earnest conviction that sepsis rarely occurred in case of abortion where meddlesome efforts to hasten the abortion were lacking, I still felt bound to admit that an occasional case does arise in which septic infection has occurred and in these cases curettage is imperatively and immediately demanded. Hence, it has long been my practice, as soon as any sign of septic infection occur. red to at once, under anaesthesia, as thoroughly as possible remove the whole remaining product of conception and not stopping at that if there be reason to believe a septic endometritis has occurred I proceed to scrape away, as thoroughtly as possible, the whole uterine mucosa, and then irrigating thoroughly with warm, sterilized water by means of an intra-uterine irrigator the bag of the fountain syringe being held at slight elevation so as to avoid any great pressure. The cavity of the uterus is now swabbed over with Tr. iodine, a strip of iodoform gauze carried to the fundus (I never pack the uterus in these cases) simply to promote drainage and the woman put to bed. Having done this I feel I have done the best that can be done under the existing conditions, and though I may have chosen between I would not dare evils I am sure I have chosen the least evil. wait until the septic process has progressed so far that the walls of the uterus are "infiltrated, softened and friable," and if a doctor does not diagnose and treat uterine sepsis until the organ is practically rotten instead of making matters worse by forcing a finger through a "friable" os that would tear under the slightest strain or pressing a "softened and friable" uterus down from above the pubis upon a finger that is liable to punch through its walls at any moment, or washing out its cavity with all the uncertain force of a Davidson's bulb syringe, taking all sorts of chances of forcing water and septic matter through the fallopian tubes, in my humble opinion it would be better to arrange for the autopsy. But apart from the folly of waiting till sepsis has progressed to the extent of producing "infiltrated, softened and friable" walls, even though a faithful effort and proper time be made to clean out the uterus in septic abortions, with the finger the result must be very unsatisfactory. It is very rare that the uterus can be thoroughly explored with the finger and if the

abortion occur at any time from the third to the fifth month the very depth of the uterus will prevent anything like a thorough exploration by the finger, and even if this could be done satisfactorily all who have had much experience in these cases will bear me out in saying adhering placental fragments cannot be removed by the "cushioned end" of a finger; nothing short of a sharp stiff nail beyond that "cushioned end" would suffice and this would be practically a curette almost impossible to make clean. Beside all this if a septic endometritis was present nothing could be accomplished for its relief or to stay its progress through the tubes into the pelvis.

In conclusion then, let me reiterate my position taken in my former paper. So long as obortion is progressing safely even though it may be slowly all sorts of interference and especially curettage is to be deprecated. Nature is, in the vast majority of cases, thoroughly competent to take care of herse'f, but so soon as septic symptoms arise then the uterus must at once be emptied of its contents and though the curette is an instrument full of possible dangers,-dangers I have carefully pointed out in my former paper,--still in the crisis at hand-a crisis I admit often brought about by previous meddling-the thorough, intelligent use of this instrument offers the best chance of escape. Let us never wait until the uterus is so thoroughly septic as to present "infilterated, softened and friable walls" and we must be sure that the operation is done as thoroughly as possible and with every attention to technique we would give to a laparatomy. No. 300 Freemason St., Respectfully, Norfolk, Va.

R. L. PAYNE, M. D.

URETERAL ANASTOMOSIS.-In the June, 1898, issue of the American Gynecological and Obstetrical Journal Howard A. Kelly has an elabo

rate article on Ureteral Anamostomosis. Like all his work it is first class in every particular. He calls attention to the fact that every operator of wide experience has occasionally injured the ureter. Martin had 2 cases in 202 total extirpations. F. von Winckel estimates 17 Robinson 3 in 100;

injuries in 774 total extirpatiens of the uterus. Kelly's average is 1 in every 500 abdominal sections for all causes. If these men of great experience and expertness sometimes injure a ureter, how can those with less experience escape this accident? I have never injured a ureter that I am aware of but Kelly points out that many more are injured and the disease not recognized than otherwise. If a ureter is cut or occluded by ligature or injured in any one of the several ways to which it is liable, the patient usually dies, unless the damage is repaired at once, but experiments on dogs prove that in them the ureter may be ligated and life continue though the kidney atrophies and in the human subject the same thing has happened.

The author enumerates the various ways in which the ureter may be surgically injured and the operations during which such injury may occur. He goes further and puts forth very clearly how this accident may be avoided, laying great stress (and very properly so) on the insertion of bougies in the ureters in all cases in which extensive dissec tion must be done, as in carcinoma. I do not think that any abdominal surgeon should consider himself properly equipped until he can introduce a catheter or bougie in the ureter and that expeditiously. Even the presence of the ureteral bougies does not invariably prevent injury to the ureter as is shown by a ureteral fistula following an operation in the hands of Dr. Kelly himself in which he used the bougies.

Kelly lays down the invariable rule that at the close of every difficult abdominal enucleation when the complications have been about the pelvic floor the ureter must be inspected and their integrity assured."

After naming the different anastomotic procedures, he says "when the ureter is divided in an operation the general rule should be to anastomose it at once, either to its divided lower end, or into the bladder." The other procedures are to bring the divided (upper) end into the abdominal wound, or switch the end into its fellow of the opposite side, or turn it into the rectum.

Should the injury escape notice at the time and a fistula result there are a number of ways to deal with it: if the fistula is vaginal the ureteral opening may be diverted into the bladder by (1) one of the several vaginal operations or (2) the abdomen may be opened and the ureter turned into the bladder, or (3) anastomose the ureter into the bladder by the extraperitoneal method, or (4) open the bladder from above expose the ureter and suture it into the bladder, or (5) extirpate the kidney. In a case cited in which both ureters presented at the upper end of the vagina, following a total extirpation, Kelly skillfully denuded a strip on the upper posterior wall just below the ureteral orifices,

split the bladder open from side to side, whipped over the posterior edge of this incision to prevent bleeding, and sutured the anterior edge to the denuded vaginal strip. The ureteral orifices without having been disturbed were now inside the bladder. This was a clever operation and worthy the man who did it.

The author claims, however, that the ideal plan of doing uretrocystostomy is the extraperitoneal method. He gives credit to Fritsch for first suggesting it but claims to be the first to actually do the operation. He cites the only case on record. The abdominal tissues save the peritoneum are divided just over Poupart's ligament, the peritoneum dissected loose from the pelvic wall, the ureter exposed and divided as far forwards as possible, the bladder split and the ureter sutured into it. This can all be done without opening the peritoneum and is certainly a decided improvement in the way of operative procedures. This article is well worth careful study by every abdomidal surgeon. J. W. L.

RETRO-DISPLACEMENT OF THE UTERUS.-In a brief clinical lecture on this subject, Robert H. Uzlie (N. Y. Poly clinic, May 15, '98) reviews the causes, methods of prevention and treatment of uterine retro-version. He enumerates the many and varied anatomical supports of the womb, about which every writer seems to have a different opinion. Constipation, faulty habits of urination in women, and subinvolution, especially after abortions, are given as the chief causal factors. Attention is called to the fact that the uterus is a particularly movable organ, and that it assumes various positions without harm or symptoms. Prevention consists in proper care of a woman after miscarriages or full-time births-tampons and cleaning out the uterus and repair of all lacerations of the perineum and cervix in the latter. As for operative measures in retro verson, the author prefers Alexander's method of shortentng the round ligaments, though he admits that it ought to be limited to carefully selected cases, having performed it himself not over 15 times He does not see the advantage of operations on the anterior vaginal wall nor of shortening the round ligaments inside the abdomen, and, theoretically, he is opposed to ventral suspension. A patient was exhibited upon whom the author had done an Alexander's operation one year ago, the womb remaining in excellent condition and position.

[Much thinking and talking is now going on anent the best treatment of the retro-displacements of the uterus. Every one of the operations done for their relief has enthusiastic admirers and opponents, while none of them seem to be invariably successful. The truth would seem to be that each case is a law unto itself and that we must suit the operation to the case, not the case to the operation. It will remain for some young man in the profession to distinguish himself by inventing an operation which will permanently cure retro-version of the uterus. The condition, however, is often greatly exaggerated and stress laid on

30

symptoms which are not due to the position of the womb. In the Medical Record of June, 4, '98 F. P. Hammond contributes a unique and very apropos paper on: "A belief that so-called displacements of the uterus are not pathological." He quotes and emphasizes the observation of Fritsch, that "since the womb is normally movable, we cannot speak of a definite normal position," and regards no position as abnormal per se, except complete prolapsus. This question is well worthy of study and, especially, by those who would attribute every pain and ache of woman to a backward-displaced womb.]

H. A. R.

GENERAL SURGERY.

IN CHARGE OF

H. T. BAHNSON, M. D.,

R. L. GIBBON, M. D., J. HOWELL WAY, M. D.

RENAL CALCULUS.-Mr Henry Morris, probably the greatest of living authorities on renal surgery thus summarizes a recent lecture delivered before the Royal College of Surgeons of England on "Renal Calculus," (Brit. Med. Journal, N. Y. Med Journal, May, '98).

1. That the aim of the surgical treatment of renal calculus should be to extend the application of nephro-lithotomy, and thereby restrict the necessity of nephrectomy.

2. Than more frequently than not the failure to find a stone is not in reality a failure of treatment, because there are so many curable morbid conditions which mimic renal calculus, and which are discoverable only by exploration.

3. That the theory that a stone in one kidney, whether that kidney is itself painful or not, reflects or transmits pain to the opposite kidney is quite unproved; that it is a dangerous theory, calculated to lead to very erroneous practice; and that the surgical principle with regard to exploratory operations should be that with pain, paroxysmal or continious, on one side only, the kidney on the painful side should be explored.

4. That neprhectomy for calculous conditions is not often called for, and should be done only in exceptional cases. Nephrotomy for calculous pyonephrosis is the proper operation, at any rate as a primary operation, because of the frequency of double calculous disease. Experience has shown that kidneys from which stones weighing eight hundred and thirty grains and one thousand three hundred grains have been removed are functionally sufficient to maintain life during the blocking of the ureter or suspended action of the kidney of the opposite