ous, if not impracticable, would, of course, not fall in the category of those to which the method here suggested might be applicable. In regard to the fourth objection as to the hindrance presented by a non-dilated os uteri; it may be said that according to the majority of authorities, the most favorable time for performing Cesarean section is after labor has set in, and should interference be delayed till the os uteri were softened and ripe for dila. tion in the greater number of cases the delay would not prove injurious to the mother or child. With the present means of dilating the cervix during labor, it is to be presumed that, while an imperfectly dilated os would not unfrequently prove a hindrance, it would not often be an obstacle in the way of the proposed operation. Barnes, Thomas and Lusk were cited to prove the ease with which the cervix uteri might be dilated. It may be inquired, what would be the relation of the ovaries to the proposed line of ligature in an inverted womb? Several writers refer to the ovaries as resting on the edge of the inverted uterus as if about to fall into the cavity. A specimen from which this statement has been deduced forms the original of one of the standard cuts representing that condition. It is a case of partial, not of complete, inversion. Some authors, as Boivin and Dugés, state that the ovaries are not within the cavity of the uterus. Other writers, as Levret, report cases in which the ovaries were found within the inverted cavity. Schultze states that they are there found,and the cut that accompanies his text so shows these organs. In a number of instances, recent and old, the amputated uterus has been found to contain one or both ovaries. In many cases of chronic inversion the appendages have not been found within the cavity of inversion. A study of the relation of the ovaries after complete inversion of the uterus will lead to indorsement of the statements of Winckel and Schroeder as correct. Winckel writes, "In puerperal inversion, as a rule, the tubes and ovaries fall into the cavity (of inversion.)" an Says Schroeder, "In recent puerperal inversion, all of the appendages are in the uterine funnel." In the records of medicine are not wanting quite a number of cases, the history of which teaches that the plan of operation here proposed may not be fatal. Cases were cited from the work of Denucé on "Uterine Inversion", to prove the latter proposition. In conclusion, Dr. Bartlett said: Mr. President: In the course of my researches in preparing this paper, I have looked expectingly for the presentation of the same proposition as I have here made, from co-laborers in the field of obstetric surgery. I have been rather surprised to have met no allusion to the method. The germ of the plan here proposed, may, however, be found in the writings of that brilliant obstetrician, to whom, more than any other, suggestions for improvement in the operation of Cesarean section are to be credited, James Blundell. In his article on laceration of the uterus, occur these words: "Would extirpation of the uterus, with or without inversion, be of service in these cases? This question may be answered next century." (After writing this article the writer found in the essay of Dr. Harris on the Porro operation in continental Europe, published in the American Journal of the Medical Sciences, in 1880, the following sentences: * * * (1) "Several other plans [of treating the cervix] have been proposed. (2) to invert the uterus after its evacuation, and constrict and remove it by the vagina. This plan tends to complicate the case and increase its dangers, etc." Had the writer been aware that the sugges tion which forms the basis of the foregoing paper, had been previously published, he would not have prepared it. Inasmuch, however, as the merits of the method proposed are in no wise affected by its having been previously suggested, he has decided not to withhold the article from publication.) DR. A. REEVES JACKSON said: I have never performed Porro's operation, and am not sufficiently familiar with the literature of the subject to be a proper person to open, or even take part in the discussion. I confess I scarcely understand what advantages this operation proposed by the essayist offers over the improved operation by Sänger. I would like to know whether Dr. Bartlett has performed this operation either upon the living subject or the cadaver. It seems to me there are practical difficulties in the way. In a review by Harris, of Philadelphia, in the Amer ican Journal of the Medical Sciences, of the work of Mangiagalli "On the More Recent Modifications of the Cæsarean Section," it is stated that it had been proposed to invert the uterus; for the purpose, however, of lessening the danger from septic infection, and not to facilitate the amputation, as is designed by the suggestion of Dr. Bartlett. DR. E. J. DOERING asked how often the Cæsarean operation had been performed in Chicago. DR. W. W. JAGGARE thought Dr. Bartlett's paper a very ingenious essay, although not On the other hand, the positive disadvantages are numerous: The dangers of shock and hemorrhage in artificial inversion of the uterus have been very much underestimated by Dr. Bartlett. The cases, collected from the literature of the subject, when they were at all relevant, were questionable as to authenticity. Accidents occurring to the uterus among the lower animals could not be adduced in evidence as to what would be the probable effect upon human beings under similar conditions. The thermo-cautery was inadequate to the arrest of hemorrhage from a large incision through the walls of the preg nant uterus. The uterus could only be inverted with ease when it was pathologically flaccid-an exceptional condition. Porro's operation was performed in cases of the simple, flat rachitic pelvis, when the antero-posterior diameter of the brim was 6 cm. or under. Above 6 em., craniotomy or the forceps is indicated. It would be very difficult to invert the uterus through the conjugate, oblique or transverse diameter, under such conditions. In the pelvis of Robert, or in the osteomalacic pelvis, in which the degree of contraction is usually higher, artificial inversion of the uterus would be wellnigh impossible. Then amputation of the inverted uterus is a dangerous operation per se. Of the fortyeight cases collected by Dr. West, (Diseases of Women, p. 240.) twelve terminated fatally. Of fifty-eight cases of amputation of the inverted uterus, reported from a German source, (American Journal of Obstetrics, Aug., 1868.) eighteen terminated fatally. "In 106 cases by ligature and otherwise, (Emmet: Principles and Practice of Gynecology, 1884, p. 436.) over 31 per cent of deaths occurred." But it is not necessary to statistics. So great is the mortality of this operation, that A. Martin (Pathologie und Therapie der Frauenkrankheiten, 1885, p. 144.) has proposed as a substitute the total extirpation of the uterus. If, then, upon a priori grounds, Dr. Bartlett's suggestion has no real advantages over the modified Porro operation, and, on the other hand, possesses actual disadvantages, it is scarcely probable that the expedient will receive serious consideration. DR. J. SUYDAM KNOX said: Dr. Jaggard has about covered the objections I intended to make. My impression is that Dr. Bartlett in his paper, has overestimated the relaxation of the uterus immediately after delivery, and the ease with which inversion can be accomplished. Atony of the uterus is the first cause of the inversion; and when we consider how minute is the percentage of inversion in the vast number of labors, we can fairly assume that relaxation immediately after delivery seldom occurs. If this be so, inversion, even with the vis a tergo, would be extremely difficult. Again, atony of the uterus is the cause of the most dangerous symptom or complication of inversion, namely hemorrhage; therefore, the cases most favorable for the operation of Dr. Bartlett would be the last ones in which so doubtful an experiment would be tried. The doctor has made a valuable suggestion. Any method that successfully removes the uterine stump from the abdominal cavity, without attaching it to the abdominal incision, advances the operation of hysterectomy. In the ablation of the non-pregnant uterus, I think Dr. Bartlett's method finds its best application. DR. JAMES H. ETHERIDGE asked if the performance of inversion by forcible traction involved the full dilatation of the neck of the uterus. How does Dr. Bartlett propose to accomplish this, does he dilate it forcibly? With the uterus well up beyond the umbilicus, how do the broad ligaments come out of the pelvis, and with the uterus forced clear down out of the vulva, how much traction is there going to be on these broad ligaments? Is there room enough to permit the uterus to be drawn down? Why, under the circumstances, could not forceps be immediately applied to the edge of the cut uterus, and arrest the hemorrhage, and the work be then proceeded with at pleasure? I speak of hemostatic forceps. DR. E. W. SAWYER said: It seems a little presumptuous for one who has never had experience in this department to attempt to enlighten the society. lighten the society. One of the most intermultiplyesting questions to be decided is which opera tion to perform. I confess if I were confronted to night with one of these cases I would be wholly incompetent to decide between Cesarean operation and the operation of Porro. It may be interesting to read the words of Lawson Tait upon this very point, showing his preference for the new operation, so-called. In the fifth number of British Gynecological Journal, he says: "The whole of my experience in meddling with the preg. nant uterus by abdominal section, consists of five cases, three of the ordinary Cesarean section and the two I am about to describe in detail. Of the Cesarean sections one was performed for malignant disease of the vagina about fourteen years ago, the other two for deformed pelvis respectively seven and five years ago, and the mothers died, and only one of the children is now living. The results indeed, are such as to determine me never to repeat this proceduce, having before me the arguments of Dr. Goodson and the fact that both my amputation cases have recovered." At the same meeting Dr. Routh said: "That he was much interested and instructed by Dr. Lawson Tait's paper. At the same time he could not help making some criticisms upon it. First, he believed that Mr. Tait had exaggerated the mortality of the Cesarean section. It was not anything like 99.971 per cent. Churchill stated that out of eighty cases twenty-three mothers were saved, or 28. 7 per cent, forty-four children being saved. Dr. Radford out of seventy six cases he col lected, found 14.28 were saved, and forty-six Dr. West, out of 409 cases states the recoveries as 38.4 per cent, 237 children being saved. Now he (Dr. Routh) could not help feeling that if in these days of improved antiseptic abdominal surgery, the same skill and care were taken in cases of Cesarean section, the safety of the mother would be much more common." It is interesting to see how gentlemen will differ in their opinions upon such an important thing as the selection of an operation in emergency case. So I am still in doubt whether to adopt the modern method of Porro or to depend upon the Cesarean section, which the remarks of Dr. Routh would indicate is quite as favorable. children were also saved. [TO BE CONTINUED.] an A quack doctor in Pennsylvania recently gave evidence in Court that he performed a post-mortem examination upon the defendant in the case, and the latter survived the ordeal. That wasn't his regular day for lying, either. CORRESPONDENCE. LONDON LETTER. LONDON, OCT. 12, 1886. He took as his Editors Review: The first of October has come and gone with the usual number of introductory addresses, anniversary dinners, and so forth, and now we have settled down to the routine work of the winter session. The addresses were for the most part of the usual type, the various lecturers doing their best to dish up well worn platitudes once more, and with varying success. The only one who ventured out of the beaten track was Mr. Morris at St. Mary's Hospital. text, Mysticism, Scepticism and Materialism in Medicine. That he was over the heads of those who are supposed to be chiefly addressed on these occasions, viz., the new students, goes without saying, but the address was much appreciated by the senior portion of his audience. When he spoke about the improvements that had resulted from the enlightenment of our own day, I wonder it did not occur to him that the introductory address was a relic of the past that ought to be swept away, but I can find no trace of any such allusion in his discourse. How long this intolerable absurdity is to go on, year after year, no one can say. There was a time when addresses were delivered at all the hospitals, but four of them have given them up. I think Charing Cross was the last to do so, some seven years ago or therabouts, and no doubt the others will gradually follow suit. I am not without hope that the process will be hastened by the re The cent combination between the two Colleges of Physicians and Surgeons. As your readers are aware, the two bodies are building an examination hall on the Thames Embankment, in which to conduct their conjoint examinations. ground they bought was a good deal larger than was required for this purpose, and the question of what is to be done with the remainder is now under consideration. The only scheme I have heard of is to erect lecture and class-rooms there, and have formal systematic courses of lectures given there under the auspices of the two colleges. If such lecture rooms are ever built, it certainly would be appropriate that an address should be delivered at the commencement of the session by one of the leaders of the profession, and this would prove a sufficient counter-attraction, I should think, to make the lecturers at the schools haul down their flags. The opening of the medical session is always the signal for a great influx of new books and new editions, and this season promises to be no exception to the ordinary rule. The nervous sys tem is the chief center of attraction, apparently, as Dr. Bastian and Dr. Gowers have each brought out new works on diseases of the brain, and Dr. Ferrier has given us a second edition of his work on the functions of the brain; but as it is ten years since that work first saw the light, and as this edition is to a much greater extent built upon clinical experience, it may practically be regarded as a new work. It is a curious thing that three men from one hospital should be bringing out books at the same time, for these three gentle men are attached to the hospital for paralysis and epilepsy in Queen's Square. Dr. Sutton has published a small volume of lectures on pathology, which cannot fail to be popular. Dr. Sutton has had quite unrivaled experience in the matter of pathology, as he has been making post mortem examinations at the London hospital for something like thirty years, indeed, until quite recently he still held the office of demonstrator of morbid anatomy there. He is best known to the public by his joint papers with Sir William Gull, and especially for those relating to Bright's diseases and the theory of arterio-capillary fibrosis. Dr. Goodhart has also brought a second edition of his popular guide to the diseases of children, the first edition having been exhausted in little over a year. Doubtless, there will be plenty to follow, but these are the chief of the newcomers up to the present. have far too often erred in excluding papers that ought to have been in, so that one must not grumble if a little too much leniency has been shown. The chief papers of interest in it are Mr. Rivington's case of wound of the carotid artery by a fish bone, Mr. Bryant's paper on amputation of the leg by lateral flaps, Dr. Cayley's case of thoracic aneurism treated by the introduction of steel wire into the sac; Dr. Theodore Williams' cases of bronchiectasis, treated by paracentesis; Mr. Jacobson's paper on supra-pubic lithotomy and Knowsley Thornton's two cases of splenectomy. So that the chief interest of the volume is almost purely surgical. The society publishes also its proceedings in a separate form from the transactions, a plan that is not without its inconveniences, as the discussions are thus separated from the papers; it is only, however, within the last few years that the discussions have been printed at all, so perhaps, one ought not to grumble, especially as they are very fully reported. Two new medical or semi-medical periodicals have made their appearance, the first of which is entitled "The Hospital,” is addressed to the public rather than the profession, and emanates from the Hospitals Association, its object apparently being to familiarize the public with the needs of the hospitals, and so promote their support. I am sure we shall all wish it success in this respect. The other is a monthly journal, and is addressed The preparations for the contest for the new to dentists and veterinary surgeons, as well as to seats on the General Medical Council has com- medical men. The first number does not strike menced in good earnest, and there are already a me as being particularly attractive, but its misnumber of candidates in the field, some self-nom-cellaneous store of information will doubtless ininated, others selected by a self-appointed committee of the British Medical Association; the latter candidates will have a good chance of being returned, as the Association contains a great many members, and numbers of men will support its nominees to save themselves the trouble of investigating the respective merits of the candidates. Lawson Tait's suggestion was not a bad one. When the committee met to select its nominees, he was in favor of returning the youngest, most energetic and most discontented men in the profession; the suggestion was not, however, followed up. The Royal Medical and Chirurgical Society has been the first this year to bring out its transactions, and the volume is a good deal thicker than most of its predecessors. The reason for this appears to be that the referees of papers have not been so hard to please as usual; the general thing is that a good many of the papers read during the session are refused admission to the transactions; this year I fancy none of them met that fate, though one or two might have been burked without the scientific world being much of a loser. It is, however an error on the right side, and they terest many. The Obstetrical Society was the first to get under way this year, and held a meeting on October 6. The chief paper of the evening was on rupture of the uterus, and was contributed by Drs. Swayne and Cox. A good discussion followed in which the merits of Porro's operation and the Cesarean section were compared, and allusion was made to the practice of suturing the uterus itself with silver wire. Mr. Doran read a paper on papilloma of the Fallopian tube, and the relation of tubal disease to hydroperitoneum. Dr. Roxall communicated a case of sudden dyspnea during a fit of coughing in a lying-in woman, followed by more serious thoracic symptoms and death; the pericardium seemed to be deficient, and the heart was found to have been dislocated into the left pleural cavity. Dr. Lewers showed a fetus from a case of ruptured tubal gestation, successfully removed through Douglas' pouch ten days after rupture. The subject of hydrophobia and the muzzling of dogs is still causing a good deal of attention here. The new chief commissioner of police,Sir Charles Warren, has shown that he is determined to en force the law as regards muzzling, and so far as London is concerned, the results have been as good as could be expected, but until muzzling is compulsory throughout the whole of the United Kingdom we can never feel satisfied that the disease has been stamped out. The present Home Secretary would earn the good will of all who are not blinded by sentimentality, if he would take the necessary steps to enforce muzzling throughout the country for the next six months. R. M. REPLY TO DR. BARTHOLOW'S LEITER PHILADELPHIA, Oct. 28. Editors Review: On my return home I notice in your journal of Oct. 9, a letter from Dr. Bartholow, in which some important facts are omitted concerning Jefferson Medical College. FIRST. Dr. William Pancoast did not retire on an understanding, but by resignation. SECOND. Dr. William H. Atkinson and myself were lecturers by appointment in Jefferson ical College. The official announcements of the school prior to this year will verify this statement. With the addition of the above facts I leave the profession to judge if the arguments used by Dr. Bartholow in his letter justified the action of Jefferson Medical College. Yours respectfully, JOHN V. SHOEMAKER. We will cite one of the many, the most dreadful enemy of mankind: Tuberculosis (consumption), which is due to a germ and is certainly contagious, as we may convince ourselves by inoculating man's infectious sputa to animals. In connection with this question naturally presents itself, the subject of vaccination for the prevention of small-pox in man. Do we pay sufficient attention to this apparently insignificant operation, which is intended to protect life, and which, instead, in certain circumstances, places it in jeopardy? Do physicians and the public always What if realize its bearing upon a man's life? vaccine contained virus of tuberculosis or hideous affections? Such occurrences are on record, and some take place in our days. This need not frighten us, but it should awaken more attention and double our prudence. It points to one principle which should always be borne in mind by the father, the mother, and the physician, never use humanized vaccine, if it can be helped; never use it from another person. No matter how healthy a subject in appearance, you know not the antecedents, and you cannot judge of the secrets of another's constitution. Nay, we know nothing of the secrets of our own system. men's consideration, have induced some of our These reflections, well worthy of scientific Med-professors, engaged in the study and teaching of comparative medicine, to study the question of vaccine more closely and to produce vaccine themselves. To this effect the University has organized a body of competent men, and has equipped suitable buildings. Our guarantee that the vaccine produced here will be reliable in every respect, is given by the following: 1st. The laboratory is a state institution, and hence is not working for financial benefits. 2. We have a supply of calves from the Agricultural College farm, which is under the supervision of Prof. Sanborn, dean. 3. Dr. Paquin, the chief operator, is a graduate in Veterinary Medical Sciences, and thoroughly competent in Comparative Medicine, relating to contagious diseases common to man and animals. He has just returned from Europe where he spent several months studying conta gious affections in various laboratories, including M. Pasteur's, in which he availed himself of the lessons of Dr. Perdrix, his assistant, and he studied, also, the various methods of cultivating small pox vaccine. His qualifications render him eminently fit for his position, and to admit to the operations of the laboratory none but perfectly healthy animals. 4. Dr. Woodson Moss, the assistant and co-laborer, is a physiologist, professor in the Medical Faculty,and a practicing physician of high and well deserved reputation. 5. The origin of our vaccine is from a recent sudden outbreak in Montpellier, and comes directly from the "Institut Vaccinal, Montpellier, France," established 1876. The legal certificates attached testify to its qualities and origin. (Useless to explain here what we all know, that vaccine is horsepox attenuated through the cattle system.) 6. The Board of Inspectors alone is a safe-guard to the public. The founding of the institution has been approved by the State Board of Health. undertaking, we will spare no means to produce a Understanding fully the responsibility of our vaccine free from any foreign germ, perfectly safe and good in every sense. THE MISSOURI STATE UNIVERSITY VACCINE AND EXPERIMENTAL LABORATORY.-This institute has been organized with the following staff of officers: General Superintendent, Prof. J. W. Sanborn, Dean of Agricultural College; Chief Operator of Laboratory, Dr. P. Paquin, Professor Comparative Medicine, State Inspector for Animal Contagious Diseases; Assistant, Dr. Woodson Moss, Professor Physiology, etc., Secretary Medical Faculty; Board of Inspectors, Members of the State Board of Health, and of the University Medical Faculty among whom are Dr. Laws, M.D., LL. D., Pres't., Dr. McAlester, A. M. M. D., Prof. Schweitzer, Ph. D. (Chemist). The following is a circular issued to the Physicians, State Boards of Health and the Public: The entire universe has become deeply interested in the doctrine of germs or microbes as a causation of contagious diseases, and it is certainly with much reason, since the latest discoveries of scientists have proven, beyond a doubt, that at least some of the most deadly and loath some maladies are from such a source. |