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advantage later in life, but it trains the minds in studies which are, so to speak, external in their kind. As physicians, we cannot too too strongly discourage the taking of young children to the theatres, where not only the late hours and bad air are injurious, but the impressions produced by the plays must be pernicious to an extreme. One cannot go to the theatre now without seeing children of all ages looking on at every variety of performance, from the most decolleté spectacular ballet to a melodrama of the highest inten sity.

If a child has already begun to have attacks of migraine, nothing is of more value than attention to the general health. Such children are often pale and thin, and have but little appetite. If change of air can be secured, it is often enough to obtain relief from the attacks. If we cannot send the patient away, we must resort to tonics and good feeding. Cod liver oil, if it can be borne by the stomach, is of the greatest possible use in such cases. If the child cannot take oil, we must introduce fat into the system in some other way. Cream and plenty of butter may be given. Devonshire clotted cream, which is now to be obtained at the Alderney dairies, is relished very much by children.

Special anti-neuralgic drugs are seldom indicated in these cases, but sometimes the bromides may be given with great advantage, especially in those children who are of a very nervous temperament, and in whom any effort at brain-work causes headache. It should be given in small doses, and continuously for some weeks.

In many cases some ocular defect will be found which will require correction by glasses, and many cases of migraine in children have been cured by this means alone. In all cases of migraine we should look carefully into the condition of the teeth, and have any unsound ones filled or removed."

[These cases come under the observation of every practitioner who has much to do with children, and, as Dr. Sinkler remarks, they can generally be traced to heredity, or parents of a highly nervous organization. The chil

dren are frequently precocious, and it will be generally found that they are stimulated in their smartness by the foolish vanity of their parents.

They are rapidly developing hot-house productions of rich soil that soon exhausts itself unless there be timely interference. They need to have the principal treatment applied to the parental tree. Suppress the vanity and stimulate the common sense in that quarter, and the child will then no longer be mentally "crammed" and physically starved, but will receive plenty of fresh air, sunshine, good wholesome food, physical and mental exercise, but little or no schooling, and probably no physic, or at least, very little.]

ORIGINAL ARTICLES.

RECENT ADVANCES IN GERMAN OBSTETRICS AND GYNECOLOGY.

BY E. S. M'KEE, M. D., CINCINNATI.

It has always been a matter of the greatest importance to diagnose early carcinoma cervicis uteri. It has gained in meaning recently, since the operative treatment of cancer of the uterus has rendered its cure possible, provided the case be recognized at a sufficiently early stage. The known symptoms are numerous, yet the difficulty will always exist of diagnosing beginning cancer from erosion. Stratz has thoroughly studied this subject and gives four important points:

1. The diseased surface is every where sharply separated from the sound tissue; it never gradually changes from one to the other.

2. A difference between the level of the diseased and healthy parts is always discernible.

3. The cancerous portions invariably have a yellowish tint.

4. The malignant parts show small yellowish-white glistening raised points, at least in certain places.

Among many German obstetricians abso

lute non-interference is the rule in the third stage of labor.

women suffering from anemia, phthisis, gen. eral cachexia, or diseases of the kidney and digestive organs; also those having extensive wounds of the vulva, or taking mercurial preparations. It is found that vaginal or in

The teachings of Credé are tending toward the entire letting alone of the genitals during labor and the days succeeding it. This distinguished obstetrician, unless some abnormal-tra-uterine irrigation is frequently followed

ity presents, does not make a vaginal examination at all. His diagnosis is entirely made by external palpation and manipulation. Unless there are positive indications therefor, he teaches that for eight or nine days after labor one should neither examine, wash out nor do anything to the genitals.

In the excessive vomiting of pregnancy Credé recommends the administration every five minutes, of teaspoonful doses of nourish ment, preferably iced milk, the patient lying absolutely quiet and taking it through a glass tube. Chazan has reported an interesting case of this complaint in which no abnormality could be discovered about the patient. She was inconsolable, however, at the idea of being pregnant. She was put under ether and made to believe that the fetus had been removed. The vomiting ceased from that time. This case has lead Chazan to believe that perhaps in most cases hyperemesis gravidorum was due to some affection of the nervous tem or of the mind, and not to some abnormality of the genital organs as some authors believe.

by absorption of the injected liquid, espe cially if its escape be in any way impeded. When this occurs mercury can be quickly detected in the feces.

The solution 1-1,000 is only injected into the uterus in severe cases, as tympanites of the uterus, putrefaction of the fetus in the uterine cavity, or septic puerperal fever. Not more than one minute's time is allowed for the injection which is followed by copious injections of distilled water. In cases where there has been an expulsion of a macerated fetus, a solution of 41,000 is used. This is also done in the endometritis consecutive to the expulsion of the fetus in premature delivery. This solution is of service in puerperal endometritis accompanied by fetid vaginal dis charge and should be followed by copious injections of water. For the disinfection of instruments carbolic acid is in general use. Angerer of Munich has claimed that the subsys-limate solution may be rendered permanent in ordinary distilled water by adding to the water as much by weight of common salt as there is present corrosive sublimate. The following are the rules for the physicians who wish to visit the laparotomies which are per formed at Olshausen's clinic: 1. On the day of the operation, not to come in contact with infectious material of any kind. 2. To come to the operation freshly bathed and in clothes which have not been worn in the sick-room. 3. To touch no sponges, instruments or any thing which is used in the operation. 4. To be there promptly at the appointed hour, as at the beginning of the operation the doors are closed. Such were the rules of Schroeder and are now carried out by Olshausen and Martin. Gusserow is not quite so strict with his visitors.

Hypnotism or syggignoscism, as a means of doing away with the pains of labor, intro duced by Pritzel, of Vienna, seems to be gaining some followers among those who possess the required power.

The question of antiseptics may be fairly stated as follows: It is the practice of the majority to disinfect the hands with a 1-1,000 solution of corrosive sublimate. External genitals, 1-2,000; vagina or uterine cavity 1-4,000. The vagina and particularly uterine cavity are washed out only on the strongest indications either just after birth or during confinement to bed. The amount used to irrigate these cavities is about two litres. In uterine post-partum hemorrhage from atony, a solution of 1-3,000 is used. The sublimate solution is considered as contra-indicated in

The question is often asked how soon after coming in contact with septic material is the physician justified in attending a case of la

bor. The reply in Vienna, is, as soon as you have time to change your clothes and go through a thorough washing with antiseptic solutions of a reliable character. In the clinic, Carl Braun's, in the Allegemeine Krankenhaus in Vienna, the assistant has charge of the wards, and conducts personally all complicated cases. At the same time he is constantly giving instruction on the cadaver to the students and practitioners taking operative courses. He is often summoned from the operating table in the pathological building to make a forceps delivery. He would proceed to a most careful washing of the hands and arms, not only washing but scrubbing them and doing it thoroughly, then dips them into a solution of permanganate of potassium, then into a solution of muriatic acid. In the second clinic the hands are cleansed by a powder consisting of ground kernels and shells of bitter almonds. This seems to possess great cleansing and absorptive properties.

The application of a a four per cent. solu tion of cocaine to the upper part of the vagina and cervix during dilatation and the ostium vaginæ and perineum during the expulsive effort is followed by good results, some. times preventing pain for twenty minutes.

The application of axis traction forceps, according to Carl Braun, would result in the bringing of children through deformed pelves in many instances, where, in the absence of these forceps, craniotomy would be necessary. He frequently uses the Simpson forceps mod. ified by himself, which he terms tri-form forceps. Thus modified he considers it can be used in the high or low operation, and indeed every possible occasion in which an instrument is indicated.

A subject which has received much merited attention of late from the Germans is vaginal total extirpation of the uterus. Sufficient material has been collected during the past ten years to decide whether this is a practicable operation, and whether it gives permanent and favorable results, which lead us to consider it superior to any treatment of the cancerous uterus up to the present time. Vaginal extirpation has obtained decided recognition

in Germany, and the purely vaginal operation of Czerny, Billroth and Schroeder has succeeded the procedure of Freund which was a combination of the vaginal and abdominal methods. In 1881 Olshausen collected 41 cases with 29 per cent mortality. In 1883, Saenger, 133 cases, with 28 per cent.mortality. In 1884 Engstrom, 157 cases, with 29 per cent mortality. A. Martin, up to the close of 1886, had collected 311 cases with 47 deaths, or 16.1 per cent. Thus we see that with increased experience the mortality is decreasing. The operation now shows better results as to immediate mortality than removal of the breast for cancer.

He

Dr. Martin who has attained a wonderful skill may be described in operating, as follows: The bowels are thoroughly emptied, the vagina disinfected by an antiseptic irrigation, the patient placed in position on her back and hips and put under chloroform. The vault of the vagina is exposed by means of a speculum and side pieces; the cervix seized by bullet forceps on its posterior border and drawn forward as far as possible toward the symphysis pubis. This stretches the posterior arch of the vagina; the insertion of the vagina can be very nicely determined. then makes an incision along the whole length of the insertion to get into Douglas' cul-de-sac as quickly as possible. This he frequently attains at the first cut; this accomplished, he enlarges the cut so that the forefinger of the left hand can enter, and then with a small needle, very much curved, he sews around the entire border of the cut in the vagina. He generally uses four or five of these sutures which unite the peritoneum of Douglas' culde-sac to the vaginal wall, and all hemorrhage at this point is stopped. He next sews up the stump of the broad ligament, using large needles with double threads. These threads must also unite the peritoneum with the va ginal wall. Generally, he uses three of these on each side, by means of which he firmly unites the floor of the pelvis and the vagina as far as the anterior border of the cervix, thus more securely controlling the vessels which pass through before they are cut.

To sepa

rate the floor of the pelvis as far as its anterior border from the cervix, the knife is thrust directly forward along the cervix on both sides; this lies entirely free, that, is as high as the fundus. After all hemorrhage has been stopped, he cuts around the anterior periphery, at the same time drawing the uterus forcibly backward, and putting the anterior vaginal wall on the stretch. Having cut through the vaginal wall, he separates the bladder with his finger nails so far as he can discover any attachment. This is found to vary from one to five centimeters, and even more, in thickness, and it is sometimes necessary to use the knife in order to separate the firmest bands of union. The suture of the vaginal wall to the surface which has been separated must be made here as exactly as possible. Here four sutures are usually sufficient to stop the hemorrhage, and restore the continuity of the vaginal wall. When the hemorrhage has entirely ceased he once more grasps the posterior portion of the uterus which has been separated, and having determined the size and mobility of the uterus, seizes the posterior lip with a Muzeaux' forceps in order to draw it forcibly forward. A Sims' speculum or a side holder placed in Douglas cul-de-sac protects the fundus as it is drawn down, from catching on the posterior border of the wound. By making successively fresh grasps with the Muzeaux forceps, the posterior wall of the cervix and the fundus are guided into the opening. If

us.

Excessive hemorrhage often accompanies the further detachment of the uterus while in this inverted condition, and renders it very diffi cult. He isolates the insertion of the broad ligaments to the organ, displays the tubes and that portion of the broad ligament lying near them, in order that he may tie it in one, two or three segments, which is accomplished on both sides before he cuts away the uterus itself. There still remains a thick mass of tissue to be separated at the sides of the lower segment of the fundus. The separation of the uterus from the bladder is easily accomplished if one always works close to the uterMartin prefers to sew the peritoneum and vagina together before completing the separation, thereby not allowing the perito neum to slip beyond control. After complet ing the left side the separation of the broad ligament stump is attained. Here the control of the hemorrhage and the fixation of the stump is also secured by sutures before the uterus is completely freed. The loops of intestine seldom come down in sight or to the seat of the intestine. If they do come in the way, protect by laying a sponge over them. The ovaries and tubes often come down into the wound, especially when they are much enlarged. In such cases they can be ligated and cut away with little difficulty. Thus far a continuous stream of a weak solution of carbolic acid suffices to keep the wound cleansed. Recently it is his practice to use two or three small sponges to clean Douglas' cul-de sac. These are secured by long bullet forceps, and drawn over the edges of the wounds to make them more safe. He has not experienced excessive hemorrhage following extirpation of the uterus. He inserts a thick drainage tube which is held in place by a cross piece into Douglas' cul-de-sac. After ascertaining the condition of the bladder the operation is concluded. The duration of the operation varies from twenty minutes to two hours, according to the difficulties encountered. Sometimes the hemorrhage is exceed

the uterus is freely movable and not too large, this procedure is simple, otherwise, it is sometimes tedious. In some instances an advantage is gained by pushing the uterine cervix up behind the pubes. In other cases a blunt sound run up into the uterine cavity is quite an assistance. A disadvantage in using this instrument is that the posterior border of the uterus is often bored through by this instrument, and the contents of the uterus escape over the surfaces of the wound. As soon as the fundus of the uterus presents itself it easily follows through the opening if the at-ingly small, not exceeding 15 grammes. tachments have been well separated. In some is exceedingly great if the neighboring tissues cases the use of the knife is necessary here. are diseased, whether they are old cicatrices

It

from a former inflammation or one just commencing. For the prompt control of this hemorrhage a considerable experience in the use of the needle is necessary. If easily done, he recommends the removal of the tubes and ovaries. It is not the custom in Germany as in France, and to some extent in England, to use the clamping forceps to restrain the hemorrhage from the ligamenta lata. Martin says you can tell that the cancer is limited to an organ by its having a layer of entirely healthy tissue about it. Leopold thinks it is not always possible to tell whether the disease is limited to the organ The prognosis in the total extirpation of the uterus is now quite as good as the supravaginal operation and is rapidly supplanting it in Germany and also in other countries.

stances.

or not.

The conservative Cesarean Section of Saenger is a method, which is rapidly gaining ground. Favorable and constantly improving reports come from all parts of Germany, and the increasing success is very gratifying to those who confidently expect this operation to ultimately displace craniotomy in most inLeopold, whose statistics are as satisfactory probably, as those of any one, recommends complete closure of the abdominal cavity by the continued suture, after the protrusion of the uterus. He controls the hemorrhage after the cut into the uterus by the rubber tube or manual compression. He takes great care that the uterine cavity be entirely clear of decidua. The uterine sutures must be very exact in their coaptation. He stimulates contraction by manual massage of the sutured uterus. Prof. Gusserow, of Berlin, follows this plan when operating. He commences the incision three finger breadths below the umbilicus, and continues it 3 or 4 inches above the symphysis pubis. The abdomen is opened, the uterus presents, and the walls close behind it. The lower half of the uterus below the child's head is surrounded by a rubber tube, the size of a finger, which is held there. Sutures are passed through the abductor muscles to prevent the protrusion of the intestines, which will answer unless there is much vomiting. If the bowels protrude retain

them with warm cloths. The uterus is opened with an incision beginning near the fundus, and extending down to the inferior uterine segment to the place where the peritoneum is movable. If the placenta lies in the line of the incision, a large amount of dark blood will burst; forth cut through this, and the liquor amnii will gush out. Drawing on the rubber band surrounding the uterus will control any hemorrhage that may arise from the uterine incision. The child is then removed; the uterus generally remains relaxed during the rest of the operation. The placenta and membranes are removed from the uterus,and the cavity is strewn with iodoform. He takes about eight silver sutures to close the incision, these enclose muscles without decidua. About sixteen silk sutures are then applied which penetrate the peritoneum only. Resection of muscles is sometimes but not always necessary; it is not if the peritoneum extends some distance over the muscles. If hemorrhage is now present,stop it by ligating the spouting arteries. If the uterus still remains relaxed, cause it to retract by applying sponges soaked in hot sublimate solution. Powder the suture line with iodoform, replace the uterus in the abdominal cavity, and close this by suture. So far 50 cases of Saenger's operation have been reported with the follow ing results:

For the mother, recovery in 36 cases or 72 per cent; death in 14 cases or 28 per cent. Result for children. Born alive, 46 or 92 per cent; died, 4 or 8 per cent. Germany had 34 with 30 recoveries and 4 deaths; children, 32 living 5 dead. Austria 5 cases, with 2 recoveries and 3 deaths; children, 5 living and 0 deaths. United States, 6 cases 2 recoveries and 4 deaths; children, 4 living and 2 deaths. Italy, 3 cases, 2 recoveries and 1 death: children, 3 alive. Russia, 2 cases, no recoveries; children 2 living. France, 1 case, 1 recovery, 1 child alive.

It is easy to see that Germany is far in the lead. The best reports come from Leipsig and Dresden. Of the seven cases done in Leipsig, there were 7 recoveries of mothers and 7 living children of the 14 cases in Dres

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