of evacuation of pulmonary abscesses by direct incision were given.

This very brief analysis of the results achieved by the French surgeons represents very fairly, we believe, the practice adopted at the present time by leading surgeons the world over, and shows the limitations as well as the possibilities of pulmonary surgery. In a word, we are now able to arrest certain forms of pulmonary hemorrhage, to evacuate septic pleural contents, to remove foreign bodies, and to drain abscesses occurring within the substance of the lungs, in cases selected with great care, and it is questionable whether the next few years are destined to show much further progress in this department of surgical endeavor.

THE AFTER-TREATMENT OF OPERATIVE CASES.

Of two surgeons possessing equal operative skill, the most successful one must, necessarily, be the one who best understands the management of his patients after the performance of the operation.

The chief dangers, apart from special dangers proper to individual surgical procedures, as has been well said by Sir Thornley Stoker, in an address published in the British Medical Journal, Dec. 7, 1895, are shock and exhaustion consequent on vomiting. Against shock the careful preparation of the patient before operation is of the greatest importance, in all cases in which we are not compelled to deal with a sudden emergency.

Sir Thornley insists upon a great and common error, to wit, the undue prolongation of operations. This, as he points out, is due to the facility afforded by the use of anæsthetics, and to the extreme care, conservatism and attention to detail begotten by the introduction of antiseptic methods.

Prolonged anæsthesia, more than any other circumstance, tends to the production of shock and of the exhaustion produced by subsequent vomiting, and, while the causes mentioned above will always produce slower operators than those of the generations that are now passing away, undue slowness in operating ought to be considered as a serious defect in the operative abilities of a surgeon.

The speaker stated that for the relief of shock he had learned to rely on three agents only: heat, alcohol, and morphine or opium. If the surface of the body can, by the use of hot applications, be brought to a wholesome warmth, the danger is generally overcome. To hot water-bottles and bags may be added rubefacient applications of mustard to the extremities, about the region of the solar plexus, or over the heart. This not only induces heat, but causes a physiological stimulation.

Failing there, we must resort to alcohol by therectum, not only because vomiting may exist, but because when shock is present the stomach has little or no power of assimilation.

If reaction fails to occur, we must resort to opium or morphine. The latter acts more rapidly, and best controls vomiting, but if this is not a feature, opium will be found to possess the most stimulating effect. It is tolerated in rather large amounts by people whohave lost much blood, and must be given watchfully. One dose must follow another until the desired effect is produced.

For the relief of post-operative thirst, Sir Thornley Stoker does not believe in ice. Frequent rinsing of the mouth with hot water is preferable, with occasional enemata of two or three ounces of warm water.

We can, in the light of our present knowledge, but agree with this distinguished surgeon as to the great value of the measures advocated by him, yet we feel compelled to believe that there are other medicinal agents than opium and morphine that are possessed of great usefulness in the treatment of shock, among which may be mentioned strychnine and nitro-glycerine. When shock has been preceded by much loss of blood, we must also remember the high value of copious saline enemata, given as hot as the rectum can stand them, and of venous transfusion of saline solutions.

SURGICAL HINTS.

When a wound, either accidental or operative,. shows signs of infection, never wait for suppuration. Immediate incision, thorough disinfection, and drainage, if necessary, relieve pain, shorten the duration, and prevent extension of the inflammatory process.

In draining a suppurating wound, never cork it up by packing gauze in it. The smallest strip that will reach the bottom of the cavity, very loosely applied, is the best.

Constitutional treatment is all-important in all forms of diffuse surgical inflammations.

Recurrence of carbuncles and boils suggests an examination of the urine for diabetes.

See that patients have a good night's sleep the night before an operation.

Skin grafting will not succeed upon an unhealthy surface.

Watch patients with burns of the pharynx and larynx; be ready to operate at once. Severe dyspnoea may occur with appalling suddenness. If the patient is getting cold and feeble, his ability to feel pain has greatly disappeared. Waste no time in anesthesia in emergency tracheotomies.

Remember that the skins of young children and delicate women may be blistered by 1 to 1,000 solutions of bichloride of mercury, and that 1 to 40 solutions of carbolic acid have produced gangrene of fingers and toes, when used in wet dressings.

When first attending a case of urinary retention due to prostatic enlargement, it is a very common mistake to endeavor to empty the bladder with very small catheters, and this very often fails. A large catheter will frequently pass much more easily, and should always be tried first.

In cases of severe orchitis, acupuncture generally gives great relief. Use a strictly clean, long needle, with a cutting point. This must rapidly be thrust two or three times through the substance of the swollen testicle. The procedure gives, when skilfully done, much less pain than might be imagined.

In local inflammations of a septic character, the external application of iodine is worse than useless.

In hydrocele, the tenseness of the sac, and not its size, is the indication for operation. Never introduce the trocar obliquely, but perpendicularly to the surface.

An ice-bag left all night upon an inflamed surface has been known to produce extensive sloughing of the parts. The skin under an ice-bag should be frequently inspected.

The tissues of the ear are possessed of a great degree of vitality. If a portion of the ear has been so cut as to hang by nothing but a mere shred, it is always worth while to stitch it in position again, suturing cartilage to cartilage and skin to skin, separately, whenever possible.

Tincture of arnica, except for the alcohol it contains, is believed to possess absolutely no value as an external application. It sometimes produces an amazing degree of cutaneous irritation and inflammation, sometimes even assuming an erysipelatoid character.

Never give a good prognosis in the case of very extensive burns in children, however well they may appear a few hours, or even a day or two after the receipt of the injury. Sepsis usually followed by pneumonia and shock often develops late, and the mortality is very great.

During the late war Japanese surgeons are said to have employed as a dressing for wounds, the ash of rice straw. This was freely applied after the wound. had been cleansed, and sublimate gauze or linen was then superposed and held in position. The ash is said to act as a perfect antiseptic, its properties in that respect being attributed to the presence of potassium carbonate, and it is certainly the cheapest dressing on record.-Pharm. Jour.

Surgical Memoranda.

Indications for Surgical Treatment in Laryngeal Tuberculosis.-Dr. L. Rethi operates in laryngeal tuberculosis if the pulmonary process is not extensive, and especially if it has remained stationary for several months; also in cases where the laryngeal disease is more or less localized, or there are present circumscribed infiltrations, small ulcers, tumor-like excrescences, granulation-stenosis. In other words, an operation is indicated when there is prospect of relieving the patient, or serious laryngeal symptoms exist, such as dyspnoea, dysphagia. On the other hand, he refrains from surgical interference in the presence of advanced or rapidly progressive pulmonary lesions, unaccompanied by dangerous laryngeal symptoms, or in the presence of fever, or when the tubercular process in the larynx is extending into the deeper layers, and, at the same time, spreading along the surface, or if extensive infiltrations and ulcers exist.- Wien. Klin. Wochenschr., No. 42, 1895.

Treatment of Fissure of the Anus.-Dr. J. Cheron recommends the following procedure. After the situation of the fissure has been determined, he applies a small cotton tampon, saturated with a five. per cent. solution of cocaine, increased to ten per cent, if great sensitiveness exists. After five minutes the anesthesia is complete, and now the fissure is cauterized with pure ichthyol, one or two drops being applied to it by means of a glass rod; this procedure is repeated after several days. On the fourth or fifth day after the application of the cocainized cotton, the anus can be readily dilated and the fissure examined and cauterized over its entire extent. As cicatrization proceeds, dilatation is carried out more and more readily, and in this manner it is possible to gradually remove the sphincteric contraction which so often complicates chronic fissures. By this procedure recent cases of fissure can be cured in about fifteen sittings; while in the chronic cases, with callous margin, a longer course of treatment is required, rarely, however, necessitating more than twenty sittings.-Rev. des malad. des femmes, No. 5, 1895.

Operations on the Vertebral Column.-Dr. R. Jasinski (Congress of Polish Surgeons) states that these operations are not difficult under employment of proper instruments. After opening into the verte bral canal, the surgeon must proceed very cautiously, as ecchymoses and conditions of irritation of the spinal cord are readily set up. A sufficient resection of the vertebræ and an accurate examination of the cord is necessary. The author observes in general the

rules laid down by Chipault. He has performed this operation five times in diseases of the cord, resulting from kyphosis tuberculosa, in order to remove severe types of paralysis which are quite common in this affection. It is his custom to excise the supra-spinous ligament, together with the spinous processes; the vertebral arches are exsected by means of a small trephine and a Lannelongue's forceps. In one of his cases a paraplegia had existed for several months; in the other cases the paresis or paraplegia had been present several months to a year. In two cases attended with complete paralysis of the lower extremities, the result was excellent and the children were able to walk well after operation; in the three others the operation was unsuccessful. In the dis. cussion, Prof. Obalinski related a case in which he had laid bare an abscess situated in the body of the vertebræ from the side and effected considerable improvement. Other surgeons who participated in the discussion expressed themselves as less hopeful, and had derived less favorable results from operation.Wien. Klin. Wochenschr., No. 43, 1895.

A New Symptom of Intestinal Perforation. Prof. L. A. Gluzinski (Congress of Polish Surgeons) calls attention to a new symptom observed by him in cases of perforation of the gut with escape of contents into the abdominal cavity; namely, that if tympanitis be present, on ausculating the abdomen the respiratory and cardiac sounds become audible. In two cases of intestinal perforation, he observed at first an acceleration, followed after a few hours, by a slowing of the pulse. This phenomenon, in his opinion, stands in an etiological relationship with the escape of intestinal contents into the peritoneal cavity, and precedes the development of septic peritonitis. He believes that gases resulting from decomposition, which are liberated in the abdominal cavity, exert a retarding influence upon the pulse, and that when this retardation occurs, no time should be lost in resorting to operative interference in order to save the life of the patient.-Wien. Klin. Wochenschr., No. 43, 1895.

Apolysin.-Under this name has been recently brought forward an antipyretic and analgesic, which possesses the great advantages of being quite soluble and rapidly absorbed, and of exerting its action without toxic effects, even when administered in large quantities. Experiments made by Drs. Seifert and Hildebrand have demonstrated its innocuousness, while it is claimed by them that citrophen, which is

While we were in St. Louis recently, we called upon the secretary of the Lambert Pharmacal Company, and in reply to our inquiry as to what they were doing to discourage substitution among the retail druggists, he said: "Yes, we are still fighting substitution; perhaps not quite so actively as we should, but we are doing more or less work all the time to prevent imposition and to protect the consumer of Listerine, The cause?' We believe that the retail druggist has in some cases been instigated to commit pharmaceutical forgery by the representations of certain manufacturing pharmacists, that an antiseptic preparation of their own make could be used as a substitute for Listerine without detection. The drug press, though, is largely responsible for the prevailing rascality by reason of publishing so-called formulæ of proprietary articles, and by suggestion, encouraging the pharmacist to adopt substitution as a means of enriching himself at the expense of the acquired reputation of valuable proprietaries, and the druggist, finding such transactions temporarily profitable, is very sure not to neglect to keep paid up his subscription to the drug journal giving to him information of this character. Right, however, always triumphs in the long run, and we are not at all surprised to note, that of late, the National Druggist and other important drug journals, have taken a positive stand against such dishonest education, and, as a result, substitution has markedly decreased amongst their subscribers. Much substitution being done in St. Louis?' No, I am sure there are fewer dishonest pharmacists in St. Louis today than in any other city of half its population. There is scarcely a druggist of any prominence in this city who would sell anything but genuine Listerine upon call or prescription; for whilst we have not made a systematic canvass of the city for some time, we are constantly doing some work of inquiry, and thus keep pretty well informed; in the large cities of the East, however, substitution is more prevalent than with us, and we have some important work to do there in the near future."

Operations for cleft palate should be performed by preference in the spring and summer, as the light is good, there are no fogs or cold east winds, and no catarrhs or cough, and, moreover, the children can be kept out in the fresh air from the moment that they have recovered from the shock of the operation.— Owen.

Monthly Index of Surgery and Gynecology.

Abdominal Surgery, Clinical Experience in (Bost. Med.
and Surg. Jour., Nov. 14, 21, 28, Dec. 5, 12, '95)
J. C. Warren.
Anastomosis-button, Report of 111 Additional Cases oper-
ated upon with the (Med. News, Nov. 16, '95). J. B.
Murphy.
Aneurisms of the Third Portion of the Subclavian Artery,
Operative Treatment of (Annals of Surgery, Nov., '95).
E. Souchon.
Appendicitis Seventeen Cases of Chronic (Relapsing),
treated by operation (Virg. Med. Monthly, Dec., '95).
Hunter McGuire.

Appendicitis, Some Salient Points in the Diagnosis and

Treatment of (Med. News, Dec. 21, '95). J. B. Deaver. Appendicitis, Symptoms and Treatment of Various Types

of (Med. and Surg. Reporter, Dec. 7, '95). T. H. Manley. Appendix and Cæcum in 128 Adult Post Mortems, with a New Theory as to the Cause of Appendicitis (Med. Rec., Nov. 30, '95). B. Robinson.

Arterial Wounds, Suture of (Centralbl. f. Chirurg., Dec. 7, '95) Heidenhain.

Bladder, Intra-peritoneal Rupture of the (Annals of Surgery, Dec., '95). Briddon.

Brain Surgery for Epilepsy (Cincinnati Lancet-Clinic, Nov. 9, '95). B. Merrill Ricketts.

Cancer, Incipient, of the Vocal Cord, Thyrotomy for (Med. Press, Nov. 20, 5). R. H. Woods. Catheterization of the Ureters in the Male (Jour. Cut. and Genito-Urin. Dis., Dec., '95). A. B. Gaither.

Chloroform vs. Ether for Surgical Anæsthesia. A Limited Compilation of the Views of Twenty-three Leading American Surgeons of To-day (Chicago Clinical Review, Nov., 9, '95).

Cholecystotomy, Temporary (Arch. Prov. de Chirurg, Nov. 11, '95). Delagéniere.

Cowper's Glands, The Treatment of Chronic Inflammation of (Wien. Med. Woch., Dec. 5, '95). Englisch. Curette, Some Difficulties in the Use of (Annals of Gynecol., Nov., '95). F. Barnes.

Ear, Surgery of the (Deut. Med. Woch., Nos 45, 46, 47, '95). Grünwald.

Ectopic Gestation, Notes on (Am. Med. Surg. Bul., Nov. 15, '95). E. H. Grandin.

Epilepsy and Allied Conditions, Craniotomy for (Americ. Journ. of the Med. Sciences, Dec., '95). R. J. Hall. Epispadias, Operative Treatment of, by Transplantation of the Ureters (Annals of Surgery, Dec., '95.) F. V. Cantwell.

Ether, The Influence of, upon the Kidneys (N. Y. Med.
Jour., Nov. 16, '95). Weir.

Fracture of the Greater Tuberosity of the Humerus (Buf.
Med. and Surg. Jour., Dec., '95). A. L. Hall
Fracture of the Patella, Operative Treatment of (Annals
of Surgery, Dec., '95) E. M. Cox.
Fibroids of the Broad Ligaments, Extirpation of (An. de
Gynecol., Nov., '95). Vautrin.

Gastric Ulcer, A Case of Perforated; Operation; Death on
the Second Day (Lancet, Nov. 30, '95). E. W. Selby.
Genu Valgum, Anatomy and Treatment of (Berl. Klin.
Woch., Dec. 2, '95). Geissler.

Gonorrhoeal Tubal Disease, The Palliative Treatment of (Med. Record, Dec. 14, '95). W. R. Pryor. Gunshot Wound of the Liver; Laparotomy; Recovery (Amer. Pract. and News, Nov. 30, '95). J A. Lewis. Hemorrhoids, Cycling and (Toledo Med. and Surg. Reporter, Dec., '95). J. A. Duncan.

Hernia, Report of 125 Cases of, in which the Radical Operation was Performed (Atlantic Med. Week., Dec. 7, 95). E. Laplace.

Hip-Joint Luxation, Congenital, Operative Treatment of (Berl. Klin. Woch., Nov. 11, 18, '95). Leser.

Hot Water, The Systematic Employment of (Med. Press, Nov. 27, '95). P. Reclus.

Hysterectomy, Supra-Vaginal, Treatment of the Stump in (Centralbl. f. Gynaek., Dec. 7, '95). Runge.

Hysterectomy, The Prevailing Indications for (Univ. Med. Mag., Dec., '95). R. C. Norris.

Hysterectomy, Total, Abdominal (An. de Gynecol., Nov., '95). Richelot.

Hysterectomy, Total, Abdominal, by Ligatures (An. de Gynecol., Nov., '95). Le Bec,

Hysterectomy, Vaginal, for Large Fibromata (An. de Gynecol., Nov., '95). Segond.

Infiltration Anæsthesia, The Value of (Med. News, Nov. 16, '95). Weller Van Hook.

Intestinal Anastomosis, The Technics of Maunsell's Method of (N. Y. Med. Jour., Dec. 14, '95). F. H. Wiggin. Intestinal Invagination, Treatment of (Deut. Ztschr. f. Chirurg., Oct. 25, '95). Rydigier.

Intestinal Occlusions after Laparotomies (Gaz. des Hop., Nov. 23, '95). Legueu.

Laparotomy, Exporatory (Deut. Med. Woch., Dec. 5, '95). Tilmann.

Location and Removal of Missiles from the Cranial Cavity (Annals of Surgery, Nov., '95). G. R. Fowler. Lung, New Method of Surgical Exploration of the (Mercredi Med., Nov. 20, '95). Tuffier.

Malignant Tumors, The Treatment of, by the Toxins of the Streptococcus Erysipelatis (Brit. Med. Jour., Dec. 7, '95). J. Swain.

Mastitis, Puerperal, Preventive Treatment of (Brooklyn Med. Jour., Dec., '95). C. Jewett.

Murphy's Button, The Application of, in Intestinal Resection (Wien. Klin. Woch., Oct. 31, Nov. 7, '95). Brenner. Myoma Operations, Disposal of the Stump in (Centralbl. f. Gynaek., Nov. 2, '95). Hofmeier.

Nephrectomy for Cystic Adenoma in a Pregnant Woman

(Amer. Jour. Med. Sciences, Dec., '95). C. L. Scudder. Osteitis, Infective and Tuberculous, as Causes of Arthritis in Childhood and the Importance of Early Treatment (Brit. Med. Jour., Dec. 7, '95). Macnamara. Ovariotomy, Bilateral, in Pregnant Women (Münch. Med. Woch., Nov. 26, '95) Mainzer.

Pericranial Lipomata (Méd. Moderne, Dec. 7,'95). Chipault. '95). G. Foy.

Pleura and Lung, Direct Exploration of the (Mercredi Méd., Nov. 27, '95). Bazy.

Prostate Gland, Surgery of the (Virg. Med. Monthly, Dec., Prostate, Hypertrophied, Recent Experiences in the Surgery of (Med. News, Dec. 7, '95). J. W. White. Pseudarthrosis, Simplified Osteoplastic Operation for (Centralbl. f. Chirurg., Nov 16, '95). Müller. Puerperal Sepsis, When Shall Hysterectomy be Performed in (Jour. Amer. Med. Assoc., Nov. 23, '95). B. Holmes. Pyosalpingitis, Treatment of (Gaz. de Gynécol., Dec., '95). Vulliet.

Rectum, Lacerations of the, in Abdominal Operations for Pyosalpinx (Centralb. f. Gynæk., Nov. 23, '95). Sänger. Removal of the Upper Extremity together with the Scap

ula and Clavicle (Annals of Surgery, Dec. '95). A J. Ochsner.

Renal Calculus in Women, Diagnosis of (Med. News, Nov. 30. '95). H. A, Kelly.

Renal Traumatisms (Arch. f. Klin. Chirurg., Bd. 51, Hft. 2, '95). Güterbock.

Skin Grafting, A New and Original Method of Obtaining Material for (Med. Rec., Dec. 7, '95). Z. J. Lusk. Suppurative Joint, Lesions of Scarlet Fever (Lancet, Nov. 16, '95). G. B. Smith.

Thumb, Injuries of the (Dublin Jour. Med. Sc., Dec. 2, '95). E. H. Bennett.

Transplantation, A New Method of (Deut. Med. Woch., Nov. 28, '95). Mangoldt.

Urethritis, Retention of Urine during (Yale Med. Jour., Dec., '95). J. W. S. Gouley.

Urinary Analysis, Importance of, in Gynecological Cases (Univ. Med. Mag., Dec., '95). H. C. Bloom.

Urine, The Importance of Careful Examinations of the, before Surgical Operations (Chicago Med. Recorder, Dec., '95). A. R. Elliott.

Vesico-Vaginal Fistulæ, Treatment of, by Intra-Vesical Suture (Bul. de l'Acad. de Méd., Nov. 19, '95). Duplay.

Vol. IX.

Original Articles.

ENDOMETRITIS.*

By JAMES T. JELKS, M.D., Hot Springs, Ark. Professor of Gynecology and Syphilology in Barnes' Medical College, St. Louis, Mo.; formerly Professor of Genito-Urinary Surgery and Venereal Diseases in College of Physicians and Surgeons, of Chicago, Ill,; Ex-President of Arkansas Medical Society; Member of Mississippi Valley Medical Society, American Association of Obstetricians and Gynecologists, and the Southern Gynæcological and Surgical Association.

The mucous membrane of the body may be called a lymph gland or lymphatic surface. This lymph surface communicates freely with the lymph spaces which surround the bundles of muscular tissue of the uterus, all these combining into large lymph vessels which run along the side of the uterus and in the folds of the broad ligament.

The mucous membrane is dotted all over with utricular glands, which dip down between the bundles of muscular fibres and are lined with one layer of cylindrical epithelium.

Inflammation of this membrane means infection with some one of the pathogenic micro-organisms, just as inflammation elsewhere means infection.

We do not believe in such a thing as simple or catarrhal inflammation disassociated from some pathogenic organisms. It is true that exposure to cold may be the exciting cause, by creating a "locus minoris resistentiæ," and thus produces an infection atrium through which the ever present pathogenic microbe may enter. This being true, we may readily divide inflammation of the uterus into septic and specific. The septic form is produced by: 1, the streptococcus, 2, staphylococcus, 3, bacillus tuberculosis, bacillus coli communis; the specific form by the gonococcus of Neisser.

* Read (by title) before the Southern Surgical and Gynecological Society, Washington, D. C., September, 1895.

No. 2.

Bearing in mind the experiments of Kuster, Winter, Doderlein and La Place, which demonstrate that the vagina is the home of fourteen varieties of microorganisms, six of which are pathogenic, we may readily understand the ease with which infection of the uterine mucous membrane takes place.

Infection with the streptococci of Fehleisen or Rosenbach is practically confined to the puerperal period, either before or at term, and is always acute in its character and results. Of this variety we do not propose to speak, but rather to confine ourselves to the chronic form which is produced by the other varieties of pathogenic germs.

From the post mortem examinations at the Johns' Hopkins University, as reported by Whitridge Williams, we have a demonstration that about ten or twelve per cent. of the cases of inflammation of the uterus and tubes are produced by the bacillus of tuberculosis. The bacillus coli communis but seldom causes this trouble, though it has been occasionally found. This gives us about eighty-five or ninety per cent, of the cases produced by the staphylococcus and the gonococcus. From my observation probably thirtyfive per cent. are produced by the gonococcus, and the remainder by the grape coccus.

These latter being always in the vagina may readily gain access to the uterus in a variety of ways. During the puerperal period, by reason of the presence of the lochial discharge and the fact that these patients are lying down, and that the vagina is filled with the debris, we may very readily understand why infection of the uterine mucosa takes place. Add to this the fact that many physicians do not realize the importance of attending every lying-in woman in the light of a wounded patient, and that they may infect this decomposing lochia with their soiled fingers, we may be surprised that infection does not occur more often than it does.

Aside from the puerperal state, the physician, whether aseptic or not, may carry infection into the uterus by means of the instruments during an examination. He may even sterilize his instruments, and, if he fails to cleanse the vagina and cervical canal, he