will be found that the patients have suffered at one incision is avoided, as much as possible, adhesion of time or another from "major" rheumatic attacks. The the tendon sheath to the skin cicatrix. relationship, then, he continues, of these "minor" rheu matic affections is perhaps a good deal nearer that of ordinary rheumatism than is generally supposed, and affords an explanation of the good effects produced by the administration of salicylates.

Though lumbago is from many points of view but a trivial affection, it produces so much discomfort that any increase in our power of alleviating it deserves some consideration; and the distinctive diagnosis and treatment on the lines here marked out will, he thinks, be found satisfactory in practice.

After sutering, the wound was wiped out as dry as possible, thoroughly disinfected, and, in the majority of The most difficult part of the operation is the search cases the skin was sutured. The wound was never for the tendon ends. Here sharp hooks should not be drained. A gauze dressing was then applied and the used, as they may damage the tendon or sheath. When hand and wrist immobilized by a zinc splint and starch single tendons of the flexor communis digitorum are bandage. divided, a simple expedient (recommended by Filiget), viz., hyperextension of the adjoining finger, is very successful in causing the tendon end to appear in the wound. If this does not suffice, an incision is neces sary.

Phlegmonous inflammation ensued in eleven cases; four of these did not come under treatment till three or five days after the injury. In one case there was exWhen an incision is determined on, an enlarging of tensive laceration of the ball of the thumb; the ends the original wound is best. Starting from one angle of of the tendon were torn and had to be resected. In the original cross-wound, an incision was made parallel two cases the inflammation was mild, its only effect be and to one side of the injured tendon. Turning up ing to slightly limit function. In four cases the results this flap gave ample room to find the tendon. By this were bad: the tendon ends necrosed, and extensive ad

hesions followed. In two cases the bad result is to be function is always distroyed by adhesions. ascribed to the operation alone.

Even though union be destroyed by suppuration in wounds of the extensors over the hand and fingers, yet function may be in some measure restored by continuous fixation of the injured finger in an extended position. In two cases dry gangrene followed. In both these cases it was found necessary to considerably en large the original wound.

As a general rule, mechanical treatment should be be gun in the third week in injuries of the extensors; in flexor injuries, during the fourth or fifth week. Yet every case must be treated on its merits. The time of beginning must necessarily depend on the extent of the injury, the course of healing, the age and the intelligence of the patient. If movement is begun too soon, the weak union is stretched, leading to lengthening of the tendon and consequent interference with function, and small hemorrhages ensue, causing adhesions.

Massage of the forearm should commence after the first dressing, viz., in ten to fourteen days. The splint, which should reach to the elbow, is now removed and replaced by a shorter one, and the forearm is daily mas saged.

The patients are now supplied with elastic cords, one end of which can be fastened to a wall or table, while the free end is grasped by the patient's finger. In this way patients can treat themselves better and with less pain than by the surgeon's hand, and while at the same time they are stimulated to obtain a good result. Mean while vigorous massage is kept up, and later on the faradic current is applied.

Of the one hundred cases, thirty five were flexor in juries. Of the thirty five flexor injuries, sixteen cases (46 per cent) obtained a good functional result. In eleven cases function was restored to 1-2 to 3-4 Many of the cases could not be followed up. It is probable that the function in some of them improved greatly. In eight cases there was almost total loss of function, due mostly to phlegmonous inflamma tion. In some of them there were firm adhesion.

The prognosis differ greatly according to the situation of the injury. In the lower third of the arm there is almost always associated an extensive injury to the neighboring muscles, and consequent adhesions of the tendon cicatrix to the connective tissue. Atrophy of the muscle further intensifies the bad result. Massage must be begun very early.

The results obtained in this case of injuries were on the whole favorable.

Injuries over the wrist joint are to be dreaded, not only for the adhesions of the single tendons, but for the frequent serious complications due to the anatomical relations. The results obtained, however, in a few of these cases were excellent.

In seven

cases both flexors were divided over the first phalanx of one or more fingers, and with the exception of three cases, where the healing was disturbed by suppuration and gangrene, flexion in the first interphalangeal joint was restored (in two cases almost to the normal).

In three of the cases a certain degree of motion was restored also to the second interphalangeal joint. Prognosis in division of the flexor profundus over the last phalanx is absolutely bad.

The prognosis in injuries of the extensors is very favorable. The search for tendon ends is not difficult, and as the tendons do not glide in tubular sheaths like the flexors, the function is not so much affected by adhesions. Sixty five cases were treated. In fifty (77 per cent) a perfect result was obtained. The simultaneous opening of a joint occurred in 37 per cent of the cases, but this complication did not as a rule prevent subsequent healing and restoration of function.-Weller Van Hook, A. B, M. D., în Medicine.

NOTES: AND ITEMS

The British Medical Association.-Dr. William Osler, of Baltimore, will deliver the address on Medicine before the British Medical Association at the Montreal meeting in August next. Dr. Stephen Mac. kenzie will be Chairman of the Section on Medicine, Mr. Christopher Heath of the Section on Surgery, and Mr. Watson Cheyne of the Section on Pathology. Lord Lister has announced his attention to be present.

Sir Spencer Wells was an ardent advocate of cremation, and left directions that such disposition should be made of his own body, says the Med. Record. Ten years ago, when discussion on this mode of disposing of the dead was active and somewhat acrimonious in England, he wrote a letter to the Times, advocating cremation, not only from a sanitary point of view, but pointing out what an impetus its adoption would give to the arts. Cinerary urns, he contended, have in all countries where the practice is carried out been among the most beautiful features of the temples and other resting places of the departed.

Percussion of the Spine.-Bechterew points out the diagnostic value of percussion of the lower part of the spine. In the sacral region over the triangular area with its base at the upper level of the sacrum and its apex at the tip of the coccyx there is normally a slightly tympanitic note. In cases where there is some morbid change, as in a case where the cauda equina was compressed by a fungoid tumor, the percussion note was definitely altered. Localization of a lesion may thus In phalangeal injuries the prognosis is not good, be facilitated; in the case mentioned the localization though not so bad as Volmann claims, who says that was proved post-mortem to be correct.

In injuries over the metacarpus the prognosis is like

wise bad.

giance to the crown. The procession has not been excelled in this century in dramatic effect and wealth of color. The illustrations from photographs give glimpses

Post-Scarlatinal Palsies.-Alekssjeeff (Vratch; Brit. Med. Jour.) says that palsies are rare sequels of scarlatina; only 7 cases, which the author has collected and analyzed, have hitherto been recorded. To these he of its splendor. adds 2 cases of his own, and on the basis of these 9 cases he endeavors to frame a clinical picture of this form of paralysis. The affection appears either as an early or late manifestation. The former occurs almost at the very commencement of the scarlet fever, and is characterized by a great tendency to involve at the same time both the upper and lower extremities, and is some times followed by aphasia. The latter forms do not ap pear till the end of the third week of illness, and only one half of the body is affected. In such cases nephritis and endocarditis are usually met with. The prognosis of post scarlatinal palsies is good, complete recovery generally taking place. Tonics combined with the use of electricity and massage are useful in promoting re

covery.

The Prevention of Hereditary Diseases.

-A number of unmarried women of New York have

formed a society for the prevention of hereditary dis eases. They have registered a solemn vow not to marry any man whose family is tainted with consumption, in sanity, alcoholism, or other heritable diseases. This is a step in the right direction, says the British Medical Journal, and if the example of these wise virgins is widely followed by their sisters, and if eligible bache lors show an equally enlightened zeal for the healthful ness of posterity, they will have done something for the betterment of the race. But if it comes to a conflict betwen Cupid and Hygeia, the betting, we fear, will not be on the latter. Love, which laughs at locksmiths, will think little of snapping the frail link of a vow which has no sanction but the opinion of a small band of enthusiasts.

The Cosmopolitan for March contains, among many other good and interesting articles, a paper on "The Methods of Banking, by the President of one of the largest banks of New York, a man of widest busi. ness experience-former Postmaster-General James; the article is one which ever person, however humble his clerkship or high his position in the financial world, will find interesting and instructive. This series will con: stitute a very complete course of business training, and every young man just entering business life and every old man will alike find it of immense value.

Scribner's Magazine.-There is nothing that Richard Harding Davis describes with more skill than a gorgeous pageant, and "The Banderium of Hungary," which leads the March number, is one of the brighest exhibitions of his pictorial abllity. The celebration at Budapest, last June, of the thousandth year of the existence of Hungary as a Kingdom passed almost unnoticed, and this is the first magazine account of a unique spectacle. Eleven hundred nobles, richly clad in their traditional costumes and family jewels, passed before the king on a bright sunny day, and swore anew alle

PUBLISHER'S DEPARTMENT. Antibrule.-The introduction of Antibrule we regard as of inestimable value to the medical profession. Practitioners have for ages felt the necessity of a ra tional treatment of Burns and Scalds, and more especially an agent for immediate relief of the attendant pain, for which, until the advent of Antibrule, nothing has ever been found efficacious; Carron Oil and similar applications abate the acuteness of pain temporarily, but the unhappy effects invariably following such appli cations are so familiar that intelligent practitioners will be only too glad to discard such treatment in favor of the new remedy. Antibrule we have had occasion of late to use in several serious cases of Burns and Scalds and we can cheerfully recommend it, as being the only preparation for this purpose we have ever used, giving immediate relief for pain and healing the affected parts. Antibrule should be in general use, and we believe will, in fact, must be as soon as its merits are fully recog

Imperial Granum.-Every medical practitioner is acquainted with the indications for and great value of a palatable, pure and highly nutritious food. It is superfluous, therefore, to state in detail the conditions in which such an ideal food is applicable. Suffice it here to say, that as a food for infants and invalids and those stages of disease where food should be administered in the liquid form, Imperial Granum is of inesti. mable value. It is easily assimilated and according to the Dominion Medical Monthly (Toronto, Canada), "especially valuable in fevers, and often the only food the stomach will tolerate in gastric and enteric diseases." According to the London Lancet, it "contains no trace of any impurity." The Post Gaaduate journal of New York, says "it is adapted to children as well as adults-in fact, we have used it successfully with chil dren from birth.”

that "Imperial Granum, as prepared by The Imperial Granum Company at their laboratory in New Haven, Conn., is not a stimulant nor a chemical preparation; but a pure, unsweetened food, carefully prepared from pend in fevers, and in all gastrie and enteric diseases. the finest growth of wheat, on which physicians can de It has stood the test of many years and has not been displaced by any food yet introduced."

The Pharmaceutical Era of December 31, 1896, says

It will be of interest to the medical profession to learn that the Imperial Granum Company has with. drawn all advertisements from magazines and lay peri. odicals and restricts its advertisements exclusively to the medical press, a step which will undoubtedly still more increase the confidence which is manifested by the medical and pharmaceutical professions in this superior article.

MEDICAL REVIEW,

VOL. XXXV.

A WEEKLY JOURNAL OF MEDICINE AND SURGERY

ST. LOUIS, MO., MARCH 20, 1897.

ORIGINAL: ARTICLES

On Trachelorrhaphy, and Exhibition
New Instruments for Its
Performance.1

NO. 12.

properly repaired these diseases are prevented or cured together with many serious symptoms directly traceable to this injury.

ETIOLOGY.-Practically we may say that lacerations of the cervix are always the result of the passage of the product of conception through the external os. Even abortions are the direct cause in many cases. Labor intensified by the use of ergot and other oxytocics, exof ternal pressure or the application of instruments may be the cause. Without any of these means, however, the pains may be so strong and the resistance of the lower cervix so great that Nature alone, only overcomes this obstacle by tearing through it without waiting for its tardy dilatation. And it is but proper to point out the fact that as a rule the obstetrician does not cause the laceration and in no way contributes to it, unless by the unskillful means above indicated, and that in fact he is in no way responsible for it. I believe that all operators should thus protect the accoucheur from the unjust charges of both patients and unprincipled prac titioners.

BY W. O. HENRY, M D ОМАНА. NEB, Professor of Gynecology in John A. Creighton Medical College, and Gynecologist to St. Joseph's Hospital, Omaha, Neb. MEMBERS OF THE SOCIETY:-In complying with the courteous invitation of your Society to prepare a paper for this meeting, I thought something very practical and of interest to the general practitioner, as well as to the surgeon, most suitable, and therefore have chosen this old subject of lacerations of the cervix which every man in general practice often meets and should know how to recognize, what the real indications are for op. eration and what the best method of simple repair. Sir James Y. Simpson first called attention to this injury in 1951, but Dr. T. A. Emmet, after having operated upon these cases successfully for seven years, published his first paper in 1869, from which date the proper study and cure of these injuries may be said to take their origin.

DIAGNOSIS.-A lacerated cervix is, alas, too often treated as an erosion or ulceration of the os, by the ordinary medical man, but if he will remember that lacerations are unilateral, bilateral, or stellate, the lips turning more or less out exposing the cervical canal and that by hooking a tenaculum in the anterior lip and one in the posterior he can roll these surfaces in and by ap proximating the tenacula can obliterate the raw like surfaces and thus re-form the external os he can at once clear up the question and settle the diagnosis. This demonstration by the two tenacula is best made with Sim's speculum, but it can be made through a large bior tri-valve. As to the general symptoms caused by lacerations of the cervix they are intimately associated with the conditions which accompany or follow this injury, as subinvolution, endometritis, endocervicitis, hemorrhages, misplacements; there may be dyspareunia, nervousness, ovarian irritation, dysmenorrhea, constipation, flatulence, headache, backache, insomnia, leucorrhea.

Whilst it is true that possibly all women who give birth to a child have a laceration of the cervix in a greater or less degree and that it is due to this fact that while the virgin os is round that of her sister who has borne a child is a transverse slit; and whilst it is also true that most of these cases are repaired by Nature herself, and that many of those not so cured give rise to no symptoms, nor do they need repair. And whilst it is further true that many cases are unwisely and improperly subjected to operation, still it is a fact that subinvolutions, inflammations, hemorrhage, displace OPERATION.-Before describing the operation, I can ments and I believe prolapsed and cystic degeneration not refrain from again emphasizing the fact that not all of ovaries, and possibly cancer are caused directly or lacerations need operation. Many do not require it; indirectly by these deeper lacerations; and that when and this brings me to consider the real indications for repair of a lacerated cervix.

Read before the Missouri Valley Medical Society, Lincoln, Neb., March :8, 1897.

1.

All deep lacerations which allow the lips to roll widely out demand it as a prevention of cancer and

other serious disease. If it be true, as Greigg Smith or may by rupturing a pus sac into the pelvic cavity says in his recent most excellent work: "It is probable during the manipulations, be the immediate cause of that small cystic ovaries have their origin in chronic your patient's death, and thus become, instead of the inflammation,” then it is easy to see why cystic ovaries, harmless operation it usually is, a fatal one. The vulva chronic ovaritis, and prolapsed ovaries may result from a long standing and severe laceration of the cervix.

2. All lacerations deep enough to give rise to hemorrhages demand it.

and vagina are well scrubbed with soap, brush and hot water, and finally with 3% carbolic solution. With a valsellum forceps caught in the cervix the uterus is drawn down and held firmly while uterine sound is

3. All lacerations accompanied by great subinvolu- passed to exactly locate the body. The uterine dilator tion, especially at the cervix.

4. All lacerations which cause extreme nervousness as demonstrated by discovering a sensitive point in the angle of laceration by pressure with the point of a probe.

is now introduced and the canal slowly distended to the size of an inch or an inch and a quarter, when the sharp curette is used as may be indicated to remove granulations from the endometrium and from the cervi cal canal and the lips of the cervix. This all having

5. When abortions are frequent and traceable to no been thoroughly done the uterine cavity is well irri. other cause.

gated with carbolic solution. The anterior and posterior lips are now held each with a single valsellum by an assistant, while the anterior and posterior vaginal walls are held apart with the retractors by a second assistant. At this point in the operation different men proceed differently to attain the same end, namely, the thorough paring of the lips, enucleating the angle of

6. When it is the cause of any distressing symptoms not traceable to other cause capable of removal by sim pler means. It should be remembered by the obstetrician that some cases of post-partum hemorrhage are due to deep lacerations of the cervix in which the circular artery is torn and can only be controlled by securing it either with forceps or by ligature. The ordinary cicatrization, and accurately coapting and holding in measures for controlling post.partum hemorrhage are of no avail here; but a ligature passed deeply through the lips and firmly compressing the angle will control the hemorrhage and cause a primary repair of the lacera tion. I am of that number who oppose the operation of trachelorrhaphy at the time of child birth in all other cases than that just given, as I believe most cases of laceration are repaired by Nature, and infinitely more harm would come to the patients by promiscuously and indiscriminately repairing all these at the time of their occurrence than now comes by letting them alone, for of these only a comparatively few ever require opera tion.

As to the preparatory treatment, I believe a great deal of useless preparation is made and valuable time is wasted in spending three or four or more weeks in get ting a patient ready for operation. As a rule most of these cases can be properly prepared in forty-hours' time, and if so, more time than this is not only useless but wasted and even worse. Let the patient's bowels be freely moved with a little mercurial followed by salts, if there are no contraindications to the former, and let her be given a hot 3 per cent carbolic douche, two or three times a day, take a good bath, have the vulva shaved, abstain from her regular meal just preceding the operation, and she is in good condition for the ether and for the following operation.

The patient being then under the anesthetic (ether, unless contraindicated by serious lung or kidney dis ease) is brought to the edge of the table in the dorsal position with legs flexed on the thigh, and thighs well flexed upon the abdomen. Examine the uterus, tubes, ovaries and entire pelvic cavity for tumors, adhesions, pus collections, or other abnormal condition before pro ceeding with the operation, lest if there be any other serious trouble your operation may either be a success,

good position the denuded surfaces. For denudation some use the scalpel, some Skene's hawk-bill scissors, and others the plain scissors, and still others scissors specially adapted for this work. For sewing up the laceration different forms of needles are used by operators and different forms of suture are used as well as a variety of methods of holding the suture in place. Silk worm gut tied is used. The same with shot is employed by others. Even some use silk, and others use silver wire. In order that this operation be both esthetically and practically a success it is very important that the torn edges of the cervix be deeply pared and that the cicatricial tissue in the angle of the tear be entirely cut out; the great difficulty in doing this in some cases led me to devise an instrument for this special purpose which far surpasses in utility anything that I have ever used that I do not hesitate to present it to this Society as worthy of inspection. It is used in this manner, with the assistants taking the parts assigned them, as given above, the operator takes the uterine tenaculum in his left hand and hooks up so much of the tissue of the lower lip as he wishes to pare off and with the cervix knife in his right hand quickly cuts from the end of the lip back into the angle and behind the cicatrix. Then loosening the tenaculum he catches a like hold upon the anterior lip and pares it in a similar manner, his upper incision meeting the one he has just made back of the cicatrix in the angle. His tenaculum now brings with it the entire V-shaped mass leaving two raw surfaces easily brought in apposition. If the laceration is bilateral the same steps are now taken upon the other side and he is ready for the sutures. Many forms of needles have been and are now used for sewing up the laceration, but I prefer this needle (my own modifica. tion of one of Wilson's) which I show you, above all others. As many of you know, Truax, of Chicago, puts