3 per cent. cannot yet be claimed by any operator in hysterectomy, and even in the comparatively safe operation of removal of the appendages, very few operators can show as favorable results as Keith has obtained with electricity.

I have carefully gone over the record of the cases reported by Keith, and have been surprised at the almost uniform improvement noted. Diminution in size of the tumor, arrest of hemorrhage, relief of pain, and general improvement in the nutrition and spirit of the patient are recorded in nearly every case.

August Martin, the greatest living gynecological surgeon of Germany, has very recently* referred to ten cases treated by him in the following words: "The results in these ten cases show that hemorrhage, the most troublesome and dangerous symptom of myomata, may usually, indeed, be controlled, in fact, in those large multiple tumors, which apparently were situated intraumurally, and included the fundus, hemorrhage ceased nearly entirely. Several small tumors were not influenced in the same manner, and the hemorrhages continued unchanged in spite of very frequent sittings; so that here the result must be regarded as a very doubtful one. One patient, who had a myoma of the size of an ostrich egg, had such violent pains after seven sittings, that she insisted upon being operated on. The operation was performed, and the patient recovered. A second symptom, often so frequently complained of, is the phenomena of pressure. These disappeared in all of nine cases, so that in this respect the result is very satisfactory. An essential decrease in size has, up to now, not been obtained in any case."

This is not very enthusiastic, but Dr. Martin admits that the symptoms for the relief of which hysterectomy is at all justifiable, were relieved in his cases. He states that he shall continue "making experiments with the procedure."

Numerous other competent observers in France, Germany, England and in this country have had successful experience with this method, and, although there is still a good deal of sneering at the method as being useless, and withal dangerous, and those who use and advocate it are denounced as quacks and "low-down, no-account sort o'possoms" generally, electricity in the treatment of fibroid tumors

*Introduction to American Translation of Martin on Diseases of Women. Boston, 1890, p. 29.

of the uterus has come to stay, and demands investigation. Ridicule and denunciation are no answers to plain records of facts submitted by Apostoli, Zweifel, Martin, Keith and many others, less eminent, perhaps, but still of some account in the world.

Some of those who use the electrolytic method apply it in office or dispensary practice, allowing the patients to walk or ride considerable distances after the application. This I regard as imprudent and likely to cause trouble. All the cases in which serious symptoms or a fatal result followed after the use of electricity were such as had imprudently exposed themselves. I regard it as important that several hours, at least, of perfect rest should follow each application. To allow this course to be pursued it is requisite that the patient should be treated at her own home or in a properly fitted institution.

It goes without saying that careful asepsis of the genital canal should be maintained during the electrical treatment as well as in the gravest and most delicate surgical operations.

Laparo-hysterectomy puts the woman in jeopardy of her life and keeps her a helpless invalid for at least one month. The electrolytic treatment keeps the patient under moderate restraint for a period of two or three months, does not endanger her life, and leaves her generally in such a condition of comfort and health that she is satisfied to live her allotted days, even though she is obliged to carry her tumor with her to the grave.

I would not advocate the exclusive use of electrical method in the treatment of uterine fibroids. As stated in the beginning of this paper, a rational discrimination is demanded of those who treat this condition. Many cases are readily relieved by vaginal or intra-uterine division of the pedicle by scissors, ecraseur or galvanocautery wire; others are best treated by vaginal, intra-uterine or abdominal enucleation. Large adematous tumors or fibro-cysts should be treated by laparo-hysterectomy; bleeding fibroids, of not too great size, are proper cases for removal of the appendages, and most large, chronic, immovable tumors, choking up the pelvis, causing pain, pressure-symptoms and hemorrhage, yield to the proper, patient employment of the galvanic current after the method of Apostoli.

18 West Franklin Street.

CURRENT OPINIONS ON PROF. KOCH'S

DISCOVERY.

PROF. KOCH'S REMEDY FOR TUBERCULOSIS.

(Editorial in the London Lancet of November, 1890.) That intense excitement is invariably followed by a corresponding depression was never more clearly brought out than in the events of the last few weeks, and the unreasoning, because too excited and too sudden, jubilation of the medical world has been followed, or is being followed, by an equally irrational reaction which has taken the form of everything that can be urged, either probable or improbable, against Koch in the first instance, and against his new method in the second. Statements that Koch never made are vigorously contradicted, and results which he never claimed are as forcibly denied. All this is to be greatly deplored, as either exultation or depression of a hysterical nature in the medical profession must necessarily be reflected in an intensified form in the minds of those poor patients suffering from tuberculous affections, the hopes of many of whom have only been raised to be unnecessarily shattered.

We were assured at first that tuberculosis was about to become a disease of the past, that Koch's new method was to annihilate the tubercle bacillus; whilst now we are assured that Koch has done nothing new, and that he is simply working out Pasteur's ideas. Let us discuss calmly the present position of affairs. Koch, like all scientific men, has his own methods of working and his own system of declaring his results. He has never yet rushed into print with a discovery until he has been sure of his facts, and all who are in any way acquainted with the circumstances under which Koch was practically compelled by his Government superiors and by his colleagues to make his premature statement at the International Medical Congress in Berlin will sympathize most deeply with him that he was compelled to break through his usual reticence. As we have already pointed out, it is evident from the carefully written statement that he made on November 14th that even this was wrung from him by his desire to counteract, in some measure, the effects of the indiscreet ardor of his friends and disciples, and to correct the misleading statements that have from time to time appeared in

the press, and so to lay before his medical confréres his exact position in regard to his new discovery, and to correct some of the erroneous impressions that were gradually gaining ground, not only amongst those who had charge of phthisical patients, but amongst phthisical patients themselves.

Koch has made a most marvellous discovery-one which in many respects is on absolutely new lines; but, with the modesty which should characterize all scientific workers, he distinctly warns those suffering from phthisis that they must not raise to too high a pitch their hopes of being benefited by it; for, although he states very clearly and very distinctly his belief that he has been able to obtain a material which, when injected into the human subject, brings about the disintegration or degeneration of any tissue that forms a nidus for tubercle bacilli, neither he nor any other can restore the normal tissue that is lost; he can localize the diseased patches, but he cannot restore them to life. This new method of treatment depends not upon the fact that the patients become accustomed to the action of the poison produced by the tubercle bacillus (though this also seems to be effected), but rather to the fact that the diseased area is so sharply defined by the reaction set up on the introduction of the lymph that the tuberculous area practically becomes encapsuled. Bacilli are confined to this area, and the whole mass may be removed. The era of surgical interference with tuberculous masses may be said to have dawned should it be found on further experience that the separation of the dead from the living tissues is as distinctly brought about as Koch seems to have proved.

Let us see how far Koch really goes, and how far ordinary pathological explanation may be brought in to support his position. As regards lupus, he has not the slightest doubt as to the ultimate success of his treatment. After weekly injections for three or four weeks of full doses of the lymph at some distance from the ulcerating surface (usually in the back), the disease is practically cured, and cicatrization takes place, even in cases where the disease has been of several years' standing. The local changes that are set up point to the fact that the lymph acts immediately on the tubercular granulation tissue of which the surface of the ulcer is composed. The lupus spots begin to swell and to redden, showing that there is an increase of fluid in the blood-vessels, and probably also in the lymph spaces. This commences before the rigor, which is a charac

teristic feature in tubercular cases, sets in.

During the fever that

follows, the swelling and redness increase, and finally may become so marked that small brownish sloughs are formed as a result of the intense reaction, the tissues apparently dying before the eyes of the observer. In those cases where the lupus is sharply defined the central portion corresponding to the tubercular granulation tissue becomes swollen and brownish, eventually undergoing necrotic changes; surrounding this centre is a whitish rim almost a centimetre wide, the exact nature of which is not evident, though one would expect to find that it consists of an oedematous fibrous tissue area; whilst outside, again, is a broad band of bright-red inflammatory tissue (corresponding to the old hyperæmic zone), in which there appears to be, from all accounts as yet received, an attempt made by the healthy tissues to still further localize the mischief. Should a similar series of changes take place in the tubercular areas of bones and joints, the question of operation, after the injection of the lymph has done its work, will of course be settled, and the same will apply to glands or other tuberculous tissues that are accessible to the surgeon's knife. Indeed, in the present condition of cranial and abdominal surgery there can be almost no limit to the cases in which surgical interference may become applicable and necessary; even in the lung, as has been pointed out by eminent surgeons, it will not be a very difficult matter to remove a localized mass of tubercle, or even a series of masses, when drainage of tuberculous cavities would be out of the question; whilst the treatment of tubercular empyæma will be much shortened and very considerably simplified.

All thoughtful physicians will be inclined to take a more hopeful view of Koch's treatment from the fact that he does not disdain to call in the aid of those means which physicians up to the present have found to be most beneficial in the treatment of phthisical patients; fresh air, good nursing and good food being all brought freely into requisition where possible. He claims for his lymph only the power of killing the weakened tissue, so removing the pabulum on which the tubercle bacilli depend for their existence, and he aims at so far strengthening the tissues of the body that they can withstand the attacks of bacilli that are driven out from the tuberculous areas by reason of scarcity of food.

There is one point to be borne in mind in all this. Koch formerly