ing a handful of scales could be gathered from the sheet, but they were not as large as is usual,and were inclined to be furfuraceous. The face was not involved. Three or four days after the first visit, there appeared upon the thighs, abdomen and buttocks a number or tense bullæ. Their appearance was preceded by a distinct chill, and followed by a moderate elevation of temperature. The blis ters did not run into each other. The bullæ appeared in successive crops of not more than a dozen, each crop being preceded by a chill. Quinine was freely administered, and at the end of a week the bullae ceased to appear. Dr. Hardaway was obliged to discontinue his visits at this period of the case, but the tient gradually improved.

pa

The writer thought that this and other cases which he had seen, showed that diseases usually supposed to run a dry course, may, under certain circumstances, be complicated with lesions containing fluid.

A Case of Probable Tuberculosis of the Skin, was described by Dr. G. H. Tilden, of Boston, Mass.

Dr. LeGrand N. Denslow, of St. Paul, made a supplementary report with reference to THE TREATMENT OF ACNE BY THE USE OF SOUNDS.

At the last meeting he had reported five cases in which this plan of treatment had been of value. Four of these cases were adults, and all had remained well. The fifth case was that of a boy about fourteen years of age, and in this case relapse had occurred.

A communication with reference to the organization of a Congress of American Physicians and Surgeons was received, and the following committee of conference, to report at the next annual meeting of the Association, was appointed: Drs. H. G. Piffard, of New York, F. B. Greenough, of Boston, R. B. Morrison, of Baltimore, G. H. Tilden, of Boston, and LeGrand N. Benslow, of St. Paul.

The following officers were elected: Presiident, Dr. H. G. Piffard, of New York; Vice Presidents, Drs. F. B. Greenough, of Boston, and R. B. Morrison, of Baltimore; Secretary, Dr. G. H. Tiiden, of Boston; Treasurer, Dr. LeGrand N. Denslow, of St. Paul.

The Association then adjourned to meet at

the call of the council.

-The Berliner Klinische Wochenschrift writes that such well sounding names as Gusserow and Winckel are booked as attendants upon the International Congress, to meet at Washington, D. C., on Sept. 5, 1887.

THE AMERICAN GYNECOLOGICAL

SOCIETY.

Eleventh annual meeting held in the G hall of the Johns Hopkins University, Baltimore, Md., Sept. 21, 22 and 23, 1886.

TUESDAY, FIRST DAY, MORNING SESSION. The society was called to order by the president, Dr. Thaddeus A. Reamy, of Cincinnati.

The first paper was on the "Division of the Cervix Backwards in some forms of Ante Flexion of the Uterus with Dysmenorrhea and Sterility." By Dr. H. P. C. Wilson, Baltimore.

From want of a judicious selection of the cases, by being done by unskilled hands in proper cases, by being done in unsuitable cases and from want of appropriate after treatment this operation has been barren of good results in certain hands and followed by bad results in other hands. But I have fonnd no measure so safe and efficient in the classes of cases to which I shall call attention, as the knife.

The classes of cases in which I would recommend the operation are

First. Those of anteflexion of the uterus, with a hard indurated cervix where the body is bent upon the neck, or the neck upon the body, forming a more or less acute angle.

Second. These cases of acute flexion where the cervix is hyperplastic and indurated and dense as cartilage.

Third. Those cases where there is a hard, unyielding internal os, through which the probe passes with difficulty, and in its passage gives the sensation of passing over rough dense cartilage, while the finger in the sulcus between the body and the neck in front, gives the sensation of a strong cord tied around the uterus.

The method of operating was then discussed. With the patient under an anesthetic the uterus is drawn downwards by a tenaculum in the anterior lip. The posterior lip is then divided with scissors up to the vaginal junction. An uterotome is next passed, and the internal os divided anteriorly and posteriorly to an extent sufficient to permit the introduction of a large sound. The parts are allowed to bleed freely. A pledget of cotton soaked in a mixture of Monsel's solution, iodine and glycerine is then introduced into the cervix and over this pledgets treated with Monsel's solution and water, and the vagina lightly tamponed. These are not removed until the third day. All manipulation of the uterus avoided

for at least two

weeks. The patient is allowed to fully recover from the operation which usually requires one month. Local treatment is then suspended for one month to allow the intra-uterine mucous membrane to improve. The patient then returns, and applications of Churchill's tincture of iodine are made to the endometrium two or three times a week. The treatment after the lapse of a month is again suspended to be resumed in the course of one or two months. If this after treatment is not carefully and properly carried out, the operation had better not be done. The speaker had performed the operation four hundred times, and had never obtained as good results from any other method. In no case has he had a death which could be attributed directly to the operation.

DISCUSSION.

DR. T. A. EMMET, New York.-We must separate dysmenorrhea and sterility as being due to widely different causes. Mechanical dysmenorrhea I believe to be a myth. We must also separate two conditions of flexion, one a flexure of the neck, a congenital defect, and the other a flexure of the body of the uterus due to preceeding inflammation outside of the uterus. Sterility resulting from this latter cause is not relieved by the opera tion, and its performance is attended with great risks to life. The congenital flexion is the only one in which I operate to relieve the sterility.

This operative procedure is not free from danger. I have known of at least twenty deaths from it. If, as has been suggested by Dr. Wilson, all the effects of previous inflammation are removed, there is not the same danger, but I can not see that the operation will do any good.

I

DR. JAMES R. CHADWICK, Boston. have not been successful with the operation in curing sterility or dysmenorrhea. I regard the flexion as always congenital, the result of the persistence of the infantile shape of the uterus. This I am convinced is not confined to the anatomy of the organ but also involves the function. I think that the operation should be restricted to those cases in which there is flexion with a small external os, but in which the uterus seems to be well developed in other respects.

DR. W. H. BAKER, Boston.-Some ten years ago, I saw a number of cases in which this operation was done, and while the immediate results were very gratifying, yet in many cases the patients did not retain these good results. Of late years, I have limited the operation to the class of cases to which

Dr. Emmett refers, in which there is a congenital malformation and those in which there had been an inflammatory condition, the results of which have been removed.

ous.

DR. W. T. HOWARD, Baltimore. I have given all the operations alluded to, a fair and full trial. My experience has not shown me that any particular operation is the one for all cases. By the antero-posterior incision, I have had some excellent results. With the precautions adopted in operating in other por tions of the body, an incision of this kind in the majority of cases, should not be dangerDr. Mundé, in a paper on this subject, reports over three thousand cases with only nine deaths. I think that forcible divulsion is attended with as much risk as incision. In my practice the method adopted has varied according to the case. In some, I have em ployed the posterior incision, in others the bilateral incision, but in the majority of cases I dilate, using antiseptic precautions and never taking less than twenty to thirty minutes to complete the operation.

DR. H. P. C. WILSON, Baltimore. I have not heard anything in the discussion to convince me that, in properly selected cases, division of the cervix is not the best thing to do. As I have already said, if the operation is not followed by proper after treatment, it had better not be done. The danger is not from the operation itself, but from the im proper after-treatment.

Another Modification of Emmet's Cervix Operation, with a case in Point. By Dr. R. Stansbury Sutton, Pittsburg.

A case of old standing, neglected double laceration of the cervix was reported. The cervix was composed of dense hard hyperplastic tissue almost cartilaginous in character. In order to remove the greatest amount of cicatricial tissue and overcome the condition, the following procedure was resorted to. The lower lip of the laceration was denuded of its altered mucous membrane, leaving only a narrow strip corresponding to one-half of the strip usually left to serve for the future os; the upper lip was treated in the same way, leaving the opposite half of the strip of mu cous membrane. When the flaps were brought together, the strips of mucous mem brane lay side by side. In this way, union in the position of the future canal was prevented. Good union followed the operation, and, at the end of three weeks, a Simpson sound was passed without difficulty.

DISCUSSION.

DR. THOMAS A. EMMET, New York.The modification seems to be an ingenious one, but its value can only be determined by

future trial. In such cases, however, where there has been such cystic degeneration, it is often better surgery to amputate a portion of the cervix, so as to get into healthier tissue. DR. GEORGE J. ENGELMANN, St. Louis.I have found no difficulty in preventing union and I have paid very little attention to the strip of mucous membrane. I have, in such cases as have been described by Dr. Sutton, cut away nearly all the mucous membrane and inserted a short piece of fine cat gut. This keeps all the opening which is necessary. When, however, we come to such extreme cases, I think that it is better not to attempt what has been termed Emmet's operation, but to resort to partial amputation as is performed in Germany.

DR. W. H. BAKER, Boston. In this class of cases I have been in the habit of removing a transverse wedge shaped portion of each lip of the cervix and then bringing the parts together. In this way, the hyperplastic tissue preventing the apposition of the surfaces is removed. If proper preparatory treatment is employed, I think that the saving of the strip of mucous membrane can be accomplished.

DR. R. STANSBURY SUTTON, Pittsburg.In the case described, there was only one of two thing to be done, either to remove the cervix or devise some new method of operating. This modification gave complete satisfaction in this case, and I purpose trying it in other similar cases.

In the absence of the author, the following paper was read by the secretary: "Notes on the Treatment of Recent Laceration of the Cervix Uteri." By Dr. Elwood Wilson, Philadelphia.

Occasionally a tear of the cervix can be recognized immediately after labor, but sometimes this can not be done. The patient should always be examined ten or twelve days later. If laceration be found immediately after labor, injections of corrosive sublimate solutions, one to five thousand, with the insertion of an iodoform suppository should be resorted to. The vagina should be irrigated every other day and the suppository renewed. When the laceration is found within three weeks after delivery, the following treatment should be employed. After the surface has been carefully cleansed and dried, it should be painted with a solution of nitrate of silver one drachm to the ounce of distilled water. From three to five applica. tions at intervals of five days are usually required. In every case in which the author had tried this measure, six in number, the result was entirely satisfactory.

DISCUSSION.

DR. FORDYCE BARKER, New York.-It seems to me that the practice recommended in the paper is worthy of trial. It is preferable to the rule laid down within the past few years, that if there is a laceration it should be closed immediately after labor. If this method will effect union it should be tried.

DR. THOMAS A. EMMET, New York.-I suppose that a certain amount of laceration occurs in every labor, but it is wonderful what nature will do to restore the cervix where septic poisoning is not present. It seems that in all cases, where under favorable circumstances nature has failed to repair the damage, there have been symptoms indicating septic inflammation. In the cases reported, I believe that the same results would have been been obtained even if nitrate of silver had not been employed.

DR. J. SCOTT, San Francisco. In only one case have I attempted to sew up the cervix shortly after labor. In this case there was an extensive tear of the cervix and of the perineum. There was considerable bleeding, and, five hours after labor, I thought it advisable to sew up the cervix. The tissues were so soft that it was with the greatest difficulty that I could get the sutures to hold. Union took place, however, both in the cervix and in the perineum.

AFTERNOON SESSION. Pelvic Inflammation; Cellulitis versus Peritonitis. By Dr. Thomas Addis Emmet, New York.

In this country the term cellulitis has come to signify pelvic inflammation without reference to the special form, but its origin is supposed to have been in the connective tissue. So close is the relation between the connective tissue and the peritoneum, that it seems impossible for inflammation to be present in one without affecting the other. There are situations, however, as between the uterus and bladder, and between the the uterus and rectum, where cellulitis might exist without involving the peritoneum. Inflammation in these situations tends to resolution, and the tissues soon regain their healthy condition if suppuration does not take place. After septic poisoning, the peritoneum rapidly becomes inflamed and adhesions occur, circulation in the blood vessels becomes more or less obstructed, and the action of the absorbents is greatly impeded. Finally a condition is produced which remains long after the symptoms have subsided, and one not prone to change or amenable to treatment. In such cases a fresh attack is provoked by slight causes.

It has been objected that when the abdominal cavity is opened for the removal of the ovaries, very slight evidences of inflammation are found. In a recent case, I expressed the opinion from the vaginal examination that a thickened and shortened left broad ligament would be found. At the operation, no broad ligament was found, but there was an enlarged tube lying against the side of the vagina. Similar cases have been noted. I should explain these cases in this way. If there is an inflammation between the folds of the broad ligament, it must involve the peritoneum. As a result of the inflammation, the connective tissue disappears, and adhesion of the opposing surfaces takes place. The broad ligament is flattened out so that Douglas's cul-de-sac disappears on that side. The vaginal wall is raised up so that it and the tube lie in contact. This is the condition found by the surgeon when he operates for the removal of the diseased Fallopian tubes. In all these cases I feel satisfied that there has been inflammation of the connective tissue. I think that the inflammation has been secondary to the cellulitis in every instance except where the primary inflammation was the result of gonorrhea. If my observations are correct, they would prove that the connective tissue never regains its integrity after having been once inflamed. If the surrounding tissue has restored the loss, the part will return to its normal condition. If the loss can now be replaced, nature can only repair the injury by a process of adhesive inflammation of the parts involved.

I have used the term thickening of the broad ligament, but I have not meant to imply that there is a deposit of lymph between the layers of the broad ligament. The enlargement is, I think, due to the dilated state of the veins. The condition is one easily aroused to activity.

It is still a moot question as to the way in which the tube has become involved where gonorrhea is not the cause of the inflammation. In septic poisoning after surgical in juries, I believe that the connective tissue of the veins and lymphatics first becomes involved, and that the inflammation of the peritoneum is secondary. There is no evidence to prove that the inflammation passes into the uterine canal and thence to the tubes, except in such cases where the process is due to gonorrhea.

history of frequently recurring attacks. In cases which can secure every attention, a cure by local treatment can sometimes be effected, but a long time is required. In cases which have to gain their own living, we may seri ously consider the advisability of an operation, after having gained the consent of the patient after a true representation and its results. We should enter a protest, and the profession should demand a recognition of the responsibility of those who are indiscrimi nately operating for the removal of tubes and ovaries. It requires an expert to determine when the operation is necessary, and still more experience and skill to do it with safety to the patient. It should only be done as a last resort after other measures have failed. In a number of cases in private practice I have succeeded in restoring the patient to health by local treatment, for whom the operation had been strongly urged. If we could get accurate statistics, I think that it would be shown that the average amount of benefit gained does not compensate for the amount of risk. I believe that the operation is done too often, even by those who have the least death rate. I believe that the operation is done too often even by those who have the least death rate. I predict that five years will not pass before it will be almost necessary to offer an apology when this operation is proposed.

DISCUSSION.

DR. ROBERT BATTEY, Georgia. From my experience it has seemed to me that the pelvic cellulitis which gives so much trouble. was in a large proportion of the cases secondary. So far as disease affecting the tubes is concerned, I believe if we throw out of consideration the gonorrheal cases, the pri mary disease starts in the ovary. I regard most of these serious inflammations of the pelvic cellular tissue us dependent upon cys tic or cirrhotic disease of the ovary.

With reference to the frequency with which this operation is done, I must confess that I am largely in sympathy with the speaker. I think that the operation is done too often. I do not believe that every case of organic dis ease of the ovary requires operation.

In reply to a question of Dr. Fordyce Barker, asking him to state the grounds on which he would advise removal of the tubes and ovaries, Dr. Battey said, that every case must termined for itself. If I had a poor miserable patient without the means of comfortable subsistence, suffering with ovarian or tubular disease I would operate. If I could put

such

a patient under suitable surroundings and under a prolonged course of treatment, I might not think of the knife, but we have to look at cases as they exist. I do not require in my cases an absolute diagnosis of disease of the tubes or ovaries prior to operation. It is sufficient for me to know that the general it health is broken down by reason of the perverted function of her ovaries, that she is utterly miserable, that there is no reasonable hope of restoration to health by other means, and that there is a reasonable prespect of res. toration by removal of the ovaries. Under such circumstances I unhesitatingly operate, and, contrary to my former view, I do find that the ovaries are diseased.

DR. R. STANSBURY SUTTON, Pittsburg.-I believe that when the ovary is diseased and cannot be cured by ordinary means, when it is interfering with the health of the woman and her duties in life, it should be removed. If the ovary is diseased and is a burden to the woman, it is as much the duty of the surgeon to remove that ovary as it is to remove a diseased eye-ball. I agree that the operation is being done too often, not however, by competent, but by incompetent men.

The conditions which require the operation are not always clearly understood before the abdomen is opened. I do not believe that a man is compelled to be positively certain of what he is going to find before operating. The speaker then presented several specimens, and described the cases from which they were removed.

DR. BUSEY, Washington. I think that if pathologists will return to the histological basis, there will not be the difference of opinion which now exists. I believe that it is now held that the cellular tissue is really a vast lymphatic structure, and that the peritoneum is alarge lymphatic sac. Instead of discussing nice distinctions between pelvic cellulitis and pelvic peritonitis, it would be better to classify as pelvic lymphangitis, these different varieties.

DR. J. SCOTT, San Francisco. I might mention some of the cases bearing upon this point which I have seen. One was a patient supposed to have fibroid tumors. The abdomen was opened, and both ovaries found to contain pus. They were removed, and the patient recovered. In a second case the patient presented a tumor in the right side. The temperature record was kept for two months, during which time it did not vary half a degree. On opening the abdomen, the ovary was found to contain ten ounces of pus. The right ovary was removed, but the left appeared to be healthy and was left in position.

During the operation the bladder was opened. This was sutured, and the patient made a good recovery. Five weeks later the patient complained of pain in the left side, and on examination I found an enlarged left ovary. This was removed, and the patient promptly recovered. In a somewhat similar case one ovary was removed. In a short time the other enlarged, but the operation was postponed, and the woman died of rupture of the

abscess.

DR. MATTHEW D. MANN, Buffalo. I wish to allude to the possibility of one tube and ovary being diseased without involvement of the other. There is no reason why it should be so. I have in several cases where the disease appeared to be limited to one side, removed but one ovary, and the result has been a perfect cure. This operation avoids some of the objections urged against the removal of both ovaries.

DR. H. P. C. WILSON, Baltimore. I believe that where there is a general cellulitis, there is more or less pelvic peritonitis. These two affections are often associated. In the early stages, the inflammation is often controlled by active treatment. if it is not controlled, it may go on to the formation of abscess. The pus may be discharged and the patient recover. Occasionally the abscess occurs in the tube or ovary, and these are the cases in which laparotomy is often called for. I agree that the operation is done too frequently. The point which Dr. Mann has raised, that it is not always necessary to remove both ovaries, is a very important one.

A CASE OF ABDOMINAL SECTION FOR SUPPURATIVE PERITONITIS.

DR. JOHN C. REEVE, M. D.,DAYTON, OHIO. A. B., aged 19, was healthy until November last. She had never been pregnant. She was attended by a physician who found abdominal inflammation. On January 18th, she was seen in consultation by the speaker, at which time she presented the evidences of chronic peritonitis but no history of a gonorrheal origin could be obtained. One month later she began to pass pus by the rectum. After other measures of relief had failed, laparotomy was offered in April, but declined. The patient was not again seen until June 20th, when she desired the operation. She had suffered with hectic fever. The menstruation has ceased since January. Examination of the urine showed no albumen. There was great tenderness and hardness all over the abdomen, pus being still passed with the stools. By vaginal examination no definite hardness could be detected. By the rectum