lay parallel with a similar crest on the other lip. These crests were about five millimetres wide and ten millimetres high, and were surmounted with what remained of the mucous membrane in their entire length. When they were placed side by side, it was easy to unite the lips with sutures not liable to cut out.

DR. EMMET, of New York, said that he was very much pleased with the ingenuity of the procedure, a device which practice only would determine whether it could be adopted in a large number of cases. But, as a rule, he believed it to be better surgery, in a cervix which was in this cystic condition, and presented the appearance of an old tonsil, to amputate a portion of it, and cover the stump with vaginal tissue.

Dr. Sutton's procedure was certainly one of the most ingenious which he had known, but ingenuity and practice did not always work together. He should think there would be fear that union would not take place at the deep angle.

The paper was further discussed by Dr. G. J. Engelmann, of St. Louis, Dr. W. H. Baker, of Boston, Dr. A. P. Dudley, of New York, Dr. James R. Chadwick, of Boston, and the discussion was closed by Dr. Sutton.

The next paper was by DR. ELLWOOD WILSON, of Philadelphia, entitled:

NOTES OF THE TREATMENT OF RECENT LACERATION OF THE CERVIX UTERI.

It was read by the Secretary, DR. JOSEPH TABER JOHNSON, in the absence of Dr. Wilson, who was summoned by telegraph to return home.

The author of the paper, in confirmation of the statement that recent laceration of the cervix very frequently may be cured by the application of nitrate of silver in strong solution, submitted the treatment of six cases with the results. Failure to discover laceration of the cervix after labor, and neglect to properly treat such a condition, entails oftentimes a great deal of suffering upon the woman, and brings a well-merited condemnation upon the physician. If at the completion of labor the physician carefully examines his patient, he will generally recognize the laceration if one has occurred, but he may not always be able to do so. The physician, however, should not be content with an examination immediately following the completion of labor, but should examine again on the tenth or twelfth day, when the process of involution of the uterus will be advanced so far that the tear, if any be present, can hardly fail to be readily detected. If the fissure of the cervix is detected immediately after labor, the best plan is to douche the vagina carefully with mercuric chloride solution, one to three thousand, at a temperature of 100° F., and to introduce an iodoform bacillum, prepared after the formula recommended by Dr. Lusk, and used by Braun and Spaeth, of Vienna. The bacillum should be perfectly smooth, not more than one and a half inches in length. The vagina should be irrigated every

third day with a corrosive sublimate solution, and a fresh bacillum introduced.

The plan to be pursued in the subsequent management of these early discovered tears is the same as that which he employs in rents of the cervix discovered within three weeks of their occurrence, and is as follows: carefully cleanse the surface of the laceration, thoroughly dry it, and then paint the whole surface with a solution of nitrate of silver, one drachm to an ounce of water, care being taken that the bottom of the rent is reached. This application is made once every four or five days until cicatrization is thoroughly established, usually three to five applieations being necessary. In bad cases this plan may not be successful, but in every case in which he had tried it the result had been all that he could wish for. His attention was drawn to this method of treatment by an article by Dr. Bradford Brown, in the Coll. and Clin. Record, November, 1885. The Doctor, however, had only used it in chronic cases. Dr. Wilson had not found it to be successful in chronic cases, and confined its use to those which were recent. Personally he felt that he had performed trachelorrhaphy when the patients might have been cured by this simple method.

DR. FORDYCE BARKER, of New York, had listened to the paper with a great deal of interest, as it seemed to him to be eminently sound and practical in many respects, and the inferences to be derived from it were much to be preferred to the law laid down by some a few years ago, that always immediately after confinement the woman should be carefully examined to see whether there was laceration, and whether it should be closed by stitches. He had never had a single patient operated upon, or one that required an immediate operation, nor had he had a single patient who required a secondary operation, until one within the last year, and he therefore felt that the law which some had laid down was altogether too arbitrary, and one which should be followed with great caution. He could say that there were cases in which the proper course would be an immediate operation, but he had not met with them in his own practice.

DR. T. A. EMMET, of New York, said that he believed that the only condition which demanded interference immediately after labor was the occurrence of hemorrhage. It was something remarkable what nature would do in the way of restoring damage done to these parts, providing septic infection is not established.

The paper was further discussed by DR. JOHN SCOTT, of San Francisco, who said that he had never operated upon the cervix immediately after labor except in one case, and then it was with the greatest difficulty that he could introduce stitches without thaving them cut through the tissue completely. Luckily union took place in both the cervix and perineum, and he mentioned the case simply to illustrate the readiness with which a tissue torn or lacerated was cut through by the stitches, and the great vascularity which was sometimes present in those cases. The discussion was closed by Dr. Barker.

First Day Afternoon Session.

DR. THOMAS ADDIS EMMET, of New York, read a paper entitled:

PELVIC INFLAMMATIONS; CELLULITIS VERSUS PERITONITIS.

What is pelvic inflammation? Is it a cellulitis, a pelvic peritonitis, or do we have the two combined? Under what circumstances do we find phlebitis and lymphangitis accompanying these conditions?

The term cellulitis in this country has come, by almost common consent, to signify pelvic inflammation without reference to the special form. But its origin is generally supposed to have been in the connective tissue. Inflammation of the connective tissue between the rectum and vagina behind; in front of the uterus, bladder, and ureters, etc., is generally accompanied by phlebitis, and is a frequent consequence of the pressure made during childbirth. But it is a matter of common observation that this form of pelvic inflammation tends rapidly to resolution, and the tissues soon regain a healthy state if septic poisoning does not take place. With the introduction of septic matter from any source, the lymphatics become inflamed and the peritoneum is rapidly involved.

There has been a tendency shown in recent discussions on this subject to undervalue the importance of apparently limited pelvic inflammations. His own convictions, based on a large experience, is that the more circumscribed a pelvic inflammation. seems to be, provided it is not a pure cellulitis, the more serious will be the consequences if its existence be practically ignored. An apparently limited one is to be the more feared from the fact that it is almost always situated in the peritoneum, and is generally the remains of a more extended inflammation.

It has been held that, as a rule, little evidence of previous attacks of cellulitis can be found when operating for the removal of diseased Fallopian tubes, and his experience comfirmed the accuracy of this observation. Yet it had cost him much thought to explain the existing condition. During the last winter he witnessed an operation performed by Prof. Polk, in a case in which he had expressed the opinion previously that the condition was one of thickening and shortening of the left broad ligament from an old cellulitis. At the operation, to his surprise no broad ligament was found, and the enlarged tube lay directly against the side of the vagina. This was so marked an instance that the explanation presented itself to him as soon as he was able to give the matter due thought. And he then recalled the fable of the two knights meeting at the cross road where a shield was suspended which was of gold on one side and silver on the other. They disputed as to the material of which it was made. Each was right from his own standpoint, and all difficulty could have been avoided if either had looked upon the other side. He mentioned this fable as applicable to the recent

discussions on the relative importance of cellulitis and pelvic peritonitis as factors in the diseases of women.

The question had been raised often as to the existence of pelvic cellulitis in these cases, since its products found after death are so few in comparison with those recognized as connected with inflammation of the peritoneum. The following explanation was offered: If the inflammation stops short of a pelvic abscess after it has entirely subsided, nothing can be detected by the finger in the vagina or rectum but a few attenuated bands running in different directions, and these also disappear in time. By degrees the surrounding connective tissue which has been involved is gradually drawn together by its own elasticity to fill the space which would otherwise remain unoccupied. The inflammation having been confined to the cellular tissue, nothing remains finally to mark the site of even an extensive inflammation but a small dense scar or line. After this redistribution of the cellular tissue, the vagina or rectum slowly returns to its former shape and size as soon as the natural elasticity of the pelvic tissue can be again uniformly exercised.

On the other hand, when an extensive inflammation has existed in the connective tissue between the folds of the broad ligament, it must necessarily involve the peritoneum covering it. In time this connective tissue also disappears as a result of the inflammatory action, but it cannot be replaced as takes place elsewhere, in consequence of its isolated position in relation to the cellular tissue in the other parts of the pelvis. As a result of inflammation of the peritoneum covering this tissue, adhesion of the opposing surfaces occurs, and, by the contraction thus exerted, the broad ligament is flattened out, so that Douglas' cul-de-sac disappears on that side. The effect of this change is, that the vaginal wall, in the neighborhood of the site of the inflammation, must be raised up and ballooned out. The same traction would also draw the tube somewhat downward until it and the side of the vagina would lie in contact. This, then, is the condition found by the surgeon when he operates for the removal of the diseased Fallopian tube. If this operation is correct, it would prove that connective tissue, without reference to its situation in the body, never regains its integrity after having been once inflamed. According to the degree and extent of the inflammation must the tissue involved be absorbed or broken down into an abscess before the parts can be restored to health. If the surrounding connective tissue can supply the loss, the part will gradually return to its former shape, and the injury will in time be inappreciable. On the other hand, if the inflammation has been more extended, so that the loss cannot be replaced, or if the tissues break down into an abscess, nature can only restore the injury by adhesive inflammation of all the parts inflamed. We have, then, according to the extent of the injury, either a small pit-like depression, or a deformity due to traction as the tissues shrink together. When cicatricial contraction is thus exerted

after a surface has healed by granulation, this contraction is due not so much to the presence of a scar of the tissues as to the absence of counter-traction from the surrounding connective tissue which was destroyed before the scar was formed.

In a limited number of cases, no permanent benefit seems to result from local treatment, and the operation for the removal of the tubes and ovaries has to be resorted to eventually. Fortunately, it is not the rule, at least among the well-to-do. In public hospitals, we see a number of poor women suffering from some form of pelvic disease, and who have lost apparently all their recuperative powers. Under those circumstances, and in the uncertainty of practical gain from local treatment, we can seriously consider the advisability of the operation after having gained the consent of the patient by a truthful representation of her condition. But he was convinced that the time has been reached when we should enter a protest, and that the profession at large should demand the recognition of some responsibility connected with the indiscriminate manner in which this operation is being done all over the country and by any one. He believed

that the operation for the removal of the tubes and ovaries should be done only as a last resort, and only after every other means has failed. For the good name of the profession, it should be recognized that it requires an expert to determine when this operation should be done, and that even more experience still is required to perform it with safety and with benefit. The operation is practised too often even by those who have the smallest death rate, and he predicted that five years would not pass before it would be necessary to offer an apology when its performance is suggested. The operation, doubtless, fills an important place in gynecological surgery, but its usefulness must be more clearly defined, and its practice greatly restricted, or the good name of the profession will surely suffer in the future.

DR. ROBERT BATTEY, of Rome, Ga., believed that inflammation of the pelvic cellular tissue depended primarily to a very great extent upon disease of the ovaries; that a pelvic cellulitis which gives rise to so much trouble is, in a large proportion of cases, secondary, and not primary. Thus, Dr. Emmet was viewing one side of the shield, and he the other, and he wished very much that both could look upon the same side of the shield, for he had great admiration for Dr. Emmet's exceeding honesty, honor, and candor. If gonorrheal cases were thrown out of consideration, to which Dr. Emmet had also alluded, Dr. Battey believed that the primary disease which induced inflammation of the tubes rested not in the cellular tissue, but in the ovaries.

With reference to the frequency with which operations are done at the present time for the removal of the ovaries, he must confess that he was largely in sympathy with the remarks made by Dr. Emmet. He did not think that every case of organic disease of the ovaries required extirpation. He had in mind a case in which he advised extirpation of the ovary several years ago on