in the therapeutics of pelvic effusions, in that, while recognizing the dangers of early interference, he does not allow the fear of inducing septicemia to intimidate him into waiting until septicemia has already accomplished its mischievous, and perhaps fatal work. The reason why Bandl's latest views have had so little apparent effect upon the profession is, that they have only been before the profession at large for a few months. I had come to the conclusion that, with our present knowledge of antiseptics, we need not be frightened out of opening up these accumulations, and had acted upon it before I knew of Bandl's views; and so had many others whose veneration for longestablished authority had not overpowered their individual judgment.

A. Martin's method of operating for hematoceles and hematoma is one method, but that it is the method cannot be maintained upon scientific grounds so as to convince the profession; nor has it as yet been so proved by its success. As to the frequent bunglesomeness of operations per vaginam and per rectum, there is scarcely to be found an opportunity for the bungler like the performance of laparotomy for pelvic disease. I doubt if I exaggerate in saying that half of the abdominal sections are done in a bungling manner, especially when compared to those of Martin and a few others.

In my paper I advocate the expectant plan of treatment, and have used it, and so far succeeded with it, in all of this series of cases except one. That case was operated upon because the conditions for a cure without the operation were not attainable; because, even if attainable, they would have taken too much time to restore the patient to usefulness; and because, if properly done, the operation in such a case is almost devoid of danger. I regard it as a good illustration of when we may operate in case the expectant plan does not afford relief. In case VI., Mary H., which I have just reported, I shall use every effort to do without surgical interference, because the interior of the sac cannot be easily and safely reached.

Protheroe Smith, M.D., M.R.C.P., of London, was then elected Honorary Fellow of the Society.

Regular Meeting, Friday, August 20th, 1886.

The Vice-President, HENRY T. Byford, M.D., in the Chair.

DR. W. W. JAGGARD exhibited

AN OVUM CORRESPONDING TO THE FOURTEENTH WEEK OF PREGNANCY, SHOWING TWIN PREGNANCY, WITH ONE PLACENTA, ONE CHORION, ONE AMNION, BOTH EMBRYOS OF THE MALE SEX.

The interesting specimen was placed at his disposal through the courtesy of Dr. Daniel H. Williams, of Chicago. The egg corre sponded to the fourteenth week of pregnancy. It was a case of twin pregnancy, with one placenta, one chorion, and one amnion. The embryos were equally well developed, and were of the male

sex.

The case illustrated one of the modes of origin of multiple preg

nancy. An ovum may have two nuclei, and an embryo may be produced from each nucleus. Under these conditions, the fecundated ovum has one placenta (or there is anastomotic communication between two fused placentæ), one chorion, and two amnions. The amniotic septum may be broken down or absorbed, and the embryos may be contained in a single amniotic sac, as in the specimen exhibited.

In a case of single placenta, or fused placenta with anastomotic communication and a single chorion, the twins are always of the same sex (Hyrtl, Spaeth, Braun).

DR. JOHN BARTLETT read a paper, entitled

A PROPOSED MODIFICATION OF PORRO'S OPERATION.

After giving a concise history of the classical and Porro's operations, Dr. Bartlett said:

The substitute for Porro's operation which I have to propose is as follows: The operation proceeds as in Cesarean section till the child is removed, the actual cautery being used in opening into the womb. Then, instead of dragging the womb out of the abdomen through the abdominal incision, it is dragged out of that cavity through the vagina. The operator passes a Wells' clamp, somewhat modified in its prehensile surfaces and properly curved in coincidence with the parturient canal, to the fundus of the uterus and there secures a firm grasp into the uterine tissues. By traction upon these forceps, and pressure, and suitable manipulation from above, the fundus of the uterus is depressed into the body of the organ, dragged through the cervix into the vagina to produce complete inversion. The clamping wire is immediately adjusted, and excision of the uterus and appendages effected at a suitable distance from the vaginal junction. The abdominal wound is closed, and attention is given to the stump with reference to hemorrhage as in Porro's operation. In lieu of the clamping forceps, in some cases it would answer better, doubtless, to pass a loop of copper wire through the walls of the uterus, to be caught upon a suitable instrument, as a rod possessing the flexibility of block tin or solder, passed per vias naturales to receive it, The advantages of this operation over Porro's method which suggest themselves are: First, that the abdominal cavity is thoroughly closed; the abdominal incision, not being embarrassed by the presence of the large pedicle, is as perfectly and as quickly closed as in any other laparotomy. By the process of inversion the pedicle is placed outside of the abdominal cavity, while what may be termed the uterine inlet made into the peritoneal sac is closed by the clamping wire opposing serous surface to serous surface, thus offering the best prospect for speedy and certain agglutination and closure. Second, the relation of the parts in the suggested procedure is much more natural, and much less strained than in the status in which Porro's method leaves them. Third,

in the event of drainage becoming necessary in the course of treatment, the effecting of an opening for a tube in the plan proposed can be accomplished very much more easily and safely than in Porro's plan, and the tube being introduced, its situation and direction would be the best possible for thorough cleansing of the cavity to be washed.

Serious objections at first thought will occur to the mind of every gynecologist. These will be here stated and subsequently met, as well as may be, by considerations that may be urged in answer to them.

First. Of all the accidents post partum, none is generally accredited with so violent a shock to the patient as the very condition which is here made a main feature in a method proposed as conservative. In the old and in Porro's operation, it almost always happens that, either with or without the partial or complete separation of the placenta, the uterus contracts. With such & condition of the uterine walls, inversion would prove difficult and sometimes probably impracticable. Hunter said a contracted uterus was as difficult to invert as a jack-boot. When to these difficulties incident to the first step of the operation are added the shock from clamping and incising the uterus, it would seem that the dangers incident to the method proposed might exceed those of the Porro operation.

Second.-In Porro's operation, as in the old Cesarean section, danger begins from hemorrhage at the moment of incising the uterus, and in the method proposed this danger would be so much the greater as the time elapsing between the two events, incision and snaring of the pedicle, is longer. In the established operations. in at least one-sixth of the cases the placenta has been encountered directly in the line of incision. In such instances the bleeding from the double wounds, uterine and placental, would, in an especial manner, embarrass the operator and endanger the patient.

Third. It must be remembered that, in the great majority of cases in which the operations under consideration are undertakenthere exist contractions of the pelvis which may seriously interfere with the main step of the operation, inversion of the uterus. Fourth. Apart from these more serious objections, it may be urged against the plan by inversion that dilatation of the os uteri, a sine qua non of the method proposed, does not always exist at the time of operation, and that it may not always, or even often. be practicable safely to effect it.

These objections will now be considered seriatim. As to the first, regarding the shock to the system so often reported in association with inversions, it may be stated that associated with inversion also is very generally hemorrhage, and to this all-powerful cause of depression may be ascribed much of the shock noticed in cases of inversion. While it must be admitted that in some instances inversion alone, entirely unassociated with bleeding,

seems to have produced great shock, and even death, it may yet have happened that, in some of these cases, other injuries, as laceration of the uterus accompanying the inversion, may have been partly responsible for the profound impression observed, and one is the more justified in assuming that this objection may be overestimated, from the fact that in a number of cases carefully observed and reported, inversion has produced no shock whatever, and has in fact been accomplished without the knowledge of either the patient or obstetrician.

Blundell, Dailliez, Dugé, Crosse, Lee, were quoted to support the proposition that shock per se is not the cause of alarming symptoms or death in inversion of the uterus.

By reference to veterinary surgery, cases may be adduced to show, not only that uterine inversion among animals is not per se especially dangerous, but that inversion, complicated with accidents in themselves accounted most dangerous, is not necessarily fatal. In such cases reposition alone, unaccompanied with any care for existing uterine lacerations, may be followed by perfect and speedy recovery. In support of this proposition, cases were cited from the writings of J. Rainard, Guillamin, Gellé, Elevout.

As to the objection regarding the difficulty of inverting the uterus after contraction, it must be admitted that contraction of the uterus into a firm body would certainly render more difficult the inversion. The facility with which the flaccid uterus may fall into itself like tripe, or a wet bladder, or the finger of a glove, certainly contrasts strongly with the difficulties encountered by experts in restoring the inverted uterus, even as early as four hours after labor. In the absence of any experience in the matter of purposely inverting the uterus, it will be necessary in support of the practicability of this feature of the proposed operation to draw upon experience derived from practice in midwifery. A variety of facts may be brought to bear to show the likelihood of success in efforts at inversion which may be in a measure classified thus: direct facts as to the ease with which it has been accomplished directly after labor; facts showing the readiness with which from trifling causes inversion may be induced within a few weeks after labor; facts seeming to show that it may even occur in the virgin uterus, and apparently from minor causes. Replacement of the uterus after inversion, whether that organ be lax, moderately condensed, or in a state of complete involution, is an act so nearly akin to that of inversion that any facts tending to indicate the facility with which an inverted uterus may be restored to position have a bearing upon the question of the practicability of inverting the uterine tissue. Hence in the category of available facts for our present purpose belong those showing facility or possibility of reduction of the inverted womb at any stage or condition of inversion. Referring

to inversion, Barnes, Hunter, Byford, Gooch, Boivin, Dugé, Baudelocque, Radford, Cowan, J. Y. Simpson were quoted to prove (1) the ease with which inversion has been accomplished directly after labor, (2) the readiness with which, from trifling causes, inversion may be induced within a few weeks after labor, (3) that inversion of the uterus may even occur in the virgin uterus. Facts were adduced to prove the ease with which even the chronic inverted uterus was restored. Fraenkel's experiments with atropia, morphine, and chloroform in cases of spastic contraction of the uterus in the second or third stage of labor were suggestive.

This combination recommended by Dr. Fraenkel, injected into the cervix uteri at the proper moment before the operation might be relied upon to antagonize any excess of contraction of the uterus which experience might show to interfere with the efforts of the operator to invert the uterus.

In regard to the objections having reference to hemorrhage from the uterine incision, it will be observed that, in the plan proposed, the incision through the uterine walls is made with the cautery. While it is probable that the protecting power of this agent would guarantee the arrest of the bleeding from the uterine wound for a time under conditions of rest, it must be admitted that, in subjecting these seared edges to the changes of relation incident to the process of inversion, there would be danger of reopening the vessels and loss of blood. In such a case, the assistant managing the thermo-cautery would follow the edges of the wound with the purpose of retouching bleeding points when practicable. That the actual cautery will arrest the hemorrhage from the uterine wound, even under circumstances of change in its size, etc., the following facts prove.

R. W. Felkin, Breitmann, Playfair, Baudelocque, Edmunds, James Whitehead, Robert P. Harris, Fancourt Barnes were cited in support of the proposition that hemorrhage is rarely the cause of death.

In regard to the third objection, having reference to the narrowing of the pelvis, and the difficulties in the way of the suggested procedure thereby presented, it may be stated that, while narrowing of the pelvis would always prove more or less of a hindrance, yet it must be borne in mind that, in the majority of cases of deformed pelvis, however much any given diameter may be shortened, there yet remains space to one or the other side of the narrowing line through which the womb might be made to pass by the vis a fronte et a tergo. Generally in the process of inversion, as the uterus would be drawn through the superior strait, four thicknesses of the organ would be presented at the conjugate; and in cases of unusual narrowing, difficulty might be experienced in this maneuvre. In extreme contraction of the pelvis, dexterity and ingenuity on the part