trivalve and screw long before he died, and used the instrument which he (the speaker) had modified, mainly by curving the tips. As for the danger from dilatation, there is none if proper antisepsis be resorted to. The objection to conical dilators is that they are apt not to dilate where we wish, at the internal os.

DR. A. F. CURRIER (New York) read a paper on

LOCAL VS. GENERAL TREATMENT IN GYNECOLOGY.

The reader contended that much of the opprobrium cast upon gynecology as a specialty arose from the fact that it was a new science, and a fashionable science, and that, therefore, the practice was likely to be abused by unskilful men. From the errors and extremes of our predecessors we might learn much of value for the future. We were still all too much inclined to ride hobbies, whilst we should rather be studying uterine pathology in order to practise better. The dependence of local symptoms on general systemic causes should never be forgotten. In a large proportion of women, all that is needed towards efficient treatment is common sense and tonics. Constipation is especially frequently at the bottom of symptoms which, at first glance, point clearly to the uterus or its neighboring organs. Every organ of the body should, in turn, be examined before jumping at the conclusion that there exists uterine disease. He would protest against the unnecessary frequency with which vaginal examinations and local treatment were resorted to. Over-treatment is the bane of gynecology. Gynecology means medicine, and the application of common-sense principles to medicine constitutes gynecology.

Afternoon Session.

The Association reconvened at 2 P.M., Dr. Hunter presiding. DR. INGALLS (Hartford), in discussing Dr. Currier's paper, said that the tendency after leaving the Woman's Hospital is to account for all symptoms by the local conditions, but that, with enlarged views and practice, it was found that general causes often were at the bottom of local symptoms, and that the reverse was equally true. Usually we could only expect the best results for our patients when we combined general medication with local.

DR. P. H. INGALLS (Hartford) then read a paper on

THE NON-SURGICAL TREATMENT OF ANTERIOR DISPLACEMENTS.

The reader contended that each case required special treatment, because there was no common cause. Emmet believed that the symptoms accompanying these displacements were the results of pelvic cellulitis. Thomas, that the position of the uterus and the state of the uterine canal caused the symptoms. The reader did not resort to surgical treatment for the relief of symptoms dependent on anteflexion. He was afraid of cutting and the glass stem. Although he had never tried either, in the practice of others he had seen serious results. The stem was an irrational instrument, and,

ultimately, would be abandoned. It could not effect a permanent cure, and was likely to do harm whilst being worn. Rapid divulsion he believed to be less dangerous in its results than discision. He often made use of simple dilatation, and, if persisted in, it cured. Neither simple nor extensive dilatation should, however, be attempted if there were any signs of pelvic exudation. As for pessaries, in anteflexion he did not know of one which was good for anything. His own experience in the treatment of ten cases was: The hot douche should be ordered till all trace of thickening has disappeared. Where there is spasmodic pain at menstruation, he uses Molesworth's dilators once a week, and just before the period. If uterine congestion be present, under iodine to the vault and glycerin tampons, great improvement would ensue. Attention to the general health should be the cardinal accompaniment of any treatment.

DR. CHAMBERS (New York) agreed in the main with the reader of the paper, although he thought that treatment a little more radical would affect cure more quickly. Incision and dilatation he did not consider dangerous. it required only weeks, instead of months, of treatment. The stem must be watched, of course, whilst worn, and it must be worn from one to six months. In from fifty to seventy-five cases treated by this method, he had seen no bad results.

DR. CURRIER considered gradual dilatation very satisfactory, compared with forcible dilatation and incision.

DR. CHAMBERS said, in addition, that where harm resulted from a stem, he believed this to be due to the fact that thorough antisepsis had been neglected. This was the key-note to the successful use

of the stem.

DR. INGALLS, in reply, said he had yet to see the case where incision had not done harm.

DR. GEO. T. HARRISON then read a paper entitled

BRIEF STUDY OF THE CAUSES OF RETROFLEXION AND PROLAPSE OF

THE UTERUS.

The reader treated more particularly of retroversio-flexio. Acute backward displacement may result in the unimpregnated organ, but usually the condition is chronic. The prevalent view that backward displacement usually follows on the puerperal state was not correct. The reader sought the cause in: 1. Arrest of development-the short vagina is ordinarily an accompaniment of retrodisplacement, and, 2. Relaxed condition of the uterine ligaments, particularly the folds of Douglas (the musculi retractores of Luschka). There results loss of posterior fixation. One factor causing this weakened condition is parametritis posterior (Emmet). The retractores becoming atrophic, the cervix losing its posterior fixation, at first effort, perhaps on account of full bladder, the fundus falls backward. A further cause of posterior displacement is laceration of the cervix. Neither prolapse of the vaginal walls, nor subinvolution can cause retro-displacement. If the ligaments are performing their normal function, it was impossible

for a full rectum or bladder or strong abdominal effort to dislocate either the puerperal or non-puerperal uterus into retroversion or flexion.

DR. T. ADDIS EMMET said that in a state of health, with normal uterine ligaments, displacement is not likely to occur. Local cellulitis, following on laceration of the cervix, was the cause of displacement commonly. Flexion was only an exaggeration of version. The organ prolapses before it retroverts, and it is the prolapse which causes the symptoms. The rational treatment then should consist in raising the uterus to its normal level. The common mistake is to force a retroverted uterus forward, and thus make traction on inflamed ligaments. By raising the uterus we restore the circulation. Forcible replacement may light up a cellulitis. It is from inattention to these truths that so many fail with pessaries.

DR. GOFFE was glad to see such stress laid on the ligaments as the supporters of the uterus instead of the perineum. All the other organs are held in place by ligaments, instead of resting on a supposititious shelf, why not the uterus? The perineum may be torn entirely through, and yet the uterus remain in place.

DR. DUDLEY believed that the most common cause of retrodisplacement was arrest of involution. This is accompanied by enlarged vagina and elongated ligaments. The ultimately resulting areolar hyperplasia must first be treated before we can expect to handle the version scientifically. He referred to the beneficial effect of trachelorrhaphy in reducing hyperplasia, and this of itself tends to relieve the displacement.

DR. HARRISON, in closing, said that he did not believe that the perineum gave support to the uterus, and he insisted that, if the ligaments were doing their work properly, subinvolution could not produce retroflection.

DR. H. C. COE (New York) read a paper on

THE EXAGGERATED IMPORTANCE OF MINOR PELVIC INFLAMMATIONS,

He stated that he did not write purely from the standpoint of the pathologist, and that in the statements he should make he did not wish to appear as dogmatically at variance with the opinions held by T. Addis Emmet. His aim was simply to give expression to his honest opinion, deduced from careful clinical and pathological work, and this was that the minor degrees of peri-uterine exudation were much exaggerated in importance, especially since not only he, but other pathologists, had utterly failed to find, post mortem, any evidence of what, clinically, almost every gynecologist was in the habit of feeling and diagnosticating daily. He referred especially to what was denominated "old (chronic) thickening,” and which was taken as evidence of an antecedent exudation into the pelvic cellular tissue. He questioned if the minor pelvic inflammations could be differentiated, in the living, by touch, any more than they could be post mortem, and if so, he would also question if these so-called thickenings ought to be deemed as contra-indicating surgical operations. The site of these thickenings was usually in the broad ligaments near the cervical junction, and

in the posterior folds of the peritoneum, which were denominated the retro-uterine ligaments. In any case of peri-uterine inflamma tion, peritonitis was the predominating element. He believed, from post-mortem findings, that the indurations and thickenings were the result of cicatricial tissue in the peritoneum and not of cellular inflammation. It is contraction in the vaginal vault which draws the cervix to one side or the other, and not contraction in the broad ligament. Neither local tenderness nor induration suffice to make the diagnosis of cellulitis, because over the site of these signs there is no infiamed cellular tissue. As for the so-called posterior ligaments of the uterus, seeing that they contain the musculi retractores, they may normally contract, so that apparent thickening may just as well be due to contraction. Increased tension as a sign of cellulitis is purely relative, and under anesthesia this increased tension disappears. To what extent, then, does "old thickening" contra-indicate operative interference ? These thickenings, being only cicatrices, can hardly exert much influence on the pelvic vessels. It is not these indurations which cause trouble, but the inflammatory results higher up which the finger cannot detect. Adhesions from a former peritonitis were far more dangerous than slight cicatrices from cellulitis. Whilst he did not think, therefore, that old indurations contra-indicated surgical manipulations, he desired to state that he was clinically as careful as any one in his behavior towards a uterus with the forbearance of which he was unacquainted. He did not rashly use the sound or make applications. He could not, however, see how hot water and iodine could be of the slightest benefit in dispersing these, in importance much-magnified, old thickenings.

DR. T. ADDIS EMMET said that he used the term cellulitis simply for want of a better. He did not think that after all there was such a great disparity in the views just enunciated by Dr. Coe and those which he himself held. He feared, however, that the publication of Dr. Coe's paper might lead to harm, because the inexpert would feel justified in doing much more than was warrantable. He (Dr. E.) took an extreme view in order to warn the non-expert. He was firmly of the opinion that pulsation and tenderness were signs of import of something, no matter what it was called, of which we must beware. If he could not trust to hot water and iodine for getting rid of this tenderness, he would give up the practice of gynecology.

DR. WYLIE stated that his experience had been rather on the living than on the dead, and that his views were based on observations drawn from a large number of laparotomies. He had been called a "tube" man, but nevertheless this did not shake his belief in the fact that in at least four-fifths of pelvic troubles the origin was in the tubes. He was satisfied, from ample clinical observation, that the bursting of small cysts often caused local exudations, in four cases out of five it was the posterior layer of the broad ligament which was affected. The adhesions in the posterior layer contract, and the ovary and tube fall down posteriorly from their normal position. In all his cases but two, he had

found old adhesions, the result, in all probability, of passage of fluid from the tube.

DR. T. A. EMMET said that if what he called thickening was the prolapsed tube, we ought never to operate in such cases, because the condition readily disappeared under appropriate treatment.

DR. COE, in closing the discussion, reiterated that his remarks referred purely to "old thickenings," and not to acute exudations. The point he wished specially to emphasize was that clinically we could not recognize such thickenings as a result of cellulitis.

TRANSACTIONS OF THE GERMAN

GYNECOLOGICAL SOCIETY.

SECTION XVIII. OF THE FIFTY-EIGHTH ANNUAL MEETING
OF GERMAN NATURALISTS AND PHYSICIANS,
HELD AT STRASSBURG.

(REPORTED BY M. GRAEFE, M.D., HALLE A. S.)

(Translated from the Centralblatt f. Gynäkologie.)

(Concluded from p. 106.)

BAYER (Strassburg) read a paper on

OPHTHALMOSCOPIC APPEARANCES IN SEPTIC INFECTION.

In the winter course of 1880-81, the speaker had the opportunity of observing a number of cases of puerperal fever, in all of which alterations of the fundus of the eye were demonstrated, and the same fact was noted in several puerpera who were suffering from non-septic affections. Since that time, despite continued examinations, B. has failed to find similar conditions. He briefly described some cases, and illustrated the results of the ophthalmoscopic examinations by drawings made at the bedside.

The conclusions at which he has arrived on the strength of his material are the following:

1. The failure to obtain a positive result does not invalidate the diagnosis of sepsis, nor does it allow of a more favorable prognosis.

2. The non-septic affections of the fundus of the eye, which occasionally can be demonstrated in puerperæ, are of the greater importance for the diagnosis the more the actual morbid process is hidden by puerperal symptoms. (In this respect, two cases previously reported by the speaker are of particular interest. In one, the disease was miliary tuberculosis; in the other, a grave