a solution of bicarbonate of sodium. Three or four days after the operation the temperature rose and was elevated for several days, while at the same time there were evidences of peritonitis. The patient's condition improved, but on the tenth day, while sitting up in bed, she suddenly fell back and expired, her death being doubtless due to pulmonary embolism. The specimen was submitted to Dr. Heitzmann for microscopical examination. He pronounced the disease to be villous cancer of the endometrium, a rare form of malignant growth in this locality, although not uncommon in the bladder. A mass presenting similar microscopical appearances was situated in one of the broad ligaments near the ovary. The speaker remarked that the association of cancer and fibroma was quite uncommon, especially when both neoplasms were found in immediate contact, as in this case; he had seen but one other similar case in which there was cancer of the cervix and fibroid of the uterus.

DR. WYLIE asked if the patient's temperature was elevated at the time of her entrance into the hospital. A negative answer was given.

DR. PERRY asked if the entire uterine cavity was encroached upon by the fibroid.

THE PRESIDENT said that it was not.

DR. WYLIE remarked that he had had two cases in his ward at Bellevue Hospital, in which a suppurating tumor presented at the os externum. He did not believe in attempting to remove such growths before antiseptic vaginal injections had been employed until the decomposing masses had been rendered practically aseptic; then the curette might be used with far less risk of carrying infection into the uterine cavity.

THE PRESIDENT believed that the peritonitis in his case might have been due to the chloride of zinc.

DR. WYLIE said that he had in former years seen many cases of sloughing fibroids at the Woman's Hospital, most of the patients dying of septicemia whenever attempts were made to remove the tumors; this experience had led him to be most careful in regard to antiseptics.

DR. HANKS asked if the patient did not really die of pulmonary embolism, and not of septicemia.

THE PRESIDENT assented to the former theory, but believed that septic peritonitis was certainly present also. In reply to a question from Dr. Wylie, he said that there had been perfect drainage.

EXPLORATORY PUNCTURE versus EXPLORATORY INCISION,

DR. HENRY C. COE read a paper with the above title. [To be published in a future number of this JOURNAL.]

The reader contended that the exploratory puncture of abdominal and pelvic cysts had fallen into undeserved disfavor. The microscope was an invaluable aid to diagnosis in many obscure cases, chiefly in malignant disease of the abdominal or pelvic viscera accompanied by ascites. When the instrument employed was the hypodermic needle, and not the aspirator, the dangers were not so great as they had been represented. An exploratory incision, on the other hand, was fraught with more risk to the patient than

was generally acknowledged, and should not be resorted to until all possible means of arriving at a diagnosis had been employed in vain.

DR. WYLIE agreed with the reader in most of his deductions, and believed that the hypodermic needle was frequently a valuable aid to diagnosis. But he added that he generally wished to be ready to operate immediately after puncturing a cyst, since alarming symptoms sometimes followed this procedure. He said that he could recall at least two cases in which death had resulted from the use of the hypodermic needle. In one instance, a distended gall-bladder was punctured; it was so tense that oozing occurred after the needle was withdrawn, and peritonitis resulted. In the other case, which was one of perityphlitis, a fatal peritonitis was produced by the oozing of pus through the track of the needle. He added that in an obscure case of perityphlitis, upon which he had operated during the previous summer, the sac of the abscess was so tense that, on opening the abdomen, the pus burst out even before a puncture was made. It would certainly have been dangerous to puncture such an abscess, unless one was ready to operate at once. He did not hesitate, however, to pass a fine needle through the vaginal vault into an intra-pelvic cyst.

DR. HARRISON concurred with Dr. Coe in most of his remarks, but he certainly thought that exploratory puncture might be followed by fatal results. He had once converted a simple dermoid cyst into an abscess by tapping it. In some cases the abdominal wall was so thick that an ordinary needle would not penetrate it. He thought that it was dangerous to interfere with an hematocele. DR. HANKS thought that Dr. Coe had made a good point in insisting upon the importance of exploratory puncture in certain cases of suspected malignant disease. When ascites was present, and there was a suspicion of cancer of the abdominal viscera, it was better to withdraw the fluid, and then to make a careful examination, than to proceed at once to an exploratory incision.

DR. HUNTER did not believe that it was possible to establish a fixed rule that would suit every case. He instanced a case of his own in which a patient had been tapped twice before submitting to an exploratory incision. After the fluid was withdrawn the first time, a careful examination failed to reveal anything abnormal about the pelvic or abdominal viscera; after the second tapping, a small growth was felt behind the uterus. At the operation, extensive disease of the pelvic organs, omentum, and intestines was discovered. The patient died of shock on the second day after the operation. Dr. Hunter could recall some accidents following the introduction of the hypodermic needle into cystic tumors, and many from the use of the aspirator.

THE PRESIDENT remarked that in a recent case of suppurating dermoid cyst which had been pronounced by Dr. Thomas and himself probably a sarcoma, after opening the abdomen he had once plunged a hypodermic needle into the tense cyst, suspecting fluid, and found no pus to escape through the needle, but on withdrawing the needle, a drop oozed out through the puncture, and appeared on the exterior of the tumor. If this cyst had been punctured through the abdominal wall, the patient would certainly have died of peritonitis from purulent infection. He had found the hypodermic needle exceedingly useful in a number of instances; it had frequently saved the patient from an exploratory in

cision, as in a case in which he withdrew a syringeful of fluid, and found, on microscopical examination, that he had to do with a cyst of the liver, with which he, of course, did not interfere. He had met with the most satisfactory results in aspirating small intra-pelvic cysts, especially hydro-salpinx; he differed from Dr. Coe in regard to the constant presence of ciliated epithelial cells in the fluid from a hydrops tube. He thought that there was less danger in tapping an hematocele if the sac was subsequently laid open and thoroughly irrigated, as he had done in two instances with good results. In conclusion, he stated that he had that same day been deterred from opening a woman's abdomen for the purpose of removing a tumor, because, on aspirating the same per vaginam, he withdrew a serous bloody fluid, which was undoubtedly indicative of malignant disease. Once before he had made a diagnosis of pelvic abscess, to which both the history and symptoms pointed, but when the cyst was aspirated by the attending physician, sero-sanguinolent fluid was removed, which was pronounced by Dr. Heitzmann to be from a sarcomatous tumor.

Stated Meeting, March 16th, 1886.

The President, DR. PAUL F. MUNDÉ, in the Chair.

SPECIMEN OF ABORTED OVUM.

DR. HUNTER showed a product of conception discharged between the third and fourth weeks of pregnancy. Its true character was proved by the presence of distinct chorionic villi. He said that the patient in question had miscarried twice before at an early period, and, as she had an extensive laceration of the cervix, it was interesting to inquire if there was not some direct relation between the latter condition and the frequent abortions.

DR. SKENE thought that the specimen was a diseased ovum, since the chorion appeared to be much thicker than normal. He believed that a laceration of the cervix might lead indirectly to a miscarriage by causing an endometritis, which latter condition might produce an inflammation of the ovum, with resulting carneous degeneration. He thought that it was rather unusual that any patient in New York should be allowed to abort three times before an operation was performed upon her cervix.

DR. HUNTER explained that he had been endeavoring for a long time to prepare the patient for an operation, but that she became pregnant so soon after each miscarriage that there had been no chance to operate.

DR. SKENE asked how long it was necessary to wait after a miscarriage before operating upon a lacerated cervix.

DR. HUNTER replied that in the case under discussion he should wait about six weeks.

DR. POLK, in reply to a question from the President, remarked that he would operate as soon as involution was complete, i. e., in from six to eight weeks; if the uterus still remained large, it might be well to reduce its size before operating.

DR. HUNTER said that he would not fix any precise limit, but preferred to be guided by the general condition of the patient.

DR. POLK asked if there was a posterior displacement in Dr.

Hunter's case. Dr. Hunter replied in the negative. Dr. Polk thought it hardly likely that a mere laceration of the cervix would in itself cause a miscarriage, unless there was an accompanying endometritis. If pregnancy occurred when the latter condition was present, there was usually a non-development of the vessels supplying the ovum, leading to atrophy of the chorion. The repeated miscarriages in the case under consideration undoubtedly pointed to some local pathological condition, probably to disease of the endometrium.

DR. B. EMMET stated that he had frequently remarked a direct relation between laceration of the cervix and abortion; a laceration that extended high up the cervical canal was especially liable to induce a miscarriage.

RUPTURE OF THE UTERUS-DEATH FROM SHOCK.

DR. POLK narrated the following case: About two weeks before he had been summoned to the Emergency Hospital to see a woman who had been recently brought in in a state of collapse. On examination, the presentation was discovered to be a left dorso-anterior, the child being dead. Internal version was easily performed, and delivery promptly effected. There seemed to be an extensive laceration of the cervix, but a thorough examination was not made on account of the weak condition of the patient. The uterus remained flaccid after the delivery of the child, and there was an occasional gush of dark blood. The organ was depressed from above, while its cavity was washed out by means of a Chamberlain's tube; the hand was not passed for fear of causing an additional shock to the patient, who was now almost pulseless. She sank rapidly and died within an hour after being delivered. From what could be gathered of her history, it seemed that she had borne several children before with little difficulty, and being very poor, endeavored to do without either a midwife or a physician. She had been in labor for forty-eight hours, when her neighbors, suspecting that something was wrong, reported her case to the police, and she was sent to the hospital. The rupture probably occurred at three o'clock on the afternoon previous to her entrance, at which time she had a succession of violent uterine contractions, after which the pains ceased entirely and did not return. with any force. At the autopsy a large rent was discovered in the left side of the uterus, corresponding with the line of attachment of the broad ligament; it began at a point two inches above the os internum and extended completely through the cervix. The peritoneal coat was not involved. There had been an unusually large extravasation of blood which had extended between the folds of the left broad ligament, beneath the peritoneum covering the iliac fossa, and upwards behind the colon as high as the diaphragm; it could then be traced between the layers of the mesentery nearly as far as the small intestine. The question which would naturally suggest itself was, whether the rupture had occurred before he delivered the woman or had been caused

during the version and extraction of the child. The latter theory was negatived, not only by the condition found at the autopsy (the effusion of blood proving that the accident had occurred several hours before), but by the fact that the version was effected so easily. The patient's condition at the time of entrance was fully accounted for by the loss of blood; the additional shock caused by the delivery was enough to kill her.

DR. WYLIE said that he had recently seen a case in one of the medical wards in Bellevue Hospital, in which a rupture of the uterus could be clearly felt. The tear, which was on the right side, had partially healed, when septic symptoms appeared. Both the uterine cavity and the original rent were freely dilated, in order to allow of free drainage, the cavity being thoroughly irrigated. The patient had done perfectly well, her temperature being normal at the time of speaking.

DR. COE said that he had observed four cases of rupture of the uterus while in Vienna. One of the patients recovered, although she was nearly moribund when brought into the hospital, having been in labor for two days. After the child had been extracted, a large drainage-tube was passed through the tear into the abdominal cavity, and irrigation with a solution of carbolic acid was continued for several days.

DR. SKENE asked if the rupture had extended entirely through the cervix. Dr. Polk replied in the affirmative. Dr. Skene did not see why, from the position which the child's head had occupied, the cervix was so extensively involved. He asked if it was not possible that the latter might have been torn during the efforts at extraction.

DR. POLK was not sure as to this point, but he did not think that he was responsible for the cervical tear. The cervix had been drawn upwards and rendered very thin on the side next to the child's head. The autopsy, which was made six hours after death, did not throw any light upon the question.

DR. SKENE cited a case (terminating fatally) which he had observed about four months before in consultation with Dr. Jewett, of Brooklyn. After a fruitless attempt had been made to deliver by a high forceps operation, she was sent to the hospital. When examined, her uterus was found to be contracted, the placenta having been delivered, while the child had escaped into the abdominal cavity. Laparotomy was performed by Dr. Jewett and the child was extracted. The rupture was situated on the left side of the uterus in the middle of the broad ligament, the folds of which were separated. It extended down to, but not through the cervix. The question which was raised in that case was whether the laceration was due simply to the violent uterine contractions, or to unskilful use of the forceps. He inclined to the former view, as the rupture did not extend lower than the os internum. DR. GILLETTE did not see how forceps could cause such an injury.

DR. SKENE said that, of course, they had been employed by one who was not accustomed to their use.

DR. PARTRIDGE remarked that he had seen two cases of rupture of the uterus, and did not understand how the accident could be caused by the forceps, unless the blades were introduced in a very clumsy manner.