upon by Dr. E. Wilson in private practice, and by the author in the surgical wards of the Philadelphia Lying-in Hospital.

Case I.-Mrs. McF., æt. 32, married, mother of three children, presented herself at the clinic of the Lying-in Charity with the following symptoms: For the past year she had noticed a tumor, about the size of a small fetal head, in the right lumbar and the right half of the umbilical region. The tumor was perfectly smooth, non-nodulated, and freely movable in the abdomen. She had had obstinate constipation, a good deal of vesical irritation, at one time had had a sanguineo-purulent discharge from the vagina; this had entirely ceased for the last seven months. She complained of deep-seated, darting pain in the lower part of the abdomen, backache, intense cephalalgia, and photophobia. Her last child had been delivered fourteen months previously with instruments. She had been under the care of a prominent gynecologist, who had diagnosticated floating kidney and recommended extirpation. After a careful examination, in which I was aided by several professional friends, the diagnosis previously made was concurred in. A careful chemical and microscopical examination of the urine failed to detect any abnormal constituent. It was then determined that laparotomy for removal of the kidney, or cutting down upon it and stitching in proper situ, would be alike unjustifiable. Upon making a more careful examination, including the uterus, the patient was found to have an extensive bilateral laceration of the cervix. The contour of the cervix was restored, and although the patient still has her floating kidney, all her distressing symptoms have ceased.

Case II.-Mrs. S., æt. 32, married, mother of two children, pelvis slightly contracted antero-posteriorly. Both children were delivered alive by forceps. This patient was sent me, by her regular attendant, with the diagnosis of cancer of the rectum. She suffered greatly from backache and headache, was constipated, passed ribbon stools, and had agonizing pain upon defecation. She had slight vaginal discharge, and a coffee-colored, foul-smelling, muco-purulent discharge from the rectum. Rectal examination revealed an ulcerated surface, extending apparently for about an inch and a half in length completely around the rectum, about three inches above the anus. Small portions of the granular surfaces of the ulcer revealed, under the microscope, no evidence of malignant growth. Specular examination of the vagina showed extensive bilateral laceration with acute retroflexion. The woman presented no evidence of cachexia. The uterus, though closely bound down by adhesions, was finally restored to its proper axis. After several weeks, the contour of the cervix was reformed. Simple astringent applications were made four or five times to the rectal ulcer. The patient made a complete recovery, and has had no return of symptoms since the operation.

Case III.-Mrs. C., æt. 22, mother of one child with history of

tedious instrumental labor. This patient suffered from violent ovarian neuralgia, augmented at the catamenial periods. She had a profuse leucorrhea, engorged uterus, and enlargement of the right ovary. She also suffered at times from suicidal dementia, which was sometimes so violent that she required restraint. Her case had been diagnosticated pyo-salpinx and oöphorectomy advised. Examination revealed an extensive bilateral laceration of the cervix extending on the left side to the vaginal junction. The cervix was restored with complete cessation of all symptoms. Examination six months after the operation failed to find tenderness or enlargement of the right ovary.

Case IV.-Mrs. S., æt. 37, married, mother of five children. This patient had been incarcerated in a private asylum for fourteen months, suffering with violent dementia. She had the typical appearance of alienation. No clear history could be obtained of her symptoms, except that she had distressing pelvic pain and profuse leucorrhea. Examination showed extensive laceration of the cervix. Trachelorrhaphy was performed, with immediate amelioration of the symptoms. Two months after the operation, she was restored to her family completely well. A year or more has elapsed since the operation in each of the cases, and the relief afforded has thus far been permanent. These cases appear to the author to have unique symptoms, following and consequent upon the lesion, though doubtless those with more extended chances of observation have met with cases presenting analogous symptoms.

DR. JOSEPH PRICE made some remarks upon the effects of cicatricial tissue in the edges and at the apex of the laceration, of the effect of laceration in inducing local engorgement and hypertrophy, and thus a long series of consequential symptoms. He spoke of the value of rest and local treatment for the relief of these symptoms, but the relief so obtained is temporary; it will last but a few months, and sooner or later, after the patient is discharged as cured, the same symptoms recur. If the cicatricial tissue is not all removed, and complete union secured throughout the entire thickness of the cervical tissue, the symptoms will return, or even be aggravated by the operation. In his experience, conception results after operation in young women.

DR. HOWARD A. KELLY remarked that he was glad to hear of the good results in Dr. Wilson's cases, as a year or more had elapsed. He thought cases of laceration of the cervix might be arranged in three classes: 1st. When the cervix, although lacerated, remains soft and flaccid, there will be no consequent symptoms. 2d. When cicatricial tissue is developed, or ectropion is present, marked reflex symptoms will ensue. 3d. When there has been natural repair, but with inclusion or formation of hard or scar tissue, there will also be marked reflex symptoms. To this latter class belong those cases, with hypertrophied glands and everted lips, of so-called erosion. These second and third classes must be relieved by rest and local treatment, and then operated upon to keep them well. Complete removal of the hard tissue, and perfect union of the coaptated edges, must be secured. Failure in either of these points will cause a return of the symptoms.

DR. BAER remarked that the symptoms were not due to the laceration, but to its inflammatory consequences. To secure a good result, the inflammatory condition must first be subdued, and then the operation of closing the laceration will be in order. It may take a long course of treatment to secure this necessary condition, but operation will probably fail to secure the desired relief without the preparatory treatment. He had found in some of these unsuccessful cases union of the external surface only, and in others fistulous tracts between the suture points. Cicatricial tissue seems to be sometimes formed after operation, when union occurs by granulation. Simple laceration without ectropion is very rare, and he would advise repair of the laceration in all cases to prevent future resultant inflammatory conditions. It is desirable to have union by first intention to avoid formation of cicatricial tissue and suture track fistules.

DR. WILSON Spoke of the choice of method in preparatory treatment. Local treatment once a week will often fail to have a good effect, when a week or ten days in bed, with douches of hot water and glycerole of tannin on pledgets of cotton, applied daily, will accomplish rapid relief of the local condition. Great care should be exercised in the removal of tissue, as complete closure of the cervical canal may happen. He has seen two such cases, which were detected at the next menstrual periods after the operation. The passage of a spear-pointed probe gave vent to dark grumous material.

DR. HOWARD A. KELLY exhibited a specimen of

HEMATOMA OF THE OVARY WITH ADHERENT FALLOPIAN TUBE.

This specimen is an example of a class of cases which stand peculiarly by themselves-cases of aggravated tubal and ovarian disease, on a small scale as compared with ovarian cyst, and yet in which there is enough change in the size and consistency in one or more of the structures of the appendages to afford most satisfactory ground for diagnostic precision under skilled bimanual examination. These cases occupy a middle ground between the larger tumors, where disease is so palpable, and those hap-hazard attempts, the present reproach of gynecological surgery, in which the operation upon appendical structures is undertaken to relieve a symptom, and the diagnosis of pathological ovarian or tubal change is made after removal, or not at all.

This is the right ovary of a patient, 21 years of age. It is about the size and shape of a large Spanish chestnut. I was able to handle it freely by bimanual examination, and determined exactly its size, shape, consistence, and relations before operating. The indications for operative interference, after I had made my diagnosis, were greater than in the case of any large ovarian cyst I have ever seen, and the prospects and result of any form of palliation were futile. Almost the whole of this large ovary is filled with a blood-clot, soft and jelly-like in part, and in part firm, fibrous, and apparently intimately united to the ovarian stroma. This clot is surrounded by a shell of apparently normal ovarian tissue,

throughout which are seen a number of follicles and old corpora lutea. A remarkable feature is the way in which the fimbriated extremity of the tube is spread out like a sucker over the surface of the ovary, and glued fast by adhesions, so that the line of demarcation between tube and ovary is but faintly indicated. From the line of junction numerous vessels course in a radiating manner down over the ovary. The left ovary is below normal size, but contains many pea-sized black clots.

The second specimens which I now exhibit were removed this afternoon. The case is an example of the third class, in which the operator has nothing but a symptom to guide him. My patient, 35 years of age, suffered from an increasing menorrhagia for fourteen years. Lately she has been bleeding half the time. She has had recourse to every possible plan of treatment with but slight and temporary relief. The only thing I could do was to perform oophorectomy and stop her menstruation. One ovary weighs one hundred and thirty-nine grains, and the other one hundred and three grains. A beautiful corpus luteum of menstruation, about two and a half weeks old, shows that the hemorrhages, which retained all along a menstrual periodicity, were in reality menstrual. The tubes are free from disease. In one ovary a globular pellucid cyst lies between the layers of the broad ligament, in close proximity to the fimbriæ, the tubo-ovarian_ligament being spread out over its surface.

DR. WILSON called attention to the fact that in the first specimen the tube had been occluded by a torsion or twist upon itself. DR. BAER remarked that it would be interesting to know the results in Dr. Kelly's last case. In such a case there is of necessity a cause for the hemorrhage; there is no apparent diseased condition of ovary or tubes sufficient to account for it. Hemorrhages from the uterus are often associated with vegetations upon its lining surface, but these are not always present. He alluded to one case in which hemorrhage continued to be profuse after the removal of the tubes and ovaries which had been very much diseased.

DR. PRICE remarked that in this last instance the continued hemorrhage might be the result of body-habit, although the original cause might be removed.

DR. HARRIS spoke of a case of fibroid tumor of the uterus with menorrhagia, in which removal of the tubes and ovaries gave complete relief.

DR. KELLY had eight months ago removed both ovaries and tubes, and the menorrhagia still continues. In the case operated upon to-day, the curette had been used, but no vegetations had been found. A strong tincture of iodine applied thoroughly to the inside of the uterus, and vaginal packing would quickly stop the hemorrhage for the time, but it would soon recur. Operation was performed to relieve the symptom hemorrhage by bringing on the menopause, and not because the ovaries were supposed to be diseased.

DR. J. PRICE exhibited specimens from a case of

PYO-SALPINX.

The tube was as large as the finger and cheesy in consistence, and was easily broken, even by the bite of the hemostatic forceps. The patient was in a typhoid condition with high evening temperature, emaciation, quick pulse, pain in locomotion. There certainly had been leakage of pus before, but two ounces escaped at the time of removal. Adhesions were numerous but were cheesy and broke down readily. After the operation there was rapid subsidence of the pulse and temperature with the other symptoms. Free washings of the abdominal cavity through a drainage tube were practised for a few days. There was a clear history of gonorrhea. The other tube and ovary were not enlarged.

DR. BEATES remarked that in one case upon which he had operated, repeated attacks of peritonitis had caused large deposits of flaky lymph in Douglas' cul-de-sac. These were nicely removed by sponging.

DR. BAER raised the question of the gonorrheal origin of the salpingitis in Dr. Price's case which was unilateral, while gonorrhea usually causes both tubes to become diseased.

DR. PRICE stated that Dr. Tait's new book reported a gonorrheal case of unilateral salpingitis. Comparing with the male analogue, epididymitis, which is usually unilateral, would support the idea of such an origin. A free leakage of secretion from the tube, and absence of constriction may prevent the accumulation of pus on one side.

DR. BEATES exhibited specimens from a case of

DIFFUSED SARCOMA UTERI WITH METASTASIS TO LIVER AND LUNGS.

The patient from whom the specimens were obtained was in excellent health until the development of this affection. Æt. 59. Catamenia established during her 16th year without undue disturbance. She has had four children and no miscarriages or pelvic disease during her sexual life. There is no evidence of heredity toward myoplastic disease. Menopause at age of 48, without incident; about five years later a hemorrhage occurred lasting a few days. It recurred with decided regularity, and the patient, believing it to be menstrual, did not have recourse to treatment until an intermenstrual sero-sanguinolent discharge appeared. Later this assumed a purulent type and was accompanied by constant pain. The condition was now regarded as carcinomatous. In June, 1885, I found the patient emaciated, cachectic and weak; digestion was impaired, and the stomach irritable. Local pain was intense with nocturnal exacerbations; there was also incontinence of urine and its consequent intertrigo. The vagina was so occluded with numerous neoplasms, varying in size from mere nodules to the size of an olive, that an examination of the uterus was impracticable. Some of these were pedunculated. There was an offensive ichorous discharge; bleeding occurred upon the slightest touch. The history was one of progressive asthenia. The autopsy by Dr. Formad disclosed the