uterine cavity could be found, and it was impossible to tell from which side of the organ the tumor sprang. The condition seemed to be one of polypus uteri with partial inversion; the sound could not be introduced at any point. As the woman was very fat, it was impossible to distinguish through the abdominal wall the cupshaped depression which is characteristic of inversion. The tumor was rapidly detached with the finger-nails and was removed. The cavity was packed with iodoform-gauze, and the recovery was uninterrupted. The interesting points in the case were the rapidity with which the protrusion occurred, and the absence of excessive hemorrhage, as well as the obscurity of the diagnosis. In connection with the case, reference was made to Scanzoni's observations with regard to the frequency with which fibroid tumors led to inversion of the uterus. The President had seen three similar cases, one at the Woman's Hospital several years ago in the service of Dr. T. Addis Emmet, where the diagnosis between inversion and polypus was in doubt for a week; another at Bellevue Hospital under Dr. Lusk, in both of which the polypus was not positively diagnosticated until an incision was made into the tumors, and enu cleation attempted and completed; and a third one in his service at Mt. Sinai, where he agreed with the diagnosis made by the physician in Worcester, Mass., who sent in the patient, until, under thorough anesthesia, he was enabled to detect a small nodule on the left side by bimanual palpation, which proved to be the uninverted left horn of the uterus. The diagnosis in this last case was greatly obscured by the adhesion of the cervical canal to the pedicle of the tumor all round, so that a sound did not enter the

uterus.

DR. W. M. POLK then made some remarks on the subject of

THE CURE OF PROCIDENTIA BY ALEXANDER'S OPERATION. After dwelling for a short time upon the anatomy of the structures which served to support the uterus, especially the pelvic muscles and fascia, he referred to the injuries to the pelvic floor that resulted from parturition, and to the plastic operations that had been devised for the repair of those lesions. All of these operations had been shown to be imperfect, since they either did not fulfill the indications at the time, or they were not permanent in their results. The speaker here criticised Dr. Emmet's operation upon the posterior vaginal wall, which had for its alleged object the uniting of the torn pelvic fascia; it was hardly possible that this was actually accomplished, in fact, the operator did not know exactly what parts were united. All plastic operations upon the vaginal wall, combined with perineorrhaphy, failed, because not only was the natural support of the uterus not restored, but the tissues were sure to become stretched in the course of time. The operation of shortening the round ligaments offered the most rational method of relieving procidentia, since it restored

the uterus to a position of anteversion in which it could be acted upon by the natural abdominal forces (especially the pressure of the intestines), which tended to keep it in position. The speaker said that he would not dwell upon the technique of the operation, as it had already been discussed in the Society, and he intended later to set forth his views upon the subject. He had operated fifteen times, sometimes under circumstances of great difficulty, and was satisfied that Dr. Alexander's contribution to surgical gynecology was an extremely valuable one.

DR. PERRY said that he had witnessed one of Dr. Polk's operations, and was impressed with the value of the procedure, as well as with the manner in which it was accomplished. He desired to ask the speaker if be proposed to give up the perineal operation entirely.

DR. POLK replied in the negative; he had only laid stress upon the anatomical fact that in the operation of perineorrhaphy it was only the integument and fascia which were brought together, and not the ruptured muscles.

DR. B. M. EMMET spoke of the causes of procidentia uteri. He thought that after the destruction of the perineal body and the prolapse of the posterior vaginal wall, the uterus first became retroverted and later procidentia occurred. If the uterine ligaments remained intact, and the perineum was restored (the redundancy of the vaginal walls being at the same time corrected), the uterus could be kept in place. It was not necessary to narrow the vagina, but simply to restore it to its original condition. If the anterior and posterior walls were in contact, there was sufficient support to uphold the uterus, unless its weight was increased by the presence of a fibroid. He did not believe that it was possible to bring the torn muscles together, and, indeed, this was not necessary. One essential point was to reduce the size of the uterus by repairing a laceration of the cervix, if one existed.

DR. POLK said that the principal object aimed at in shortening the round ligaments was to keep the uterus in a position of anteversion, and thus to prevent the retroversion which favored procidentia.

Stated Meeting, April 20th, 1886.

The President, Dr. P. F. MUNDÉ, in the Chair.

SPECIMEN OF PREGNANT UTERUS WITH SUBPERITONEAL FIBROIDSDEATH FROM SEPTICEMIA FOLLOWING PYELO-NEPHRITIS, THE RESULT OF RETENTION, DUE TO PRESSURE ON THE NECK OF THE BLADDER.

DR. LEE exhibited a uterus removed post-mortem from a patient who was between the fourth and fifth month of pregnancy, together with the bladder and kidneys. Projecting from the anterior aspect of the uterus were three fibrous tumors about the size of lemons. The bladder showed marked evidences of cystitis, the mucous membrane being necrotic; the kidneys were large, soft, and riddled with abscesses, the calyces were distended and contained pus. The history of the case was as follows: The patient

was a multipara, æt. 40, who had entered Dr. Lee's service at the Woman's Hospital three weeks before, having an abdominal enlargement which had been diagnosticated as an ovarian cyst by her former physician. A careful examination revealed the presence of a retroverted pregnant uterus (at the end of the third month), the fundus of the organ being impacted in the sacral cavity, while the cervix was situated so high above the arch of the pubes that it was not accessible to the examining finger. By palpation above the symphysis some subperitoneal fibroids could be felt anterior to the uterus, and pressing upon the neck of the bladder; the latter organ was distended to such an extent that it extended upward above the umbilicus. It was clearly evident that the patient was suffering from retention of urine, since the supposed cyst disappeared entirely on catheterizing the bladder. It was impossible either to replace the uterus or to dilate the cervix, in order to induce premature labor, since the latter was so situated behind the symphysis pubis that it could not be reached. The patient was kept in the hospital under observation, with the hope that, as the uterus enlarged and tended to rise out of the pelvis, the impaction might be overcome and the organ replaced. She suddenly developed pneumonia in the right lung; the local trouble diminished, but a high temperature (103° to 104° F.) persisted, associated with symptoms of septicemia. There was no vomiting, the bowels were regular, and the patient did not appear to be in immediate danger; but on the day preceding this report she sank rapidly and died. At the autopsy, the bladder was found to be greatly distended, the distention being directly due to the compression of the vesical neck against the symphysis by the fibroids. The bladder was the seat of marked inflammation, while both kidneys showed extensive suppurative pyelo-nephritis. An interesting feature in connection with the latter condition was the presence of only a small amount of albumin in the urine, while repeated microscopical examinations revealed but few hyaline casts in addition to the ordinary deposit of pus. The important question involved in the case had reference to the matter of inducing premature labor. Dr. Lee was sorry that he had not attempted this, yet the difficulty was so great, and the condition of the patient caused so little uneasiness that he had felt justified in waiting, for the reason stated.

[At the request of the Society, Dr. Lee opened the uterus. It contained a fetus of about four and one-half months.]

DR. SKENE thought that Dr. Lee was perfectly right in waiting. He asked how long the case had been under observation. DR. LEE replied that she had been in the hospital about three weeks.

DR. SKENE thought that an effort to produce an abortion would not only have been unsuccessful, but would doubtless have hastened the death of the patient. He recalled a case of retroversion with pregnancy, in which it seemed to be impossible for the uterus to expel its contents even after the cervical canal had been dilated.

Dr. Skene did not know why it was so difficult for the uterus to empty itself, unless it was because it was difficult for the organ to work against gravity. This was the third that had come under his observation in which fatal pyelo-nephritis has resulted from pressure exerted upon the urinary tract by fibroid tumors; this fact went to prove that death from this cause was not so very rare. DR. FOWLER asked concerning the condition of the urine.

DR. LEE replied that it contained a moderate amount of pus, and on a few occasions some hyaline casts, but no characteristic epithelium; albumin was never present in any considerable amount. The diagnosis of pyelitis had been inferred.

DR. WYLIE asked if the patient had complained of pain in the region of the kidneys.

DR. LEE replied in the negative. The patient had been so comfortable that she was not confined to her bed until the evidences of septicemia had appeared; the renal symptoms were secondary to those of pneumonia.

DR. FOWLER remarked that pyelitis and pyelo-nephritis often existed without the presence of any characteristic appearances in the urine, a deposit of pus alone indicating suppuration at some point in the urinary tract. He recalled a case in which the sediment consisted almost entirely of pus, the diagnosis being made from the presence of a few pelvic epithelial cells.

DR. WYLIE said that he had recently heard of a case of uterine fibroid, in which the patient had been seized with a sudden pain in the right lumbar region which probably pointed to some affection of the kidney.

DR. EMERSON asked how long the patient had suffered from retention of urine before she entered the hospital.

DR. LEE was unable to say. In reply to a question as to the character of the urine first drawn, it was stated by Dr. Hooker (present by invitation) that much of the urine escaped spontaneously on raising the fibroids during the bimanual examination, but that over a pint must have been withdrawn through the catheter, which had an acid reaction, a high specific gravity, and contained a small amount of albumin. Dr. Lee agreed with Dr. Fowler in believing that the presence of pus and pelvic epithelium were sufficient to establish the diagnosis of pyelitis.

DR. EMERSON thought that, in the case under discussion, the condition was analogous to that of enlarged prostate in the male in which a residue of urine remained after the bladder had apparently been emptied and became decomposed, causing cystitis and pyelitis. The obstruction was really at the neck of the bladder, and not at the ureters.

DR. SKENE said that the ureters were rarely obstructed by direct pressure, but rather as the result of retention of urine, their mouths being compressed and a dangerous inflammation resulting, the whole being secondary to hyperdistention of the bladder. He had recently seen a lady who had been confined some time before, whose bladder had been neglected for forty-eight hours after delivery. As a result she had been suffering for several months with marked renal trouble, albumin and casts appearing in her urine; she was then just recovering from the nephritis due to that brief distention of the bladder.

DR. HUNTER did not think that the mere presence of the fibroids, aside from the renal trouble, would have interfered with the favorable progress of the case. He had formerly reported to the So

ciety a successful case of forceps-delivery in which the uterus contained a mass of fibroids much larger than those in the specimen exhibited.

DR. LEE explained that he did not intend to convey the impression that the fibroids alone would have prevented the induction of premature labor. It was the impaction of the retroverted uterus in the hollow of the sacrum, and the manner in which the tumors were wedged against the symphysis, that rendered the case such a complicated one.

DR. SKENE agreed with Dr. Lee that it was the retroversion of the uterus that would have prevented the pregnancy from going on to term, and not the presence of the fibroids. He recalled an unpublished case that had occurred in the practice of Dr. Bodkin, of Brooklyn, in which a large submucous fibroid filled the superior strait and caused dystocia. Version was performed and a living child delivered. Twelve days after the woman was seized with expulsive pains, and the tumor was delivered spontaneously.

DR. HUNTER asked if it was not unusual for pregnancy to advance to the fourth month in a retroverted uterus.

DR. SKENE had seen a case in which the fourth month was reached without the interruption of gestation.

SPECIMENS OF DOUBLE PYO-SALPINX WITH ABSCESS OF ONE OVARY -LAPAROTOMY, WITH DRAINAGE-RECOVERY.

THE PRESIDENT exhibited the specimens, and mentioned the following facts with regard to the case: He had first seen the patient eight years before, the diagnosis of chronic oöphoritis having been

made at that time. Two years later, he told her that oöphorectomy would probably have to be performed at some future time. He had not seen her for several years, when about two weeks ago he was called to her on account of a sudden, severe paroxysm of pain in the pelvic region, such as she had often had before. A vaginal examination revealed the presence of a soft enlargement to the right side of the uterus, which appeared to be intra-peritoneal rather than in the cellular tissue; it was slightly but distinctly