movable, within a limited range. On the left side of the uterus was a smaller enlargement, of a more irregular shape, also slightly movable. The uterus itself could be moved upwards and downwards, but only to a limited extent. The presence of this mobility, said the President, was an important point in the differential diagnosis between an intra-peritoneal tumor and diffuse cellulitis. The diagnosis of pyo-salpinx was made, and was apparently confirmed by introducing an aspirator needle through the vaginal fornix into the right-hand tumor and withdrawing a small quantity of pus. Laparotomy was performed a week ago. On opening the abdomen, a cyst was found to the right of the uterus, adherent to the bottom of Douglas' pouch; in attempting to free the sac, which was extensively attached to the surrounding parts, it ruptured and several ounces of pus oozed out of the wound. There was a smaller cyst on the left side, also adherent. There was extensive oozing from the torn adhesions, which was controlled by long sponging, finally with hot vinegar and water. A Sims' drainage-tube was introduced, and the cavity was washed out at frequent intervals, sometimes as often as once every three or four hours. The tube was still in situ, and thick, inoffensive pus was escaping from it. The patient had done perfectly well and there was no doubt as to her ultimate recovery. [She convalesced without the slightest drawback.]

The President said, in conclusion, that the most interesting point in the diagnosis was the distinct, though limited, mobility of the enlarged tubes associated with limited mobility of the uterus. This he had never found when the exudation or abscess was in the cellular tissue, that is, extra-peritoneal.

DR. HUNTER, who had witnessed the operation, said that it was complicated from the fact that the patient was very stout. DR. SKENE asked regarding the length of the abdominal incision; was it sufficiently large to admit the entire hand?

THE PRESIDENT replied in the negative. The wound was at first so small as only to admit one finger; it was subsequently enlarged so as to allow of the introduction of two fingers, but no more.

DR. WYLIE remarked that he had operated upon three patients during the past winter in whom the condition seemed to be similar to that in the case just reported. He believed that when both tubes were distended with pus, and only one could be reached through the vagina, it was better to perform laparotomy. From the fact that a purulent discharge was still present, he inferred that possibly the entire sac of the abscess had not been removed. He always irrigated the cavity with a weak solution of corrosive sublimate after removing such tubes, and he accordingly rarely found that drainage was required later than the third day after the operation. If the study of diseased tubes and ovaries had effected no other good results, it had taught us to recognize the presence of abscesses before they ruptured, and thus to anticipate that accident.

THE PRESIDENT remarked that he had not been so fortunate as Dr. Wylie. He had met with many cases of cellulitis which had

culminated in true pelvic abscess, but that he had not seen so many abscesses of purely tubal origin as that gentleman.

DR. GILLETTE asked for a description of Sims' drainage-tube, which the President gave briefly (see transactions of last meeting).

DR. SKENE asked the President if he did not make a sharp distinction between pyo-salpinx and pelvic abscess proper.

THE PRESIDENT replied that this was precisely the "bone_of contention." On this point he had insisted in his discussion of Dr. Wylie's paper read before the New York State Medical Society last February. He certainly did make a distinction, but Dr. Wylie did not.

DR. WYLIE affirmed that at least four out of five pelvic abscesses originated from diseased tubes and ovaries.

DR. SKENE said that he had always been of the opinion that seventy-five per cent of all pelvic abscesses began primarily in the cellular tissue; pyo-salpinx was secondary to disease of the endometrium, either simple or specific.

DR. WYLIE explained that he, of course, excluded from his category some of the acute abscesses of the puerperal state. He had proved his theory to his own satisfaction at the operating table, having had at least six cases during the winter, which had confirmed his views.

DR. SKENE thought that it must be extremely rare for an abscess to originate within the peritoneal cavity and then to burrow downwards into the cellular tissue.

DR. B. M. EMMET believed that an abscess might be limited either to the peritoneal or cellular tissue, the former being movable, as the President has pointed out, while the latter was fixed; there was no doubt as to the possibility of these distinct types of exudations. A diffuse exudation within the peritoneal cavity might be very difficult to diagnosticate.

SUBJECT FOR DISCUSSION.

THE INDICATIONS FOR DRAINAGE AFTER LAPAROTOMY.

DR. HUNTER opened the discussion by saying that he had always been in the habit of employing drainage when there were extensive adhesions, free hemorrhage during the operation and oozing afterwards, and also when there had been rupture of a cyst, with escape of its contents into the cavity. He had never regretted the use of a drainage-tube, but had frequently been sorry that he had not introduced one. He had used different tubes, straight and curved glass ones, with and without lateral perforations, and, recently, the hard-rubber tube devised by Dr. H. M. Sims. This instrument had given great satisfaction; in using it, it was unnecessary to disturb the dressings, and irrigation could be easily and safely performed, even by a nurse. He had used small glass tubes, as well for the purpose of affording an indication of hemorrhage, as with a view of securing drainage.

THE PRESIDENT asked Dr. Hunter how long he left the drainagetube in position, and how he closed the track left after removing it.

DR. HUNTER said that he had no definite rule; he was accustomed to throw a little carbolized water into the tube each day, and after it continued to come away clear for twenty-four hours, the temperature remaining low, the tube was removed. He always

passed a silver wire through the abdominal wall in the track of the tube, and twisted it after the latter was removed, thus closing the sinus.

DR. WYLIE said that he regarded the presence of ascites, oozing from adhesions, and a noxious fluid in the abdominal cavity as indications for drainage. The principal objection to the use of drainage was the greater liability to ventral hernia, especially if the tube was kept in too long. He did not remove the first tube immediately, but exchanged it for a shorter one before he discontinued its use entirely. Most of the drainage was effected during the first forty-eight hours following the operation; when such a tube as that of Dr. Sims' was used and irrigation practised, it tended to keep up an irritation of the peritoneum, thus really causing a discharge. We should not wash out the cavity unless the temperature rose to 103° F., but should be content with siphoning out the fluid without disturbing the organizing lymph. He had had an extended experience with abdominal drainage, especially when associated with the late Dr. Marion Sims, and believed that much harm was done through the endeavors of surgeons to irrigate the peritoneal cavity.

THE PRESIDENT asked Dr. Wylie if he did not believe in washing out the cavity when the tube contained pus.

DR. WYLIE replied in the negative. He preferred to siphon out and clean the tube, but would not force fluid into the peritoneal cavity. His practice was to remove the first tube at the end of twenty-four hours, and to substitute a smaller one, provided that the discharge had ceased. In reply to a question from Dr. Hunter, he stated that he used a glass drainage-tube, perforated only on the side which looked towards the symphysis pubis, so that neither omentum nor intestines could become engaged in the holes. He had recently used a double tube, one-half of which was longer than the other.

DR. LEE agreed with Dr. Hunter in his remarks on drainage. He had never had good results from the use of straight glass tubes, and believed that they were productive of more harm than good. Of the hard-rubber tubes he preferred Sims' to Thomas'; the use of any tube increased the patient's liability to hernia. He had always considered elevation of the temperature as the chief indication for irrigation; he had used the tubes rather as a precautionary measure. They were certainly used too seldom rather than too frequently.

DR. B. M. EMMET did not believe that the presence of adhesions, moderate oozing (unless it continued after the operation), or ascites necessitated the use of drainage-tubes; it was not even called for after the rupture of a simple ovarian cyst. The escape into the cavity of a purulent, or otherwise injurious fluid of course indicated drainage. Even if suppuration occurred within the cavity after the first twenty-four hours following an operation, the tube was of no use, since it drained a circumscribed space which might be shut off from the affected spot.

DR. SKENE remarked that there was another indication for drainage which should be mentioned-the presence within the abdominal cavity of a large number of ligatures. He took excep tions to the statement made by Dr. Wylie that organized lymph was thrown out around drainage-tubes. He had witnessed an

autopsy in which the lower end of the tube was loose within the abdominal cavity. He preferred a glass tube sufficiently long to

reach to the bottom of Douglas' pouch. He agreed with the speakers who opposed frequent irrigation; any fluid that accumulated in the tube could be pumped out, and it was seldom necessary to throw in water, which only tended to stir up and disseminate the pus within the cul-de-sac. There was no harm in using perforated glass tubes, although there was no advantage in having the holes only on one side.

DR. COE ventured to differ from Dr. Skene upon a point in pathological anatomy. He had performed several autopsies upon patients in whom drainage-tubes remained in situ after death, and could not recall a single instance in which the track of the tube was not completely shut off from the general peritoneal cavity by a wall of organized lymph. Moreover, he had noticed that even when a tube was removed shortly after an operation, an isolated canal was left, so that water pumped into it remained at a constant level, and did not sink down and disappear as it would have done had there been a communication with the general cavity. In reply to a question from Dr. Skene, Dr. Coe admitted that in nearly all of the cases which he had observed the tubes had been in position for several days.

DR. SKENE said that, as a rule, after twenty-four, and even after seventy-two hours, no organized lymph was found around the tube.

DR. HUNTER Could not agree with those gentlemen who disapproved of irrigation, since he had had several cases in which the patient's life was certainly saved by this means, the temperature rising as soon as it was discontinued; he had occasionally continued to irrigate as late as the tenth day.

THE PRESIDENT concluded the discussion by remarking that, as the result of his experience, he favored abdominal drainage, but not irrigation as a rule; contrary to Dr. Skene, he believed that lymph was early thrown out around the drainage-tube, thus isolating its tract from the general cavity. This fact he had confirmed in two cases in which he had found it necessary to re-open the abdomen on the third day after operation.

Stated Meeting, May 4th, 1886.

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

A CASE OF HEGAR'S OPERATION FOR SESSILE SUBMUCOUS FIBROIDDISEASE OF THE TUBES AND OVARIES.

DR. C. C. LEE showed a pair of cystic ovaries with double pyo-salpinx, which he had removed from a patient, twenty-one years of age, who had long suffered from uncontrollable hemorrhage. She entered the Woman's Hospital early in April, giving a history of dysmenorrhoea and metrorrhagia of over seven years' standing, with severe pelvic pain during the intermenstrua] periods. Her menstruation recurred at irregular, and too frequent intervals. She had received the usual treatment, but without benefit. On examination, the uterus was found to be enlarged and retroverted, and there was evidently some mass within the uterine cavity. Nothing else could be detected in the pelvis. After dilating the os internum, a large sessible fibroid could be felt occupying the region of the fundus, but not projecting far into the

cavity. The uterus was tender to the touch, and was replaced with difficulty. The examination was repeated under ether, and it was decided not to attempt to excise the tumor or to enucleate it with the spoon saw, because of the great danger of perforating the uterine wall. Ergotin was administered sytematically; it caused the patient great discomfort, and did not produce any appreciable effect. Hegar's operation appeared to be justifiable. On opening the abdomen, the uterine appendages were found to be firmly adherent, and were the seat of well-marked disease, the ovaries being cystic, while the tubes were both dilated and contained pus, showing that the patient would not have been cured if the fibroid had been enucleated. The case was reported because it illustrated the important fact that the appendages of uteri which had long been the seat of fibroid tumors generally underwent degenerative changes, and as an illustration of Hegar's operation for the cure of the intra-uterine fibroids. The patient had a high temperature for several days after the operation, but was then doing well; it was too soon to report on the final success of the measure.

DR. POLK remarked that he had performed Hegar's operation twice. On the first occasion, however, one ovary was so firmly attached to the uterus that, on attempting to free it, the hemorrhage was so alarming that it became necessary to remove the entire uterus. The patient made a perfect recovery. In another case a subperitoneal fibroid pushed the uterus forward against the bladder (the pelvis being at the same time contracted), causing retention of urine, and consequent cystitis. It was impossible to lift the tumor out of the pelvis. The appendages were removed and the patient did well. Dr. Polk regarded the operation as both safe and easy, since the appendages were generally elevated above the pelvic brim, so as to be quite accessible; it was certainly preferable to enucleation of the tumor. The statistics of Hegar's operation would be found to compare favorably with those in which blind attempts were made at enucleation, frequently with fatal results. In such a case as the one reported, there was certainly less risk in removing the appendages.

DR. B. MCE. EMMET asked if any attempt had been made to cause extrusion of the tumor by dilating the cervix. DR. LEE replied in the affirmative.

DR. WYLIE said that he had performed the operation three times with good results. In one instance he had attempted to enucleate the tumor, and had partially succeeded; on finding that he could not extirpate it entirely, he desisted, and removed the tubes and ovaries at the same operation. Suppuration occurred in the mass during the second week, and a week later at least onehalf of it sloughed away. The tumor was subsequently removed from the vagina with a pair of obstetric forceps. He had performed an operation similar to Dr. Lee's on the day preceding that gentleman's, the result of which had been quite satisfactory. He believed that it was a valuable measure, but was sure that it was often resorted to for the relief of hemorrhage in cases in which temporary relief might be obtained by a thorough use of the curette. DR. HARRISON had had a similar experience with the curette.