DR. SIMS had only performed Hegar's operation once for the relief of an intrauterine fibroid. The patient was a young married woman who suffered with persistent uterine hemorrhage, accompanied by pelvic pain. Her ovaries were removed two years ago. She was examined three weeks before by Dr. Sims, who found the tumor perceptibly smaller. The old pain was gradually disappearing.

DR. B. MCE. EMMET said that he could report only a single operation, the patient dying from the bursting of a mural abscess into the peritoneal cavity.

DR. HUNTER indorsed all that Dr. Wylie had said with regard to the use of the curette in the palliative treatment of uterine fibroids. He thought, however, that, in the case of rapidly-growing tumors in young women, curetting was sometimes insufficient, and it was necessary to resort to a radical operation. Ho had been satisfied with the results of Hegar's operation in his own experience.

DR. JANVRIN bore witness to the value of curetting as a temporary measure.

DR. LEE said that he had not referred to the use of the curette in his case, because he regarded this as simply a palliative measure, whereas he had discussed the radical means of relief.

DR. FOWLER cited a case of menorrhagia due to a small interstitial uterine fibroid; the patient also developed an ovarian cyst, which was successfully removed by Dr. Mundé. As the lady was still comparatively young, and the menorrhagia was not in any sense alarming, the healthy ovary was not removed. As menstruation had remained profuse since the operation, he raised the question whether it was not wise to remove both ovaries whenever fibroids were discovered during the course of an ovariotomy.

DR. HUNTER thought that Hegar's operation was indicated in the case of soft (cavernous) or rapidly-growing interstitial fibroids, but not when they were subperitoneal in character.

DR. POLK said that he had shortened the round ligaments in a case of small fibroids on the posterior aspect of the uterus, so as to bring the organ upward in contact with the anterior abdominal wall. The uterus retained its position, but the pain was not relieved. After waiting a year, he performed Hegar's operation, and thus had an opportunity both to relieve the patient and to observe the results of the former procedure.

The PRESIDENT said that he had happened that very morning to receive the last number of the Centralblatt für Gynäkologie, No. 17, April 24th, 1886, in which a case of "castration for cavernous myofibroma of the uterus was reported by Dr. Goldenberg, of St. Petersburg, for his chief, Professor Lebedeff; the result was said to be a "remarkable" one, only one other similar case, with like result-cessation of hemorrhage and marked diminution of the tumor-being said to be reported by Prof. von Säxinger, of Tübingen.

The President said that, so far as the diagnosis of "cavernous" fibroid went, he did not see how it could be made with any sort of positiveness, since the soft, doughy feel of such a tumor as imparted to the fingers on bimanual examination would scarcely differ from that peculiar to muscular neoplasms (myomata) of the uterus. As for the marvellous result claimed by Goldenberg for oophorectomy in such cases of menorrhagia from uterine myofibroids, the President had, curiously, been called upon that same day, a short time after reading the above article, by a lady from

whom he removed the ovaries last November for hemorrhage produced by a soft interstitial myoma of the anterior uterine wall, which could not be removed through the virginal vagina, and which had reduced her to a bedridden, excessively anemic condition. Since the operation, she had had but one very slight show of blood, about two months after operation, and was now perfectly well, had gained flesh, had good color, and had recently married. The myoma had shrunk nearly one-half.

The reason why he did not remove the second normal ovary, in the case referred to by Dr. Fowler, was because he did not deem the menorrhagia sufficiently profuse, according to the information given him, to warrant his increasing the risk of the operation (as he then thought would be done by a second ligated pedicle), and in removing the chance of future conception, if marriage should take place. The fibroid was small, chiefly subperitoneal, and did not particularly incommode the lady. In a similar case now, with his increased experience, he probably would remove the second

Ovary.

He had frequently used the curette as a palliative measure, but had seen it fail to arrest the hemorrhage, even when followed by iodine and iron applications to the endometrium.

In one case, he had seen almost complete disappearance of a hard, subperitoneal fibroid, after three electropunctures per vaginam, twenty four to thirty-six cells being used. A year later, the tumor had shrivelled away, so as to be no longer distinguishable as an outlined mass. In another case of an interstitial myoma, where the curette had failed, utero-abdominal galvanization had after several months produced marked decrease of the menorrhagia without reducing the tumor.

He had assisted in one operation of oöphorectomy for an enormous fibroid, where the ovaries were situated so far back as to be very difficult to reach, and where each attempt at ligation of the pedicle produced alarming hemorrhage from the needle punctures. The Pacquelin finally secured the oozing, but the patient died of shock. Hysterectomy would have been preferable.

A SPECIMEN OF DOUBLE CYSTOMA OVARII PAPILLARE-LAPAROTOMY— RECOVERY.

DR. LEE also exhibited two small papillomatous cysts removed from a second patient. The case was interesting because the tumors, being nodular, non-fluctuating, and projecting downward into Douglas' pouch, were mistaken by Dr. Lee and his colleagues for multiple fibroids. Even when the patient was examined under ether, the growths presented the slight elastic feeling characteristic of softened fibroids. An exploratory incision revealed the error. The cysts were sessile, and were removed with great difficulty on account of the numerous and firm adhesions; the hemorrhage resulting from the tearing of the latter was controlled by a Paquelin's cautery. The patient was making a good recovery. A Sims' drainage-tube was introduced, and left in position for four days.

THE PRESIDENT asked if the original intention was simply to make an exploratory incision, or to remove the tumors, whatever their nature might be.

DR. LEE replied that he only made an exploratory incision, with the view of removing the uterine appendages, provided that the presence of multiple fibroids was established.

DR. WYLIE thought that it was sometimes impossible to distinguish small cystic tumors from fibroids.

sac.

THE PRESIDENT remarked that it was exceedingly difficult to tell the precise nature of a small, hard tumor in the posterior cul-deHe recalled a case which he observed ten years before in Philadelphia, in which the uterus was prolapsed, and Douglas' pouch was occupied by two masses which he supposed to be prolapsed ovaries. They were subsequently proved to be subperitoneal fibroids.

A SPECIMEN OF SMALL OVARIAN CYST, WITH HEMORRHAGE INTO ITS INTERIOR, SIMULATING HEMATO-SALPINX-OVARIOTOMY-RECOVERY. DR. HUNTER showed the specimen (about the size of a lemon) which he had removed two days before from a woman, 25 years of age, who had had successive attacks of gonorrhea. She had been under observation at intervals for two or three years. Six months ago she reported, complaining of dysmenorrhea and inter-menstrual pain. On examination a small fluctuating tumor was felt behind the uterus; it subsequently increased in size rapidly, and was painful to the touch. The history and symptoms were typical of pyo-salpinx, but, on opening the abdomen, the growth was found to be of probable ovarian origin. The cyst was firmly adherent, so that it was necessary to enucleate it. The hemorrhage was slight, and no drainage-tube was used. The patient had done perfectly well.

THE PRESIDENT asked if the tumor gave, on examination, the sensation of being cystic.

DR. HUNTER replied that it did. He further stated that he had supposed it to be a pyo-salpinx.

[At the request of the Society the cyst was opened. It contained a chocolate-colored fluid, and was a pure monocyst, which subsequent examination proved to be ovarian.]

DR. SIMS remarked that he had removed, four weeks previously, a sloughing ovarian cyst, in which a hemorrhage had taken place some time before; the contents resembled the fluid in the cyst presented.

In reply to a question from DR. EMMET, DR. HUNTER stated that the patient had had several attacks of peritonitis, which accounted for the number and firmness of the adhesions.

DR. WYLIE believed that the specimen was an example of hemato-salpinx, similar to tumors that he had removed. Referring to the condition of thickening of the wall of the Fallopian tube, he said that he possessed several specimens. Patients with such hypertrophied tubes generally suffered a great deal of pain; as the patients advanced in years, such tubes seemed to become shorter than normal.

THE PRESIDENT said that this condition was originally described by Kaltenbach, and that he himself had seen several well-marked specimens of thickened tubes; he had suggested the term “pachysalpingitis," as one that seemed to aptly describe the condition. Pure hypertrophy should be clearly distinguished from dilatation;

in the former case there was generally a shortening, or curling up of the hypertrophic tube, as Dr. Wylie had said, while severe pain was the prominent clinical feature.

DR. COE did not believe that the specimen was a hemato-salpinx, as some of the Fellows had asserted. The shape and general appearance of the tumor, the fact that the tube, or a portion of it, was still attached to its exterior, and the character of its lining membrane and contents-all negative the idea that it was a dilated tube. The relations of the growth, as observed during the operation, were those of an ovarian, rather than of a tubal, enlargement.

[A microscopical examination of the fluid revealed the presence of blood-corpuscles, ovarian cells, and Gluge's corpuscles. The cyst appeared to have been lined with columnar epithelium.]

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF PHILADELPHIA.

Stated Meeting, March 4th, 1886.

The President, B. F. BAER, M.D., in the Chair.

MENSTRUAL EPILEPSY.

DR. HOWARD A. KELLY exhibited recent specimens of tubal and ovarian disease removed within the past two weeks. The first specimens to which he called attention were removed from a patient 21 years of age, who had suffered from an aggravated menstrual epilepsy from the very first appearance of the function. There was no difficulty whatever in the removal through a small incision into which two fingers could just be slipped. The whole operation from beginning to complete closure took but twentyfour minutes. The right ovary was deformed by a very prominent nodule, about one and a-half centimetres in diameter, which burst on removal, discharging a watery fluid, and was shown by its lining membrane to be the last corpus luteum.

The second specimens are rare examples of

HYDRO-SALPINX WITH CONGENITAL DEFICIENCY OF TUBES AND BROAD

LIGAMENTS.

In this case there was malformation of the distal ends of the tubes, broad ligaments, and ovaries. The left tube is as large as a Bologna sausage. It was brought into view with great difficulty, after separating many light adhesions to the pelvic walls; while the isthmus is much enlarged and thickened, the great distention is at the involuted ampulla. The operator was materially assisted in bringing this tube into view by upward pressure on the cervix

by a hand in the vagina. The fimbriated extremities were lost in a mass of vascular and fibrous tissue, forming a broad ligament and deep down in this were imbedded the somewhat hard, elongated, large ovaries. It was utterly out of the question to attempt a removal of the ovaries, and any such operation would have been of a very desperate character, nor did he, Dr. Kelly, regret this in the least, as he had planned his operation for tubal disease, to which he attributed all the patient's sufferings. The right tube was as large as his middle finger, and was also distended with watery fluid.

The other specimen was a very large

HEMATO-SALPINX.

This tube, the left, about four inches long, burst as he was removing it, discharging four ounces of tarry blood. It was very adherent, having several attachments to intestine and omentum. The dilatation is here, too, seen to be at the ampulla which extended far beyond the ovary back into the cul-de-sac. The ovary is embraced by the isthmus and presents a curious appearance as it lies, about twice the normal size, imbedded in a sort of ball-andsocket manner below the isthmus. Where it is laid open, the tube is converted into one large sac.

DR. W. C. GOODELL had been surprised at the size of the tubes. DR. JOSEPH PRICE remarked that the tube was so large that the uterus had been pushed aside by it. Great care was required in its removal.

DR. CHAS. HERMAN THOMAS said that some time since he should not have recognized such a condition, but now he can; the result of experience in bimanual examination. He would like to hear further on this point of diagnosis.

DR. B. F. BAER thinks it very unfortunate that the ovaries as well as the tubes could not have been removed in the case just reported by Dr. Kelly, for their presence will probably result in the usual monthly congestion, and consequently the pain and other pelvic distress, for the relief of which the operation was performed, may continue to exist. There are several cases on record in which the tubes were removed and the ovaries allowed to remain, but the results have not been reported.

He can see no reason why this should be done unless the ovaries cannot be found, or some other insurmountable difficulty presents itself. He fully believes in the advantages of prolonged and thorough palliative treatment in these cases. Benefit usually follows, and sometimes cure; at least operation is rendered less difficult and more likely to be followed by recovery of the patient, both from the operation itself and the symptoms. Certainly the application of remedies such as iodine to the fundus of the vagina and the interior of the uterus with prolonged rest and general buildingup of the system will have a strong influence in attenuating adhesions, promoting absorption of lymph, and possibly, if not probably, in cure of the patient without operation.

It should not be forgotten that removal of the tubes and ovaries in these cases does not cure absolutely in every case. He believes that we will be called upon in a few years by many of these cases