which have been operated upon to relieve symptoms which still exist or have returned, and for the relief of which operation had been performed; just as we have been called upon from time to time, and pestered by those old cases of chronic hypertrophy and retroflexion of the uterus with pelvic adhesions. He has now under his care one of his own cases upon which he operated for the relief of symptoms, the result of disease of the tubes and ovaries with pelvic adhesions. The patient made a good recovery and appeared to have been cured, but the symptoms have returned. and she is now complaining almost as much as before the operation. She also has periodical attacks of metrorrhagia. This, of course, is an unusual case. He has another patient under his care, who was operated upon in a neighboring city by removal of the tubes and ovaries, and is treating her for the same symptoms of which she had complained before the operation. He is an advocate of the operation in some cases, but he pleads for due deliberation and the exhaustion of careful palliative and preparatory measures before operation is resorted to. Many cases will get well without operation. Some will not be benefited, even if the operation is performed, and there is some danger in laparotomy, although Tait has had such remarkable success.

DR. DA COSTA inquired if Dr. Kelly had tried the benefits of rest and treatment before operating.

DR. JOSEPH PRICE said that the recurrence of symptoms seemed to indicate partial removal of the tubes and ovaries. One of the fundamental rules of surgery is to seek for pus when it is probably present, and in all cases to remove it if possible. When the ligatures will cut through the tubal stump on account of its cheesy character, hemorrhage may be prevented by the application of the cautery.

DR. KELLY, in closing the discussion, said he did not in the least regret that the ovaries could not be removed, as he had operated for tubal disease, not for ovarian, and he admired the zeal of Schroeder, who, instead of always removing the ovaries, sometimes resected diseased portions. In all the cases of tubal and ovarian disease upon which he had operated, months and years of careful treatment had been wasted, and now where he diagnosticated pyo-salpinx, the only delay he allowed was to put the patient in the best possible condition for operation. Topical, external, and internal treatment is utterly futile, and will never do more than secure temporary palliation.

Dr. Kelly's reliance regarding diagnosis lay entirely in a skilled bimanual examination, by which he always accurately mapped out all the peculiarities of the case before operation. If there is rigidity and resistance, it is necessary to etherize, but he has yet to see the case, where the presumptive signs were those of tubal and lesser ovarian disease, where the structures could not be picked up between the two hands and outlined. He considers that this tact has been largely developed by persistently examining the condition of the appendages to the utmost possible extent as a routine practice in all cases which come under his notice. Introducing the finger as high as possible, by forcing the hand well under the pubic arch, and carrying the sensitive pulp up against the postfornix or either lateral fornix, and then playing up and down with the other hand pressing on the abdomen, and creeping a quarter inch at a time without ever fully relaxing, and letting structures in between roll through the two fingers, and in case of an ovary

running round its whole periphery, or of a tube tracing it up to the cornu uteri and down into the retro-uterine pouch where it generally terminates, gives often most surprising results, and would doubtless, if universally carried out, change hundreds of diagnoses of leucorrhea, endometritis, and flexions with adhesions, to the far more serious ones of pyo- or hemato-salpinx.

PYO-SALPINX.

DR. JOSEPH PRICE exhibited specimens of pyo-salpinx from two patients, and afterwards remarked that Tait and Keith have ended the dark period by showing us how to operate on the abdomen and pelvis without fear and with little risk. The wonderful advance in pelvic and abdominal surgery should be placed to their credit. He believes it is now universally admitted that they have reached the very acme of perfection. One surely must be a convert to Tait's law to contend with the great difficulties in pelvic surgery: "That in every case of disease in the abdomen or pelvis, in which the health is destroyed or life threatened, and in which the condition is not evidently due to malignant disease, an exploration of the cavity should be made." Standard works on ovariotomy dwell at great length on the subject of adhesions as the most important and difficult complication with which the operator has to contend. In short, in pelvic operations the risk and the difficulty will ever lie in the separation of organized inflammatory products. Adhesions, when old, between the pelvic viscera and diseased tubes, become degenerate, and hence easily ruptured. In one case only did strong adhesions, deep in the pelvis, stay his hand. The right tube and ovary adhered strongly

to the sac and right side of the uterus, and the whole adherent mass was absolutely inseparable. Again, the rupture of pus tubes or cysts filled with inflammatory, septic, or malignant elements, will be followed by serious symptoms. Operation becomes difficult when the ovaries and tubes, tightly distended with pus, and softened through pathological changes, cheesy in consistence, are matted together with the rectum and small intestines.

UTERINE APPLICATOR AND DRESSING-FORCEPS COMBINED, exhibited by DR. CHARLES HERMON THOMAS.-This instrument, which is specially adapted to making applications within the cavities of the neck and body of the uterus, but which is also available for making dressings and applications to the vagina and external surface of the cervix, has borne the test of two years' use. It is in forceps form, the blades are strong and resistant from the handles forward about two-thirds of their length, when they narrow rapidly, so that taken together they become about equal in size to the ordinary uterine sound. This narrow portion, somewhat suggestive of the long beak of the angular ear forceps, is about three and a half inches in length, the tips being roughened on their opposed surfaces. It holds securely

the smallest pledget of cotton, and, by reason of the springy character of the beak, will permit the locking of the handles when a full-sized pledget or tampon is placed within its grasp. The point is slightly probed as an extra precaution when introduced to the uterine fundus, though a small cotton ball answers all needful purposes as a protective tip. I have usually employed the plain point on account of its occupying less space at the internal os

GEMRIG

uteri. The beak is curved to a shape corresponding very closely to that of Ellinger's dilator, and which has been found so generally well adapted to entering the uterus. This portion is electroplated with gold, when so ordered (a proceeding of moderate cost and to be commended), as a protective against the corrosive action of iodine, iodized phenol, and the like which so rapidly destroy nickel-plating and corrode polished steel surfaces. The instrument was made under my directions by J. A. Gemrig & Son, of this city.

Some practical points of use may be mentioned. Soiled or medicated cotton is easily removed with the use of one hand only, by simply unlocking the handles and wiping the point in a crumpled paper, thus leaving the other hand free for other employment and avoiding the trouble, the soiling of the fingers, and the whittling often involved when the wire applicator is used. In its use there is immunity from the rasp action of the closely-wrapped cotton of the wire applicator, and also a greatly increased carrying capacity of the cotton for medicated liquids. Moreover, it will be found convenient and desirable to make use of the instrument as a uterine sound incidentally in certain instances. In my own experience it has proved practicable as an applicator, one fully meeting the needs of most cases; while as a uterine dressing forceps for general use it has been found so satisfactory as to have superseded all other instruments of this class.

DR. BAER said the instrument presented by Dr. Thomas was a very ingenious one and would doubtless serve a good purpose where the cervical canal is patulous. A greater quantity of the medicating agent used can be carried to the diseased surface than when thetightly-wrapped cotton is used.

DR. J. F. WILSON had nothing to add to what Dr. Thomas had said. He has used one for several months and could agree with Dr. Thomas as to the ease of application and removal of soiled cotton.

DR. PARISH said that the forceps was valuable and would be much used. As an applicator it will be very convenient. A few years ago the sound and applications were too much used, but extremes either way are wrong. Applications to the endometrium are sometimes needed.

DR. H. A. KELLY said this was a very valuable instrument.
DR. PARISH exhibited a specimen of

OVARIAN TUMOR

removed the previous day. The symptoms had been very peculiar, and the form of the abdomen was misleading, there being a deep groove across the hypogastric portion of the tumor. Numerous adhesions gave great fixity. These adhesions embraced the colon, parietes, and bladder, and were old and dense. Its rapid growth had raised a question of malignancy. A great portion of the tumor was solid.

DR. HARRIS remarked that a microscopic examination of the tumor should be made. There had been great difficulty in diagnosis as to the origin and character of the tumor. A slight fluctuation could be detected in the lower portion under the use of an anesthetic. There had been no uterine symptoms, and menstruation had been regular. The long Fallopian tube crossed the tumor and made a deep constriction across its middle.

DR. BAER did not think rapid growth a proof of malignancy. He had seen five or six cases of very rapid development, one in three months containing a bucketful of fluid. In none of these cases has there been any return or other sign of malignancy.

The

presence of papillomatous growths within the cyst is no proof of malignancy.

for the complete closure of the trocar puncture in ovariotomy.

OF WASHINGTON.

Stated Meeting, December 4th, 1885.

DR. A. F. A. KING, President, in the Chair.

DR. T. C. SMITH reported a case of

EXCESSIVE VOMITING IN PREGNANCY.1

By request of the President, the discussion was opened by DR. S. C. BUSEY, who said he would endeavor to comply with the President's request, but feared his remarks would be desultory in character. The Society was indebted to Dr. Smith for bringing up the subject of vomiting in pregnancy, in the case reported, as the history involved all the questions at issue, and the discussion to follow would naturally raise the questions of etiology, pathology, and treatment of such cases, and especially that of treatment by inducing abortion. While commending the paper as a whole, he hoped the doctor would pardon him if he made exception to the lesson inculcated by the paper, as well as to the expressed views of its author. He must also object to the attempt to treat such a patient by daily visits to his office, because absolute rest was the paramount factor of success in treatment. He must also except to a medication continued without avail for six 1 See original article in this number.