DR. BYRNE asked Dr. Polk if he had ever had any trouble from secondary hemorrhage. [Dr. Polk replied that he had on two occasions.] Dr. Byrne said that he had frequently opened pelvic abscesses through the vagina, and even through the rectum, but that he had never seen any hemorrhage. He thought that the surgeon should hesitate for a long time before undertaking such an operation as that just reported. It was not only difficult to separate the peritoneum in the manner described, but that delicate membrane would certainly be injured during the process.

DR. SKENE asked if pelvic abscesses were not frequently followed or accompanied by cellulitis.

DR. POLK replied that his experience had led him to believe that pelvic cellulitis in the non-parturient uterus was a rare condition.

DR. SKENE believed that he could generally do better by aspirating pelvic abscesses through the vaginal roof, and then washing out the sac by simply reversing the current.

DR. POLK agreed with the speaker, but thought that aspiration was merely a temporary expedient, which should be followed up by the radical operation.

DR. SKENE thought that the needle could be left in situ, and a fine thermo-cautery knife could be passed along it as a director, the abscess being thus opened with much less risk of hemorrhage and subsequent inflammation.

DR. POLK said that he would have been afraid to use a cautery in his case on account of the close proximity of important structures, especially the ureter. He remarked, in conclusion, that it would have been impossible to open the abscess by laparotomy, and since it did not point, and could not be reached through the vagina, there was only the one other alternative which he had adopted. If he had another similar case, he thought that he would perform the same operation, as no difficulty was met in separating the peritoneum, and that membrane, as was well-known did not seriously resent that proceeding.

Stated Meeting, December 1st, 1885.

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

NEW INSTRUMENTS.

A URETHRAL CLAMP FOR LOCAL ARREST OF THE CIRCULATION

66

DURING THE BUTTON-HOLE OPERATION.

DR. B. M. EMMET exhibited a spring clamp, made of steel wire, which he had found useful in operations upon the urethra where cocaine was employed as a local anesthetic. One limb of the instrument was inserted into the canal, while the other grasped the urethro-vaginal septum. A limited capillary area was temporarily shut off, so that the effects of the cocaine could be obtained more rapidly than when it was carried off in the general circulation. He had used it in one instance with favorable result. It was adapted particularly to the "button-hole" operation.

DR. COE referred in this connection to several surgical cases in which constriction of the part was practised before injecting cocaine. The action of the drug was found to be more rapid and

permanent.

Dr. Emmet had made use of the same principle in the construction of his clamp.

THE PRESIDENT thought that the application of the instrument to the urethra before the cocaine was injected would be attended with considerable pain.

DR. EMMET replied that in the diseased urethra the tissues were hypertrophied, and from extrusion of the mucous membrane at the meatus the latter was quite patulous, and offered little or no resistance to the entrance of the clamp; there was consequently not the pain which would be experienced in a normal urethra.

AN INSTRUMENT FOR DILATING THE CERVIX UTERI.

DR. HANKS presented a dilator that he had devised, which consisted essentially of two pieces of metal which could be separated by an intervening wedge, advanced by a screw at the other end. He recommended it as being simple and inexpensive, while it was free from the main faults of most of the steel instruments, i. e., it did not slip out of the cervix, and there was no springing at the tips of the blades. Both a straight and a curved dilator were shown.

DR. B. M. EMMET thought, from an examination of the instrument, that it would dilate the cervix gradually and effectively. He never used this form of dilator himself, however, because he did not meet with that condition about the os internum which called for forcible dilatation.

THE PRESIDENT believed that the internal os ought to be dilated gradually by a series of oscillatory movements, as it were, and he doubted if it was possible to do this with Dr. Hanks' instrument.

DR. WYLIE objected to the dilator, because it could not be. cleaned easily. He was perfectly satisfied with the Sims instrument, which he used constantly. He did not pull down the uterus with a tenaculum while introducing it, but followed Dr. Sims' original directions, which were to insert the dilator as far as the shoulder, following the curve of the canal, and allowing the uterus to move before it, then to gradually separate the blades, while watching closely the degree of separation. He believed thoroughly in dilatation, and was in the habit of practising it whenever he intended to make an intrauterine application.

DR. NOEGGERATH agreed with the last speaker as to the advisability of dilating the os internum before making applications to the endometrium, since in this way only could he feel assured that he had thoroughly touched the mucous membrane of the cavity. For this purpose he used the instrument devised by Holst for dilating the urethra. When he desired to dilate thoroughly, but at the same time very gradually, he employed Hegar's rubber dilators, which were so constructed that the calibres of two successive sizes varied by only half a millimetre.

DR. HUNTER said that he had found Sims' instrument perfectly satisfactory for ordinary purposes.

DR. CLEVELAND also preferred Sims' dilator, and added that he always used it before making an intrauterine application.

DR. HANKS replied to Dr. Wylie's objection that the instrument was perfectly simple, consisting of only three pieces of metal, which could be easily taken apart for cleansing. He also concurred with that gentleman in the necessity of dilating the in

ternal os before attempting to apply medicaments to the endometrium.

DR. B. M. EMMET asked if, as a rule, the internal os was not already sufficiently dilated in those patients whose condition called for intrauterine treatment.

DR. HANKS said that the os was not always sufficiently patulous, especially when anteflexion was present.

DR. WYLIE said that the mucous plug, which so often obstructs the cervical canal, was dislodged during the process of dilatation, and was expelled without the necessity of resorting to the syringe. DR. JANVRIN insisted on the importance of introducing a small canula, through which the applicator could be passed, so that the medicament should actually reach the fundus, and not be lost in the cervical canal. He always used such a canula, even after the cervix had been thoroughly dilated with tents. He dilated ordinarily with Peaslee's or Hanks' instrument.

DR. WYLIE said that he always kept several sizes of canulæ on hand, and used them constantly.

PROBE-POINTED SCISSORS FOR OPENING THE PERITONEUM.

DR. HUNTER Showed a pair of scissors, the lower blade of which terminated in a probe. He had devised them a year before, and found them useful for dividing the peritoneum in making an abdominal incision.

THE PRESIDENT was under the impression that a similar pair of scissors had been used by Dr. Skene Keith.

DR. NOEGGERATH suggested that the lower blade of the scissors ought to be much broader. He thought that the danger of wounding the intestine was great, even when the peritoneum was incised on the finger, and recalled an operation (at which the President assisted) in which the accident happened to himself.

SPECIMEN OF MALIGNANT ADENOMA OF THE UTERUS-SUPRA-VAGINAL HYSTERECTOMY-RECOVERY.

DR. WYLIE exhibited the specimen, and read the following history:-"The patient, Mrs. G., aged 44, has been married twentyfive years, and had one child nineteen years ago. Her menses are irregular in their recurrence, and since 1876 have been excessive in amount, so that she was treated for 'congestion' of the uterus. In March, 1883, a kind of cauliflower growth was observed protruding from the os externum, and soon after a number of small gelatinous masses were expelled, a continuous hemorrhage prevailing at this time. In 1884, the uterus was curetted by Dr. Brocken, of Nashville, a quantity of friable tissue being removed. The operation was repeated a few months later, but the hemorrhage continued, and gelatinous masses were again discharged. In October, 1884, she came under Dr. T. G. Thomas' care, and remained at his hospital for six weeks, the curette being again used. A specimen of the growth then removed was examined microscopically, and was pronounced to be non-malignant. The patient returned home, and was relieved for a season, but the hemorrhages began again, and a mass protruded from the os as before.

She placed herself under my care, July 5th, 1885. On.making an examination I found the uterus enlarged to the size of a child's head, and irregular in shape, while from the dilated os protruded a mass, composed of numerous small bodies, which resembled a bunch of sumach. I removed with the curette five or six ounces of soft, gelatinous material, and sent it to Drs. Heitzmann, Biggs, and Billings. The first two gentlemen pronounced it non-malignant, but Dr. Billings was of the contrary opinion. The diagnoses given were respectively myxo-adenoma, hyperplastic endometritis, and epithelioma.

"I kept the patient under observation for three months, when it became evident from the increased size of the uterus and recurrence of the hemorrhage that the growth had returned in spite of repeated intrauterine applications. As the uterus was freely movable, and the cervix unaffected, I advised abdominal incision, with a view to removing the body of the organ, in case the disease had not extended to the appendages to the periuterine tissues. After due consultation and preparatory treatment, the operation was performed on November 26th, nearly the whole of the uterus, with the ovaries and tubes, being removed. I found the organ uniformly enlarged, except on its anterior aspect, where there was a protuberance about the size of an egg. The ovaries were enlarged and cystic, their outer surfaces being covered with recently organized lymph. The wire of a small écraseur was passed without special difficulty around the broad ligaments and the cervix, just at the vaginal junction, the included parts were constricted, and after the abdominal cavity had been carefully protected by means of sponges, an incision was made through the uterine wall at the fundus and three or four ounces of dark blood were evacuated. The uterus was then transfixed with two steel pins, at a point just above the wire, and the entire mass was cut away. The peritoneum was carefully drawn up beneath and around the stump, the latter being treated with pure carbolic acid, solution of corrosive sublimate and iodoform, and included in the lower angle of the wound, which was closed with silk sutures and covered with a dressing of cotton. There was very little shock after the operation, and there have been no serious symptoms since, except a rapid pulse at first. The highest temperature has been 100° F. in the axilla (102° F. in the vagina). To-day, which is the sixth day since the operation, the pulse is 100, and the temperature is normal, the wound is perfectly healthy, and the patient takes her nourishment regularly and is free from pain."

A portion of the uterus was submitted to Dr. Coe for microscopical examintion. His report was as follows:

"[The sections included the entire thicknes of the growth, and about one centimetre of the subjacent muscular layer.] The growth itself consists of numerous acini, or irregular spaces, lined

with cylindrical epithelium, the spaces being separated from each other by fibro-muscular tissue. With few exceptions, this adenomatous structure is sharply limited by the line of separation between the mucous and muscular layers. In one or two places, however, scattered alveoli are seen in the midst of the muscle (as in fibro-adenoma of the breast ?). There is no tendency to cyst formation in the sections examined, nor are there any signs of degeneration in the new growth, except in one of the sections, where there are appearances almost identical with the drawings of Ruge and Veit, which are intended to represent epithelioma developing from the glandular epithelium. In some spots there are long, delicate branching processes covered with cylindrical epithelium, and closely resembling in structure the papillomatous masses found in the bladder, rectum, and on the inside of ovarian cysts. These are directly continuous with the deeper muscular layer. The smooth muscle-fibres are enormously increased in size and number, showing that hypertrophy, as well as hyperplasia, which are normally observed in the pregnant uterus. There is an increase in the lumina of the blood-vessels, as well as in the number of vessels. Leucocytes are scattered throughout the muscular tissue in considerable numbers. Several deposits of blood-pigment are visible, and other evidences of former hyperemia or hemorrhage.

"From its histological structure the growth can only be an adenoma, which is limited to the mucous membrane and submucous muscular layer. Through the congestion caused by the new growth, there has resulted a general hypertrophy of the fibromuscular tissue. It is difficult to see how any positive inference of the malignancy of this adenomatous growth could be drawn from an examination of small portions removed by the curette, since a dozen sections, with a single exception, agree entirely with the rule of Friedlaender's, that an innocent growth remains limited to the tissue from which it originated, and either leaves the neighboring parts entirely intact, or merely pushes them aside. Applying Ruge's test (which Friedlaender thinks is inaccurate) the wide lumina of the glands in the present case ought to favor the idea that the growth is not cancerous. 'The diagDosis of cancer of the uterus cannot be surely established, unless it can be shown that the muscle is affected.' This principle cannot be applied in the present specimen, or at least only to a very limited extent. The absence of granulation tissue, and of distinct processes of atypical epithelium, make the diagnosis of epithelioma very difficult. Sarcoma, and all the benignant polypoid growths (including fungous endometritis) are readily excluded. This is one of the cases in which the microscope is at fault. Benignant histologically, the growth gives a clinical history which would seem to justify the radical operation that was performed. Under the circumstances I can suggest no better name for the specimen than