that of Schroeder, who, in his chapter on 'Adenom des Uterus' ('Krankheiten der Weiblichen Geschlechtsorgane ') describes and figures a "malignant adenoma of the uterine mucous membrane," both figure and description agreeing perfectly with the present specimen. He is inclined to regard this form of adenoma as occupying a position midway in the scale, which begins with fungous endometritis and ends with epithelioma. Cancerous degeneration is, of course, the common, if not the usual, sequence of such adenomata. It is important to note that the present growth is a diffuse adenoma of the mucous membrane, and not the adenoma polyposum of Winckel. There is all the difference as regards malignancy that there is between diffuse, round-celled sarcoma of the uterus and localized fibro-sarcoma. If there is any

practical deduction to be drawn from this interesting case, it is this, that the long observation of the patient by the surgeon frequently furnishes him with a more correct notion of the true pathological condition than does the microscope of the expert. It is rather unsafe to base a decision involving the life of a patient solely upon the report of the pathologist, because pathologists, above all other men, disagree. When they do, there is nothing for the surgeon to do but to decide for himself."

DR. B. M. EMMET asked if the patient was much emaciated. DR. WYLIE replied that she was well nourished in spite of the profuse hemorrhages.

THE PRESIDENT thought that adenoma of the uterus was one of the conditions mentioned by Martin as indicating vaginal hysterectomy.

DR. WYLIE said that it would have been impossible to remove the specimen presented per vaginam on account of its size.

DR. NOEGGERATH recalled a similar case that he had seen in Berlin, in which portions of the growth were examined by a wellknown microcopist, who only found in a single section evidences of commencing epithelioma, such as were described by, Dr. Coe in the present instance. He cited a case of adenoma uteri which occurred in his own practice. The growth continually returned after removal, but did not become epitheliomatous, although the patient was so much reduced by repeated hemorrhages that Dr. Noeggerath was on the point of proposing hysterectomy as a last resort. He finally cured her by intrauterine injections of iodine.

DR. COE spoke of the impossibility of always deciding as to the benignant character of a growth merely from its microscopic appearances, and referred to a specimen of recurrent papilloma of the rectum which he had examined. Although it presented histologically the character of a perfectly benign tumor, clinically, the age of the patient and the rapid recurrence after complete removal, showed that it was not as simple as one would suppose. DR. JANVRIN thought it possible that the portion of the growth sent to Dr. Billings might have presented evidences of carcinomatous degeneration, hence the difference between the diagnosis of the various observers.

DR. WYLIE said that the three factors which induced him to operate were: the increasing size of the uterus, the mobility of the

cervix, and the fact that the patient lived at such a distance from New York that it was not desirable to permit her to return home without trying every possible means to relieve her.

THE PRESIDENT said that he had frequently noted the recurrence of intrauterine polypoid growths after their complete removal with the curette. It was usually necessary, after curetting, to make frequent strong applications (such as Churchill's tincture of iodine) to the cavity for some months to prevent recurrence.

DR. WYLIE remarked that iodine had been used repeatedly in his case without any results.

DR. NOEGGERATH thought that stress ought to be laid upon the immediate application of iodine after curetting, so that the submucous tissue might be thoroughly affected. The use of iodine was even more important than the operation itself.

DR. B. M. EMMET had found fuming nitric acid more effective than iodine, since it penetrated more deeply into the tissues.

DR. NOEGGERATH considered crystallized muriate of iron as more useful than either of the applications mentioned; it could be introduced through a uterine pistol. He remembered an instance in which the curette was employed with but little benefit until its use was supplemented by the crystallized iron.

THE PRESIDENT stated that he had for a number of years been in the habit of introducing, immediately after curetting, a plug of cotton soaked in iodine, iodized phenol, iron, or whatever styptic he desired to use, the plug being kept in position by an aseptic tampon, both to be withdrawn after forty-eight hours.

DR. WYLIE said that he generally applied pure carbolic acid to the interior of the uterus after curetting, but did not use a tampon, since it prevented free drainage, and hence favored septic trouble. He preferred to watch the patient for half an hour after the operation rather than to trust to a tampon to arrest hemorrhage.

THE PRESIDENT said that he did not introduce a tampon to arrest hemorrhage, that being done, if necessary, by the uterine plug, but simply to prevent the plug from slipping out of, or being expelled by, the uterus.

DR. JANVRIN remarked that he had used the sharp curette many times at the Skin and Cancer Hospital in cases of advanced malignant disease, sometimes scooping out almost the entire uterus, and leaving only a thin shell of muscular tissue; it was his practice, after stopping the hemorrhage by means of a solution of acetic acid, tannin and glycerin, to pass a Paquelin's cautery, if necessary, up to the fundus, cauterizing the entire cavity of the cervix and body. He had used the cautery in this manner between thirty and forty times during the past two years, and had never observed any except favorable results. The slough generally separated in the course of a week, and the patient was relieved for some time. In ordinary cases of fungous endometritis he applied the tincture of iodine after curetting.

DR. NOEGGERATH was surprised that Dr. Wylie should fear sepsis as a result of plugging the vagina at the present day, when there were so many means for rendering a tampon aseptic.

DR. WYLIE insisted that it was nevertheless bad surgery to dam up the discharge from a wounded surface, when it could be avoided. THE PRESIDENT did not see how any bad results could follow if the uterine canal was properly plugged, since during the first

forty-eight hours, after which time the plug and tampon were removed, no secretion could take place.

DR. HANKS agreed with Dr. Wylie that it was better to watch a patient after curetting and to arrest the hemorrhage, if necessary, with hot-water injections, than to trust to a tampon, because in using the latter we ran the risk of septic absorption, and there was also a danger from the escape of blood into the abdominal cavity through the Fallopian tubes. But especially because the tampon, when made sufficiently styptic, acts as an irritant to the cervicovaginal mucous membrane, and often having been applied very tightly, and allowed to remain some time, leaves an eschar which may require weeks to heal. He would watch his patient for half an hour if need be.

DR. WYLIE recalled two cases in which tampons applied for the arrest of hemorrhage after curetting of a cancerous cervix had been forced through thinned uterine walls into the peritoneal cavity.

DR. NOEGGERATH recalled two similar cases, but the accident was clearly traced to the fact that the tissues were destroyed by the action of the strong styptic iron with which the tampons were saturated.

DR. HARRY SIMS recommended for the arrest of hemorrhage intrauterine injections of very hot water, followed by applications of iodine.

DR. B. M. EMMET favored the intrauterine injection of iodine by means of a long-nozzled syringe. He was accustomed to inject at least a drachm at a time.

DR. NOEGGERATH was firmly convinced of the efficacy of intrauterine injections of iodine. It was not even necessary to dilate the internal os beforehand, provided that the injection-tube was perforated at the sides, and not at the end. A strong alcoholic tincture of iodine should be used, as a solution in weak alcohol might do harm.

THE PRESIDENT cited in support of the possible occurrence of hemorrhage after the operation of curetting, the case of a patient under his care, who two years before was curetted for menorrhagia by an eminent gynecologist, no tampon being applied. She had a violent hemorrhage on the night following the curetting; the operator's assistant was sent for and a firm tampon was required in order to arrest it. No after-treatment was adopted. The menorrhagia continuing, she went to Berlin, and was under Prof. Schroeder's care for several months and left apparently cured. Nevertheless, on her return to this country the menorrhagia returned, a few small vegetations were found, removed, and the case was permanently cured by iodine applications continued for several months.

DR. WYLIE recalled a case of secondary hemorrhage following the operation of incision of the cervix (performed by the late Dr. Sims), in which a tampon failed to check the bleeding, and claimed that unless tampons were very firmly placed, they failed to stop serious hemorrhage.

DR. NOEGGERATH thought that the President's case was irrelevant, because it bore upon the question of secondary, not primary, hemorrhage.

THE PRESIDENT replied that the point was to prevent hemorrhage after curetting, whether primary or secondary, and that his case illustrated the advisability of tamponing after that. operation.

A CASE OF HYDRO-SALPINX DIAGNOSTICATED AS EXTRA-UTERINE

PREGNANCY-LAPAROTOMY-RECOVERY.

DR. WYLIE reported the case of a patient upon whom he had operated in Hornellsville, N. Y., with the assistance of Drs. Cridler and Baker, who had called him to see the case. Her history was briefly as follows:-She was a widow, forty-three years of age, who had had two children, her last pregnancy having occurred seventeen years before. Her menses stopped last spring, and soon after she had nausea and enlargement of the breasts, while the abdomen increased in size, so as to lead her attending physicians to think that she was pregnant. She was sent to Buffalo, where she was placed under the care of Dr. Mann, who found, on examining her under ether, that the uterus was only three inches in depth, while on one side of the organ was a tumor which he judged to be an extrauterine fetation. He applied electricity for ten days, and then sent the woman home. Soon after her abdomen enlarged rapidly, the enlargement being most prominent on the left side, and the attendants thought that they could hear a fetal heart. Dr. Wylie saw her on November 4th, and learned that three days before she had had an attack of syncope, followed by profuse diarrhea, after which the abdominal swelling became smaller. These phenomena led her physicians to believe that the fetus had died. On making an examination, Dr. Wylie found that the uterus was three inches in depth and was pushed over to the left side of the pelvis by a soft placenta-like mass in the right broad ligament. He could not feel anything which resembled a fetus, but the abdominal walls were thick, and an exact diagnosis was impossible. He thought that the woman might be pregnant. An exploratory incision was proposed. On opening the abdomen, a large, elastic tumor, of a dark color, was found in the right broad ligament; it was firmly attached to the uterus and surrounding parts, and appeared to be either an enlarged tube, or one of the cornua of the uterus that had become dilated. The cyst was tapped with a trocar, and about three pints of clear, straw-colored fluid were withdrawn. The inner wall of the cyst was smooth, and the cavity contained nothing but fluid. The ovary could not be distinctly felt, but it seemed to lie beneath the outer portion of the growth. Several small pieces of the sac (varying in thickness from one-eighth to onequarter of an inch) were excised, and the edges of the remaining portion were stitched to the lower angle of the abdominal wound, a drainage-tube being introduced. The patient was left in good condition, and when last heard from (November 24th) she was practically well, the wound having healed entirely, with the exception of a small opening at the site of the drainage-tube. Dr. Billings had examined the portions of the cyst that had been removed and was confident that the cyst was a dilated Fallopian tube.

DR. COE asked if it was possible for a pure hydro-salpinx to attain such a large size as the cyst described.

DR. NOEGGERATH replied in the affirmative.

THE PRESIDENT referred to a case reported by Wiedow, in which the dilated tube was as large as a child's head.

DR. NOEGGERATH did not see the necessity of performing laparotomy, since the patient might have been cured by tapping, or at least the diagnosis might have been established in this way, because the presence of ciliated columnar epithelium in the fluid would have been positive evidence that it came from a dilated tube. He described a valuable method of obtaining fluctuation in obscure cases such as the present one. It consisted in placing one finger in the posterior cul-de-sac, and the other hand, upon which percussion was performed, firmly upon the abdomen. The wave of fluctuation was often felt in this way, when it could not be perceived in any other.

THE PRESIDENT asked what special indication there had been for laparotomy in the case reported, except for diagnosis.

DR. WYLIE replied that the presence of dragging pain in the abdomen, and the strong suspicion of extrauterine pregnancy, justified an exploratory incision. There was also evidence of in

testinal obstruction.

THE PRESIDENT thought that the aspiration of a hydrosalpinx through the vagina for diagnostic purposes was a perfectly innocuous proceeding. He cited three cases in his own practice, in which the cyst had disappeared completely after tapping and did not refill. The fluid in all was examined microscopically, but no columnar epithelia could be found.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF PHILADELPHIA.

Stated Meeting, October 1st, 1885.

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

DR. WHARTON SINKLER read a paper on

THE DIFFERENT FORMS OF PARALYSIS MET WITH IN YOUNG CHILDREN.

The form most frequently met with is infantile spinal paralysis, or polio-myelitis anterior. This term indicates the pathology of the disease, which is an inflammation of the nerve cells of the anterior horns of white matter of the spinal cord. This affection may come on at any period of life, but is generally seen in children and usually at the age of two years. The children are generally strong and apparently healthy and the paralysis is sudden in its onset. Fully two-thirds of the cases I have seen have been attacked in the summer months, hot weather and teething seeming to be predisposing agents. Dr. Barton, of Manchester, England, reports that of fifty-three cases in which he noted the time of on