cal fact, because the idea of sunken sutures had again been revived some time ago. Now, if in the operation of Baker Brown an internal suture had been placed along the internal edges, where union was most apt to fail, besides having brought the middle and external parts together by means of the quilled suture, the operation would perhaps have been followed by better results. This failure led to the next step in the operation of perineorrhaphy, the burying of the sutures entirely within the wounded surfaces. The idea, here again, is by drawing upon the ends of these sutures to force the denuded surfaces against each other throughout their whole depth. The liability to failure in this operation lies in the fact that the surfaces are not placed flatly against each other, as was the object of the quilled sutures, but they are apt to become puckered up, just as drawing on the string of a tobacco pouch closes the opening only by throwing the edges in folds. Skene has alluded to this puckering of the sides, and proposes to remedy it by introducing the suture just at the edge of the wound (instead of at a distance from it), and then inserting it in a circular manner around the lacerated surface, burying it in the tissues underneath. Therefore, in the speaker's mind, a method which would bring the torn surfaces together flatly upon each other like the pages of a book, would, after all, be the ideal operation for restoring the parts to their original position. When a lacerated perineum is of old standing, however, the hypertrophied and diseased tissues in the vagina must be removed often to a considerable depth, and it is just this amount of denudation or removal of tissue which determines the good or bad result. The speaker believed it impossible to prescribe one form or method of perineorrhaphy for all secondary operations, even if the extent of the laceration in different instances was originally the same. Sometimes the tissues must be removed higher up in the vagina; at other times, lower down or more to the sides. Sometimes the denudation of the mucous membrane ought to be very superficial; at others a large portion of cicatrized tissue must be removed to a considerable depth. This is the reason why the various methods have been followed by good results if they were resorted to in the proper cases, and, conversely, why they have proved unsuccessful if employed in the wrong place. The speaker, for this reason, had no criticism to offer against the essayist's method, which was essentially that of Hegar's triangular denudation, differing only in the manner of introducing one suture (No. 9 in the first diagram). As the only proof of the correctness of this suggestion is an actual test, the speaker would refrain from making any comments upon it. DR. PALMER, in conclusion, said that the views expressed by Thomas and Emmet as to the function of the perineal body were diametrically opposed, and represented either extreme. It seemed to him that a middle-ground was the most correct one. As Hart has said, the perineal function has been overrated and underrated. The paper had called attention to the injuries of the pelvic floor as distinct from those involving the perineal base. These were doubtless quite frequent, generally overlooked, but of a nature of the greatest importance. He first obtained the idea of using transverse_vaginal sutures from a diagram represented by the late Sir James Y. Simpson. This was before he had had an opportunity of seeing Hegar's and Simon's works. The operation which he was now performing differed from Hegar's in that the denudation was probably deeper, and the transverse sutures altogether imbedded (if possible), these sutures being always used whether the operation was a pure perineorrhaphy or a colpo-perineorrhaphy. In the other or ordinary methods of suture adjustment, the internal or vaginal edges are often imperfectly coaptated, the posterior wall commences to sag, and the upper perineum is not perfectly restored. The sutures are placed deep, so that they will not cut through, will not be put on a strain, and so that the muscular structures stretched and separated by injury and its results, may be better gathered together along their central attachments." TRANSACTIONS OF THE GYNECOLO- Meeting, Friday, March 19th, 1886. The President, DANIEL T. NELSON, M.D., in the Chair. DR. W. W. JAGGARD wished to call attention to a new instrument and a pathological specimen, in order to remind the Fellows of the Society of the first regular order of business, and on account of the intrinsic interest the instrument and the specimen possessed. DR. ALEX. J. STONE'S PELVIC-OUTLET FORCEPS. Dr. Alex. J. Stone, of St. Paul, has designed a very valuable pelvic-outlet forceps. The characters of the instrument are: Length, 24 cm. (spoons, 14 cm., handles, 10 cm.). Fenestra, length, 12 cm., width, 3.5 cm. Cephalic curve, 8 cm. Weight, 210 grams. The instrument is bent backwards on its long axis, so that the angle, at the junction of the spoons and handles, is about 160°. The object of the perineal bend is to maintain flexion of the head during its passage through the vulvar orifice. Dr. Jaggard had recently employed Dr. Stone's forceps in a case in which the head was arrested at the vulvar orifice, the result of uterine inertia, caused by a large intramural fibroid. It was possible to apply the forceps in the left lateral position without the patient's knowledge. He thought the instrument possessed obvious advantages over Dr. Sawyer's excellent pelvic-outlet forceps. PUERPERAL UTERUS AND ADNEXA. The pathological specimen was the uterus and adnexa removed from the body of a patient who died at the Cook County Hospital, on the third day of the puerperium. Dr. H. H. Frothingham, one of the resident obstetricians, had kindly placed the material at the speaker's disposal. The patient, 30 years old, multipara, was admitted to the Hospital on the 13th of November, 1885, and gave a history of forceps delivery of a dead child, with perineal laceration, on the 11th of November. Temperature 103.4° F.; pulse, weak and rapid; respiration, shallow and frequent; tongue, dry and brown; pulmonary edema; rigors; profound prostration. Abdominal tenderness, tympanites, dulness in both flanks; two tumors the size of a hen's egg on either side of the vulvar orifice; labia majora apparently gangrenous; recent perineal laceration; foul odor from vagina; complete cessation of lochial secretions. The patient died soon after admission to the hospital. Autopsy. Both pleural cavities about half filled with sero-purulent fluid and flakes of lymph; lungs edematous; pericardium contained three ounces of fluid similar to that within the pleuræ; endocardium apparently normal; myocardium soft and friable; no metastatic abcesses could be found. Peritoneal cavity contained about one gallon of sero-purulent fluid, with flakes of lymph; intestines contracted, but no adhesions; liver enlarged, congested, giving evidence of extensive fatty degeneration; spleen of normal size; kidneys, cortex giving evidence of fatty degeneration, pelvis injected and intensely hyperemic; peritoneum injected. The uterus was of a size corresponding to the third day of the puerperium. The ring of Bandl was plainly demonstrable. The endometrium exhibited the pseudo-membranous necrosis clearly described by Birch-Hirschfeld and other pathologists by the term endometritis diphtheritica. The mucous membrane of the vagina showed similar diphtheritic changes. Pus oozed through both Fallopian tubes. The left ovary and tube were intensely injected. Puerperal ulcers were visible on either side of the vulvar orifice. The tumors on either side of the vulvar orifice proved to be caused by hemorrhage into the perivaginal connective tissue-pudendal hematomata. examination for micro-organisms was made. No Dr. Jaggard thought the case was a typical example, both as regards the clinical course and anatomical findings, of that form of puerperal fever described by Buhl, in 1861, as Puerperal Fever without Pyemia (endocolpitis, endometritis, salpingitis, peritonitis-subsequently pleuritis and pericarditis). The entire absence of splenic tumor was worthy of particular notice. Carl Braun has justly attached great significance to this sign-even going so far as to call it pathognomonic. The apparently normal state of the endocardium was remarkable. ADJOURNED DISCUSSION OF PELVIC CELLULITIS. DR. A. REEVES JACKSON stated that he understood from the notice received that he was expected to introduce the general subject of pelvic cellulitis. If anything should cause a sense of humiliation to come to us as medical men, it was the impression which was forced upon us of how little accurate knowledge we had upon even the most ordinary topics when we attempted to study any medical subject in detail. In order to introduce the subject of pelvic cellulitis, he should say at least something about its pathology, diagnosis, and treatment. In regard to the first of these subjects, Dr. Thorburn says that he inquired of several experienced anatomists whether they knew of the existence of cellular tissue in the broad ligaments, and they replied that they did not know of it except from current gynecological literature; of course, that was because they had not investigated the subject practically; we do know there is a substance called cellular tissue in the pelvis, that it exists in and between folds of the peritoneum forming the broad ligaments between the uterus and the bladder, and also posteriorly to the uterus. When we speak of cellulitis, we mean an inflammation affecting this tissue and all that is connected with it; that is, its lymphatics, glands, blood-vessels, and nerves. Some think the starting-point is nearly, if not always, in the lymphatic glands, so that here in the outset we are met with this evidence of lack of certain knowledge. He thought it did not matter much to us as practitioners whether that layer called cellular tissue is affected in one portion only, or whether other structures are also involved. The diagnosis presents difficulties, as we all know. In the first place, we do not always know when the disease is present, and in every stage we feel doubt as to whether this disease or some other is present; sometimes even when it goes on to its later stages we have doubt. The first evidence of this disease consists in an effusion of serum which produces a hardness in the part, and which becomes more and more marked as the disease progresses; this may be of longer or shorter duration; it may disappear by absorption, or it may not disappear at all, but go on until the effusion becomes pus, forming pelvic abscess. Pelvic cellulitis and pelvic peritonitis frequently exist together, and as it does not affect our treatment of the case in the early stages, this fact does not make much difference to us as practitioners. Coming to the question of treatment, he had always felt a great deal of doubt as to the efficacy of the usual means employed-opium, digitalis, quinine, etc.; that is, as to whether they have any controlling influence upon the progress of the disease. From the very nature of the inflammatory process, he scarcely thought that these things could do more than simply palliate the symptoms. Prolonged hot-water douches are doubtless remedial, and may abort the disease. Latterly, interest has been more centred in the treatment of the condition when it has advanced to the stage of abscess. Heretofore, the treatment has been notoriously unsatisfactory, so that cases have gone on for weeks, months, and years, the woman being constantly subject to discharges of pus, and the remedial means have done little more than assist nature in the escape of the fluid. But during the last few years, since attempts have been made to treat the disease radically by surgical means, there has been offered an additional and efficacious method of dealing at least with some of these cases. He alluded to laparotomy. The success that has been attained in this way should lead us to look upon it with favor. He thought, however, that where radical surgical means are resorted to, there is danger of too frequently performing operations dangerous in themselves, to relieve a disease which perhaps would not end life, although rendering the patient an invalid during her lifetime. He believed the discussion would be profitable if it should largely take the course of considering this latest and most formidable measure of treatment. He had read the account of Dr. Fenger, giving an account in detail of three operations made by himself; two of the operations were followed by death, which was attributed to some other disease, co-existing perhaps with the abscess itself; the other was successful. You are familiar with Lawson Tait's treatment for these encysted collections of pus. His success is simply marvellous. In 1883, the British Medical Journal published an account of twenty-four cases in which he had been successful, and in a letter which Dr. Jackson had received from him recently he said that up to that time he had operated successfully on thirty-two cases. This was all the introduction Dr. Jackson had to offer, and it opened the whole subject. He was reminded that he had not stated whether he approved of abdominal section for this cause. He said he did, unhesitatingly, and thought there was as good reason for operating in inflammation of the pelvis as in any other disease which produces lifelong invalidism, provided it were not curable by other means. Laparotomy offers a method which is perhaps applicable to a comparatively small number of cases, and yet here it is the only remedy, that is, in cases of long standing in which the abscess cavity cannot be otherwise reached for the purpose of drainage, and where the woman is of such an age that makes it reasonable to suppose she will suffer for many years. He considered it a dangerous operation, and there had been errors in diagnosis. Mr. Tait is justified in his bold method of diagnosticating abdominal disease by laparotomy. He follows it up with removal of the disease. Where the diagnosis is fairly established, he believed that laparotomy is a proper procedure as a last resort. DR. W. H. BYFORD thought there was not much more to be said than had been said by Dr. Jackson, who had given an admirable résumé of the subject in all its bearings in such a way as to set it before the Society with clearness, and he approved of all Dr. Jackson had said, without exception. Dr. Byford had already said to the Society what he had to say upon the subject of pelvic abscess, and what he thought of the conditions of the operation of laparotomy for the abscess. He could not get rid of the idea that the operations performed by Lawson Tait were cases in which the abscesses were largely in the abdominal cavity, and were not pelvic abscesses, properly speaking-certainly were not confined to the pelvis; and he believed from what he had seen in regard to his cases that almost all were encysted peritoneal, instead of encysted pelvic abscesses. In speaking upon the subject before, he had taken the stand that the operation of cutting into the peritoneal cavity for the purpose of going down into the pelvis when the abscess did not reach above the pelvic rim was not justifiable in many instances, if at all. Where there has been a bar thrown out by the effusion of lymph in the peritoneal cavity so as to isolate the purulent collection and it extends up into the abdominal cavity, then he had no doubt of the propriety of the supra-pubic operation. He had recently seen an abscess, which formed mainly above the pelvic brim, open into the rectum at the top of |