ascribed to intrauterine or periuterine inflammation. Dr. Coe further called attention to the fact that the cervix uteri was one of the least sensitive regions in the body. In conclusion he disclaimed any intention of denying entirely the existence of reflex genital neuroses.

DR. HARRISON said that the intra-vaginal portion of the cervix was not sensitive except when hyperemic, then it was exquisitely sensitive. He had seen a case shortly before where vomiting was induced whenever the cervix was touched; there was hyperemia and ovaritis. In another instance the cervix was insensitive except one point at the angle of the rent which was extremely tender.

DR. GOFFE did not believe in doing the operation without anesthesia. He had seen it attempted once, but the patient complained of great pain, and the operation was far from being a neat or successful one.

DR. COE said that he had laid stress on the point that the cervix was not, as a rule, highly sensitive. He had seen a number of cutting operations performed without ether, and had observed that the pain was much less than in minor operations in other regions of the body.

DR. TOWNSHEND thought that Dr. Coe was mistaken; while the normal cervix was not sensitive, the diseased cervix, and especially the cicatricial plug at the angle, was highly so. He had done the operation without ether, injecting first Magendie's solution mx., and then cutting out deeply the sensitive angle. The patient had suffered from a rapidly increasing loss of vision which was cured by the operation.

DR. HUNTER agreed with Dr. Moseley in his clinical deductions: it did not matter what the tissue was called. He had operated on about nineteen cases without ether, and had not had much difficulty: there was but little pain, especially in old chronic cases where there was not much hyperemia. He had met with several cases in which the "skin operation" had been done, where a secondary operation was necessary in order to remove the old plug. DR. MOSELEY, in closing the discussion, said that when the fibrous tissue (the so-called "cicatricial plug" of Emmet) was dissected out, the rest of the cervix was left soft and normal in consistency. The cases which he had reported had no lesions except the cicatricial plug, no eversion, etc., to cause symptoms. He had done the operation under cocaine anesthesia; while this drug dulled the sensibility of the immediate surfaces to be denuded, he had found exquisite sensitiveness when he attempted to pass the deep sutures. This would seem to support the view that the cervix was more sensitive than some of the members supposed.

DR. A. PALMER DUDLEY, of New York, then read a paper on

THE SURGICAL TREATMENT OF SUBINVOLUTION.

Dr. Dudley said that this condition was not particularly noticed by gynecologists, and that there was especially a paucity of histological evidence as to the nature of the condition. Retzius, of Sweden, had called attention to this twenty years ago. The reader then gave a history of the physiological processes leading to an increase of uterine tissue and to involution and subinvolution.

The terms areolar hyperplasia, chronic metritis, and subinvolution were often misapplied. Most writers gave more attention to chronic metritis (which was a misnomer) than to subinvolution. He had sought to discover the histological conditions present in this affection and would give the views of various authors. Dr. W. H. Welch, in a personal letter to him, had stated that he could find no evidence of any true inflammatory process in subinvolution. Cohnheim had reached, practically, the same conclusion.

The usual treatment of subinvolution, by local remedies, iodine, phenol, douches, etc., even when faithfully carried out, relieved the patient only for a time; the uterus again increasing in size, and the symptoms returning when the treatment was suspended. The reader believed that Emmet's operation for lacerated cervix was the best means of curing subinvolution, even when there was no laceration. He then gave in detail the histories of twelve cases of subinvolution, all of which suffered from pelvic distress and dragging, supra-pubic pain, backache, leucorrhea, etc., the uterus being tender on pressure. Seven of these cases had laceration of the cervix; in six there was no laceration; ten suffered from dysmenorrhea; eight from constipation and dysuria. Treatment by means of hot douches, iodine, glycerin-tampons, the tapping of cysts, curetting, etc., was faithfully carried out, and the patients were relieved but were not cured.

After this, hystero-trachelorrhaphy was done where the cervix was lacerated; in the other cases, a slender wedge was removed from the cervix, the apex of the wedge being carried deep enough to divide the circular artery. The depth of the uterine cavity was in all cases carefully measured when the patients began treatment, before the operation was done, and again some time afterwards. Of these twelve cases, there was in all a marked diminution in the length of the uterine cavity and improvement in the symptoms; in three cases where there was displacement, the uterus returned spontaneously to its normal position; a thirteenth case, in which the wedge-shaped mass was excised, was complicated by the presence of a large fibroid; here, after ninety days of ordinary treatment, the uterus measured three and threequarter inches (a diminution of one-quarter inch by treatment); fifty-four days after the operation, the uterus measured two and five-eighths inches, and there was marked relief from symptoms and diminution in the size of the fibroid.

DR. CLEVELAND thought that the views just expressed were very sound; surgical treatment was the best. He had performed the operation when the laceration was but slight, and had obtained the most happy results. He did not believe that the operation was too frequently done by gynecologists. Slight tears should be closed where there was subinvolution.

DR. INGALLS thought that many cases would be damaged by the operation in relation to future pregnancy. He could not conceive of marked subinvolution except as the result of some injury to the uterine tissue.

DR. MOSELEY believed with the reader that in true subinvolution a thorough operation would in most cases do good; in cases of enlargement of the unimpregnated uterus, he had performed it with no result.

DR. BUCKMASTER considered the seat of pain in cases of subinvolution to be in the utero-sacral ligaments which would be found to be very tender; he doubted whether surgical treatment was as efficacious as was represented. He did not believe that measurements of the uterine cavity were reliable, no two men could measure the same cavity alike, nor would one man get the same results at different times.

DR. VAN NEST thought it necessary to remove some cicatricial tissue, but he did not see how simply removing a V-shaped piece of undiseased tissue would do any good.

DR. BAKER had seen some temporary results from medication, but the uterus grew large again after cessation of the treatment: he thought that the results of surgical treatment would be better. DR. DUDLEY said that subinvolution was always the result of some injury, but not necessarily a cervical laceration; it might be from too early rising after confinement, uncleanliness, instrumental delivery, forcible removal of the placenta, etc. He cut the circular artery purposely to rapidly deplete the uterus, and by interfering with the circulation to promote atrophy, and thought that this measure made the cure more rapid. The removal of the V-shaped piece was necessary to reduce the size of the cervix. In these cases of subinvolution, while the mucous membrane and submucous tissues were hard, the tissues beneath were soft. His thirteenth case was a good example of the benefit resulting from the operation. He had offered the results of his own experience to serve as a guide to those who had not had the opportunities offered by the Woman's Hospital.

In the absence of DR. THOMAS L. AXTELL, of Waterbury, Conn.. his paper on "Hobbies in Gynecology, and the Importance of Avoiding them" was read by title.

Afternoon Session.

DR. JAMES B. GOFFE read a paper on

THE DIFFERENTIATION OF THE VARIOUS KINDS OF PELVIC

CELLULITIS.

In the light of the knowledge yielded us in late years through careful post-mortem research, and through the findings during laparotomy, the reader had come to the conclusion that pelvic cellulitis had been dethroned from the prominent position it had held in uterine pathology, and that in its place we must substitute salpingitis and peri-salpingitis, oöphoritis and peri-oöphoritis, periuterine adenitis and lymphangitis, peritonitic bands and adhesions. When cellulitis as such occurs, it is acute in its nature and harmless in its action, for it leaves no trace behind such as may be detected by the pathologist. The small indura tions around the uterus, deemed by Emmet to be evidence of cellulitis, had been unquestionably shown to be the result of peri

tonitis. Large exudations around or to one side of the uterus were due to plastic peritonitis. These exudations may either be absorbed or break down into pus, in which latter event we had pelvic abscess. The reader believed it a rare occurrence to find such a collection of pus primarily in the pelvic cellular tissue. The original cause of these abscesses, exclusive of the puerperal condition, was disease of the ovary or tube. The tissue involved was a serous membrane, and not the pelvic areolar tissue.

DR. W. GILL WYLIE agreed in the main with the views advanced in the paper. He most certainly believed that the pathological factor at the outset was disease of the tube or of the ovary. He would differ from the reader, however, in the opinion that the pus remained intra-peritoneal. If not absorbed, the pus became encysted, and then became really extra-peritoneal. When the pus exceeded a certain amount in the tube-from three to six ounces it either burst into the peritoneal cavity, or else perforated into the pelvic cellular tissue, and then we had a pelvic abscess in the sense that it existed in the areolar tissue underneath the peritoneum.

DR. A. P. DUDLEY related the history of a case of ovarian cyst where, on laparotomy, the peritoneum was found healthy, but beneath it, in the cellular tissue, existed an abscess containing fully a pint of stinking pus. Here then we had an abscess which was limited to the cellular tissue, and primary there.

DR. W. M. POLK was requested by the chairman to participate in the discussion, and said that the essential point seemed to him to be that of treatment, however much we might differ in regard to pathology. A tube dilated by pus or mucus was often presented by the laparotomist in justification of his operation. The speaker thought, however, that we ought to carefully differentiate our cases. He believed acute cellulitis to be only acute salpingitis with peritonitis. In certain cases of the kind, if the patients be put to bed and treated after Emmet's method, they get well after some months, and, on examination, the tumor and tenderness have disappeared, and the uterus is again movable. Such patients continue to menstruate, and they bear children. In another series of cases, however, the tumor does not subside, but the acute lapses into the chronic, and here rest in bed, counter-irritation, and glycerin did no good. The only hope of cure lay through laparotomy; else, the recurrent attacks of peritonitis would kill the patient. Lawson Tait has shown us how to cure such cases. The cellulitis of the past, therefore, has merged into the salpingitis of the present.

DR. H. C. COE desired to correct the impression that he had stated in his paper, read at the last meeting, that such a condition as cellulitis did not exist. He read passages from the paper in question, to prove the contrary. He had seen clear cases of pelvic abscess in which neither tubes nor ovaries were at all affected.

DR. GOFFE, in closing, stated that, even though the pus did become encysted, it is still intra-peritoneal, although shut off from the general peritoneal cavity. As for Dr. Dudley's case, he thought it was too imperfect in detail to prove it a case of extra-peritoneal abscess.

DR. BACHE MCE. EMMET read a paper on

THE ABUSE OF INTRAUTERINE MEDICATION.

The reader passed in review the various discharges from the uterus, and showed that, whilst their source was usually from the mucous membrane of the organ, this was only a secondary source, the primary being pelvic congestion, cellulitis, distended tube. Obviously, therefore, intrauterine medication was not only not indicated, but might be the cause of serious damage to the patient. Before we make the diagnosis of endometritis, we must carefully seek for a cause of the discharge external to the uterus. A slight prolapse of the uterus, whether due or not to cellulitis, would cause pelvic congestion, and this, in turn, discharge from the uterus. The same reasoning held with versions and flexions of the uterus. Anemia, chlorosis, polypi, fibroids were also causes of discharge, and must be carefully differentiated before we resort to intrauterine medication. A concealed cause, overlooked by all but the careful observer, is laceration of the cervix extending up the canal to the internal os, and healed only externally. Here again intrauterine applications are not indicated for cure, but repair of the laceration. In all these conditions, intrauterine applications, being misdirected, not only fail to do good, but are harmful. The average time of cure is shorter when these applications are not resorted to, for thus relapses, due to our own misjudgment, are avoided. Endometritis is by no means the common ailment that daily talk would lead one to expect.

DR. T. ADDIS EMMET, in discussing both this and Dr. Goffe's paper, said that discharge from the uterine canal was a symptom and not a disease. For seven years he had not made an application to the endometrium, except where there evidently existed granulations. On looking over his records, he found that his patients required seven weeks' less treatment than formerly when he had been in the habit of making intrauterine applications. Applications to the vagina were as efficient, and far safer. As regarded cellulitis, the name mattered not. There existed something which must be treated with respect. He was glad of the discussion, because it might lead to correct opinions. That we may have an inflammation of the cellular tissue could not be questioned. After a time, the cellular tissue became destroyed and disappeared, and the peritoneum became affected, the vagina being drawn up against the broad ligament and its contained tube. Hence why pathologists could not find old exudations in cellular tissue. Whether the exudation be cellulitic or peritonitic, the main question was how to get rid of it.

DR. W. H. BAKER stated that he could not speak from the standpoint of the pathologist, but that clinically he agreed with Dr. Emmet in regard to the importance of getting rid of the exudation, wherever its site. He believed that in most cases the inflammation began in the peritoneum, and affected the cellular tissue secondarily. Septic absorption was an almost invariable cause of cellulitis. In regard to the tolerance of the peritoneum of pus, it must be granted that cases varied markedly. He would agree entirely with Dr. Bache Emmet in regard to the importance of most careful differential diagnosis before resorting to intrauterine