others is similar, and would like to hear something on that point. I formerly removed them with a snare of some kind, but recently I find it only necessary to snip off the pedicle, which is a much easier method than the introduction of the snare. About five months ago I removed one from a woman who had lost a great deal of blood and was very anemic, and in that case I found it impossible to get the snare around the tumor, because it filled out the entire uterine cavity. It was a firm, submucous fibroid, and still by simply pressing the pedicle and snipping it off I had no trouble. I left a tampon in a few days, and there was no subsequent hemorrhage whatever.

DR. BONIFIELD.-I do not believe there is any danger in cutting the ordinary fibroid polyp off with scissors, if the pedicle is small and it has been completely extruded from the uterus. I have frequently done so and never packed the uterus, and had no hemorrhage to speak of. The most interesting case of this kind I have seen I saw a few years ago with a gentleman in the suburbs. He said he had delivered a patient about a week before. The day before asking me to see her he examined her and found the uterus inverted and the body filling the vagina. I went out to see the case with him, and on a casual examination I was inclined to agree with his diagnosis; but after putting the patient under an anesthetic and examining more carefully, I found the cervix, and the pedicle of a polypus issuing from it. The growth was probably as big as a cocoanut or larger, and after removing it with the scissors we had no trouble. About two years ago I removed a polypus, a little larger than a hen's egg, over in Newport. Recently I was called to see the patient, and found another polypus similar to the first. They were hard specimens and not like the one exhibited.

DR. WENNING.-The case reported by Dr. Stark recalls to my mind a case, which I saw a year ago, of a woman, æt. 45 years, who had menstruated irregularly for some time, and had excessive pain so that she had acquired the morphine habit. The pain became so excruciating that she sought relief, among others, from two gynecologists in the city, who pronounced it due to extra-uterine pregnancy. On examination I found the uterus enlarged to about the size of four months of pregnancy. I was very particular in the examination, and after thoroughly examining it I came to the conclusion it was either an intrauterine pregnancy or a polyp. Dr. Trush agreed with me. I said, if it was a pregnancy, an abortion would result in a few days, and if not a pregnancy there would be time to wait. The woman when seen next was in extreme pain. We placed the patient under ether, and on introducing the fingers we discovered a body, evidently a fibroid polyp. She was sent to St. Mary's Hospital, and the next day I removed the growth, without much difficulty, with the scissors. For this purpose I have found the snare very unsatisfactory. After removing it I curetted the base. The patient experienced relief at once.

DR. MITCHELL.-I do not remember that hemorrhage after the removal of a fibroid polyp is ever regarded as an element of danger. It seems a very easy matter to enucleate or cut off with a pair of scissors a small fibroid polyp, but in this case there was a history of several attacks of peritonitis, the uterus was not easily dragged down, and, after I had dilated with the Goodell dilator and made a bilateral incision of the cervix, it was difficult to introduce my finger, and it seemed to me easier to slip a wire over it than to try to cut it off with the scissors. I have removed polypi very easily in which the tumor did not fill up the entire uterine cavity or had become extruded into the vagina. The chief point of interest is the mistake I made when she called at my office: I thought it was a mucous polyp and that it had its attachment near the os externum. However, before she left the office I found the attachment was higher up. The uterus now measures only about three and one-half inches; at the time I saw her, a year ago, the uterus was fully five inches. I expect to have a microscopical examination made of the tumor, but I do not think it is malignant.

DR. C. A. L. REED.-At the last session of this Society I exhibited a specimen which I had just removed, and which I supposed to be an abscess of the ovary. It was an ovary with the tube attached. The specimen was not opened at that time, but since then an incision has been made by Dr. Bettman and the pus evacuated. It is a beautiful specimen, probably papillomatous. I wish to show this and incorporate it in the report of the specimen I presented at the last meeting. It is a beautiful specimen, the like of which I have never before seen.

I have here another specimen, which I wish to present in the fewest possible words. I was called to a neighboring city to operate for what had been diagnosed as a fibroid tumor of the uterus. I arrived in the morning, and found a tumor filling the abdomen well up to the ensiform cartilage. On vaginal examination this same tumor occupied the left iliac fossa and pressed far down into the excavation of the pelvis, pushing the cervix, occupying a position to the right of the tumor, bigh up and posteriorly. I proceeded to operate, and, on making my incision down to within an inch and a half of the pubes, I suddenly came to a point where the parietal peritoneum was reflected over the tumor. In other words, I had to deal with an extraperitoneal myoma. Slipping my hand over the growth, I discovered the uterus occupying a position quite independent of the growth, still posteriorly and to the right of it. Somewhat enlarging my incision at the upper angle, I then lifted up the peritoneum and enucleated the growth extraperitoneally. This was an exceedingly difficult matter, as you can readily understand from this specimen. I found the growth, a pear-shaped myoma, occupying the left iliac fossa. Getting my hand under the peritoneum, I had little difficulty in stripping it up; then, not endeavoring to remove it from its nest down in the iliac fossa, I

encountered bands, which I divided with my fingers, simply cutting them off. Going around on the right side of the tumor, I found I got under a deeper capsule than I had found on the other side. I simply tore up the capsule, lifted the growth out, and it was absolutely without a pedicle. It left an enormous opening in the pelvis, from the surface of which there was considerable oozing. I had to do considerable ligating en masse. On examination I made the unpleasant discovery that in dividing the large band I had divided the ureter. I permitted this to stand in statu quo for the time, and addressed my attention to the uterus, which I found to abound in myomatous nodules. I found, when I had lifted up the peritoneum, I lifted it up to the fundus of the uterus anteriorly. I took out the uterus, tied off the tubes to either side outside of the peritoneum, simply clipping off the appendages internally without ligature. This proved to be entirely satisfactory, and for the purpose of closing the peritoneum required only a single stitch. I then stitched the peritoneum, which had been lifted from the pelvis, fast to the margins of the abdominal incision, thus entirely closing off the peritoneal cavity. But before I did so I made a lateral anastomosis of the ureter. Although she was in the Trendelenburg posture, it was exceedingly difficult to draw that segment down so I could get at it easily. I drew the renal end of the ureter into the cystic end and then closed it around in the usual way. On the following day the bowels moved, and she has been taking nourishment from the start. I packed the peritoneal cavity with iodoform gauze, bringing the end out through the vagina. When this was removed about an ounce of urine escaped. For the last two days no urine has been passed from it. I used silk sutures in the ureter.

TRANSACTIONS OF THE WASHINGTON OBSTETRICAL AND GYNECOLOGICAL SOCIETY.

Meeting of April 7th, 1893.

The Vice-President, H. D. FRY, M.D., in the Chair.

DR. J. FOSTER SCOTT read a paper entitled

PATHOLOGY AND TREATMENT OF PERIUTERINE PELVIC

INFLAMMATIONS.'

DR. E. L. TOMPKINS said he would take exception to Dr. Scott's recommendation of the use of alcohol and water to sponge

1 See original article, p. 803.

the body with a view of reducing temperature. He thought the alcohol was objectionable, as it hardened the skin; water was preferable.

DR. A. F. A. KING said that Dr. Scott's paper was very complete. It would be interesting to consider the causes of these conditions. Dr. Scott said that most of them originated from endometritis. They seem to be of more common occurrence than formerly, or is it that diagnosis is more accurate now than then? Preventive methods should be sought after. As to the use of alcohol with water, he said the alcohol was added to increase the evaporation, and to that extent it was advantageous. In his early gynecological practice he had used leeches to the vaginal portion of the cervix with advantage, but they were troublesome. He thought that superficial scarification was

better.

DR. W. SINCLAIR BOWEN said that as sepsis was the cause of these pelvic inflammations, antiseptic midwifery was the best preventive.

DR. H. D. FRY said he arose to commend the views set forth

in the paper. Formerly it was held that this pelvic inflammation was a cellulitis, but the modern view that it was tubal disease was well established. Tait was early in demonstrating this. It arises by direct extension from the uterus to the tube. Cellulitis might develop after laceration of cervix by transport of germs through lymphatics. He gave an illustrative case, in which he evacuated pus under Poupart's ligament.

DR. J. FOSTER SCOTT said that Dr. King had answered the objection of Dr. Tompkins as to the use of alcohol. Alcohol was refrigerant and cleansing, and aided in removing impurities from the skin.

He said that while the majority of cases of pelvic inflammation were of the form considered in the paper, he maintained that there was cellulitis developing from lesions of the cervix through lymphatics. Its origin was almost invariably from puerperal cases. Inoculate the cervix in any way and cellulitis might follow.

TRANSACTIONS OF THE

OBSTETRICAL SOCIETY OF LONDON.

Meeting of April 4th, 1894.

The President, G. E. HERMAN, M.D., in the Chair.

Specimens.-DR. W. H. TATE: Ruptured tubal gestation. DR. W. DUNCAN: Fetus and placenta from a ruptured tubal gestation. DR. ETTLES: Fetus cyclops.

ON CASES OF ASSOCIATED PAROVARIAN AND VAGINAL CYSTS FORMED FROM A DISTENDED GÄRTNER'S DUCT.

This paper was read by DR. AMAND ROUTH. Details of three cases of the above are given, and also of two analogous cases of patency of the whole length of the duct, with an anterior opening allowing free discharge and thus preventing distention of the duct along its course.

Comparison is drawn between such cases and those of distended but imperforate Müller's ducts.

Evidence adduced from these cases is thought to establish, or at least to render plausible, the following propositions :

1. That Gärtner's duct can be traced in some cases in the adult female from the parovarium to the vestibulum vulvæ, ending just beneath and slightly to one side of the urethral orifice.

2. Homology tends to show that Max Schüller's glands are diverticula of Gärtner's ducts, just as the vesiculæ seminales are diverticula of the vasa deferentia. Some evidence is given that Skene's ducts are not necessarily identical with the anterior termination of Gärtner's ducts (as most of those who have traced Gärtner's duct to the vestibule have thought), but that Skene's ducts lead directly and solely from Max Schüller's urethral glands, Gärtner's ducts being continued to the vestibule behind, but parallel to, Skene's ducts.

3. That Gärtner's duct, if patent, may become distended at any part of its course, constituting a variety of parovarian cyst if the distention be in the broad-ligament portion, and a vaginal cyst if the distention be in the vaginal portion. The cases described are instances of the association of both of these cysts, owing to simultaneous patency and distention of both portions of the duct.

4. Attention is drawn to these cases as affording explanations of some obscure cases of profuse watery discharge from the vagina, not coming from the uterus or bladder.

5. The question of treatment is also approached, and the opinion is expressed that where the whole duct is distended the vaginal part of the cyst may be laid open as far as the base of the broad ligament, and the broad-ligament portion encouraged to contract and close up.

MR. ALBAN DORAN thought that if cysts of the parovarium and vagina were found in the same subject, the theory that the vaginal cysts were developed from Gärtner's duct was thereby supported. Fschel found that in one human fetus the duct ran into the cervix, and, turning upward, ended in a blind extremity without reaching the vagina. This did not prove that the tube did not at an earlier stage of development run further. Mr. Bland Sutton's theory as to the homologies of Skene's tubes might be perfectly correct, even if Gärtner's ducts