lining a uterus whose texture and nutrition are of such quality as will favor the development of the fertilized ovum.

Now whether the flaccid uterus of infancy and childhood fails to develop at puberty, either in its anterior or posterior wali, or whether in later years shortened ligaments or adhesions binding the fundus down have accomplished a flexion, the result is not only a flattening and more or less occlusion of the canal, but with the flexion of cervix, or body, or both, atrophy of uterine wall at the angle of flexion, plus an impaired circulation, with congestion and hyperplasia in other portions of the organ; and still more important, an added endometritis with altered secretions, forming a combination most hostile to spermatozoa. Thus it is, when this mechanical deviation is a cause of the pathology here outlined. as also a hindrance to its cure, that flexion exercises its most potent influence against conception, and makes hazardous the development of the fetus, if in spite of these combined obstacles, conception has perchance taken place. This mechanical hindrance to the cure of endometritis (and the consequent relief of sterility) operates in at least two ways. First it is difficult in flexion to thoroughly apply to the diseased endometrium the local treatment so helpful. Second, the uterine cavity, like any other, heals far more readily when drainage is free. The easy mechanical removal of purulent or muco-purulent discharge is invariably helpful to the cure of any secreting surface.

An interesting study on the part of an author, whose name I do not now recall, has shown that pregnancy is far more frequent in women with normal contour and capacity of the vaginal vault posterior to the cervix. Here ordinarily is room for the seminal fluid, the so-called seminal lake, which, either in the horizontal or even upright position, may be retained a considerable time, bathing the cervix and filling the os. This is especially the case when the cervix is normally straight and rests against the posterior vaginal wall in this upper chamber under Douglas' cul-de-sac. (This space we frequently find wanting in unmarried women past the menopause, but occasionally also in young single women and the childless married. The finger, on examing, feels the cervix, not projecting into the vagina, but rather forming the whole roof of the vault, the vagina being cone shaped, truncated at the junction with cervix. The examining finger may almost fill the space, so narrowed is it found to be.)

When, however, even in a normal upper vagina the cervix is sharply flexed in either direction, but especially forward, the os is lifted up, away from the deposited seminal fluid, pointing quite in the opposite direction from normal, viz., upward and forward. If now the anatomy be still more defective in the way of a conical cervix, as quite likely may be the case, there exists a mechanical combination decidedly inimical to family increase. So much for the mechanical and anatomical.

Turning to the physiological for a moment, there are those

who stoutly maintain that the uterus itself in sexual orgasm plays an important though not essential part, in the entrance of spermatozoa to the uterine cavity. They claim that it has the power to open and close in such manner as to draw to itself any fluid within reach: making the vaginal canal and the uterine canal for the time being more or less continuous. Such advocates would find in flexion a serious interference with this physiological function of the uterus so interesting if true. The writer disclaims any personal observations substantiating this theory, but has heard it taught by those who would command respect in any circle.

As before intimated, I look upon an infected endometrium with altered secretions as the chief cause in curable sterility, giving second place perhaps to stenosis as found at the internal os, or seen in conical cervix with pinhole os. Next come flexions, causing, not often absolute, but relative, sterility.

It

Now the best remedy I know for flexion sufficient to cause sterility, is pregnancy; very easy to prescribe, difficult to apply, to be sure, and not satisfying to our patients who have perhaps long years desired offspring in vain. We therefore keep this prescription to ourselves, and advise dilation and straightening of the canal, a mild approximation to pregnancy in its results, because in some cases, at least, a certain uterine development is seen to follow through dilation. In ordinary flexions the uterus straightens with the dilating, continues straight, or more nearly so, if an intra-uterine stem be worn for one, two or three or more weeks, as the case may require. This must be carefully fitted, as indeed must all pessaries if they would, avoid being consigned to oblivion. Especially should the stem be not too long. Patience and care must be exercised in dilating too. is comparatively easy in hurried and forcible dilation to rupture the uterine wall at one side or the other. Should this accident occur, no further attempt should be made to dilate, as only wider laceration takes place. Most good obtains when the dilation is accomplished slowly, twenty minutes being none too long for the best results. For remember that we are dealing as a rule with a uterus never pregnant. The degree of success depends naturally on the degree of flexion to be overcome, combined with the chronicity and extent of consequent changes in the uterine walls. But much also depends on the gradual and thorough dilation and careful fitting of stem pessary, securing the minimum amount of irritation. Surgical cleanliness is of course imperative. Relapses are bound to occur, but many of the failures are due to nonobservance of the few points just mentioned. The twentyfive or thirty per cent. not benefitted or cured in this way require a more radical surgical treatment.

Observe that this discussion has to do with relative or curable sterility, not absolute sterility. It assumes normal spermatozoa, normal ovum and fallopian tubes. It should therefore give a favorable prognosis, and does where flexion is the chief cause, since flexion may generally be cured, or at least circumvented.

As above stated, the conical cervix with pinhole os, sharply anteflexed, is the mechanical or anatomical combination forming an effectual barrier to conception. It requires likewise pretty radical operative treatment for its cure. It has been my intention not to detain you with technic or details, but rather to speak of principles in treatment, and that very briefly. Dilating and curetting, together with mechanical attempts to straighten, avail in about three-quarters of the cases. And mechanical measures succeed not by virtue of correcting anatomical deviation alone, but through incidental correction of concomitant conditions. Of the three-quarters of cases remaining reasonably straight after operative treatment, one-half or more will not become pregnant, showing that some cause other than flexion must be sought. (Incidentally let me remark that man is sterile far more frequently than we used to think. So that in the cure of sterility we should by no means spend all our time and give all our attention to the woman. Wilson, for instance, says that forty-two per cent. of men having gonorrhoea are sterile. Even with very liberal allowance for possible high estimate, one concludes that in a fair proportion of cases the trouble is with the man.)

With this rather meagre treatment of the topic assigned me I would close by calling attention to the "Stomato-plasty" of Pozzi, a radical measure which I believe to be good surgery theoretically, and which has yielded excellent practical results. It leaves no raw surface to invite infection; leaves the uterus something as obtains in a bi-lateral tear of childbirth, with little eversion or thickening. Pregnancy results in more than twentyfive per cent. of the cases, and goes to full term without miscarriage. Dysmenorrhoea is always immediately and definitely cured, and the cervical endometritis due to stenosis, together with the leucorrhoea, rapidly disappear.

The operation consists in bi-lateral slitting of the cervix with scissors as in repair of double laceration, but carried as high as the vaginal junction with cervix. This gives four raw surfaces, two anterior and two posterior. Up the middle line of each of these four surfaces a wedge of uterine tissue is removed with the knife, so that by sutures, cervical mucous membrane is approximated to vaginal mucous membrane laterally, thus rolling in each quarter section of the cervix. The immediate result is a rather clumsy gaping cervix suggesting an open duck's bill. A few weeks, however, suffice to contract and shape the cervix into tolerably normal proportions.

The Governors of the N. Y. Skin and Cancer Hospital announce a course of nine lectures to be given at 4.15 o'clock on Wednesday afternoons from March 1 to April 26, inclusive, in the Out-Patient hall of the Hospital, Second Avenue, corner 19th Street, New York. The lectures will be given by Drs. Bulkley and Bainbridge, and cover the subjects Eczema, Acne, Psoriasis, Syphilis, and Cancer. The course will be free to the medical profession.

SALPINGITIS.*

BY J. EMMONS BRIGGS, M.D., Boston, Mass.

Salpingitis is an inflammation of the tube, due in all cases to the introduction of infectious micro-organisms, the most common of these being the gonococcus, streptococcus, pneumococcus, colon bacillus and tubercle bacillus. The acuteness of the infection depends upon the virulence of the micro-organisms introduced and the resistance which the patient offers to the infection. It is well known that bacteria differ greatly in their intensity, and among the pus producers some are very active and others quite bland. Thus, we should expect a more rapid and destructive process in a streptococcic infection than in one produced by the pneumococcus.

Gonorrhoea is responsible for over fifty per cent, of all cases of salpingitis. Streptococcic infection ranks next in point of frequency and is of greater virulence.

This latter infection occurs quite frequently following miscarriage or childbirth, it being much more common in induced abortions than in miscarriages. In these cases, it is usually introduced by unclean instrumentation.

A gonococcic infection is usually introduced by intercourse with a person infected with gonorrhoea. There may be a few exceptions to this statement, as in a case which I am about to relate. Nevertheless, the above described method of infection will cover practically all cases.

In November, 1898, I was called in consultation to see a girl, twenty-two years of age, of excellent character, who was suffering from a pelvic abscess following a gonorrhoeal infection. She denied intercourse and had an unruptured hymen. About a month before I saw her, she lent her douching apparatus to a young girl who had a leucorrhoea. She used this apparatus herself afterwards and within a week developed a profuse leucorrhoeal discharge. Soon after that her symptoms became very acute and she developed a gonorrhoeal salpingitis, for which a salpingectomy was performed. One week after operating upon her, I operated upon her mother, a woman over fifty years of age, who also had an acute gonorrhoea with tubal involvement. She gave a history of having used her daughter's douche point. I am convinced that both of these cases had their origin in the contaminating douche point, although of course no proof of this exists.

In discussing the subject of salpingitis. I shall have nothing to say regarding the infection or its manifestations upon the external genitalia, but shall confine myself to the lesion of the tube, in its acute, semi-acute and chronic manifestations, inasmuch as it affects the tubes, adjacent organs, uterus and peritoneum.

* Read before the Massachusetts Surgical and Gynecological Society, Dec. 14. 1910.

The earliest pathology of a septic inflammation of the tube is redness, swelling and oedema of the mucous lining of the tube, followed by involvement of the muscular and peritoneal surfaces. Inflammation of the mucous membrane causes an outpouring of mucus, which soon becomes turbid. As this process advances, there may be a leakage of fluid from the fimbriated end of the tube into the general peritoneal cavity, or if the inflammation is less acute, the fimbriae become sealed and an accumulation of fluid occurs within the tube, which distends it to a greater or less extent.

As the inflammatory condition encroaches upon the peritoneal covering of the tube, the irritation caused thereby results in a plastic exudation and usually in the formation of adhesions between the tube and adjacent structures. These same adhesions, although marking the progress and extension of the disease, serve in themselves as a barrier against further extension, for they wall off and circumscribe the inflammatory zone. When both the fimbriated extremity and uterine end of the tube are sealed, the condition known as pyo-salpinx develops. When this is present, the tubes become enormously distended, the normal mucous membrane lining the tube becomes transformed into granulation tissue and the mass becomes firmly adherent to all neighboring struc

tures.

With further extension of the disease, rupture of this tube may occur and pus find its way into the pelvic cavity, where it usually becomes surrounded by protecting adhesions, which alone. prevent general peritoneal involvement. Not all cases of salpingitis go on to pyo-salpinx, or to pelvic abscess formations. Some of them are so acute that nature has no time to form protective adhesions and the infected fluid formed within the tube finds its way readily into the peritoneal cavity, resulting in a general peritonitis and death to the patient.

In other, and in more frequent cases, the inflammation runs a semi-acute and less destructive course, confining itself to the tube. That is, there is no transudation of fluid into the general peritoneal cavity and no extensive pyo-salpinx results.

This condition is at first attended by considerable rise in temperature and acute pain, but in the course of a few weeks the temperature falls and the acuteness of the pain diminishes, yet the patient complains of soreness in the pelvis, in the region of the tubes and is very miserable from repeated attacks of pelvic discomfort. In very chronic cases of salpingitis, the original elements of infection disappear, that is, the gonococcus, if it were the initiative, is no longer to be found within the tube, neither in the contents nor in the mucus or transformed lining of the tube. All germ life may have disappeared. In such cases the tube may still remain distended. When such a condition as this is present, the fimbriated extremities of the tube will be found sealed and the liquid contents clear. The term hydro-salpinx is applied to