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* Read at the second meeting of the Alumni Associatiou of the Woman's Hospital. much the same effect as " damning a man with faint praise.'' Dr. Goodell says ("Lessons in Gynaecology," 1880, p. 218) : " I shall now proceed to denude the edges of the fissure and to dissect away all the cicatricial tissue in a wedge- shaped piece." Cut he continues : " In freshening so deeply situated an angle, the circular branch of the uterine artery- is in Levitra Online Us Pharmacy danger of being wounded, and I shall merely skim the surface with this delicate knife curved on the flat." In a more recently written article (" Am. Jour, of Obstet.," vol. XV, p. 124) he says: "Another occasional indication for the operation Levitra Online Us Pharmacy is the presence of dense cicatricial tissue in the angles of the fissure. . . ." But adds : '' From my Levitra Online Us Pharmacy observa- tions I am disposed, indeed, to believe that the baneful in- fluence on the system of hard and gristly cicatricial tissue left after some cervical tears has been overrated." Dr. Munde ("Minor Surgical Gynsecology," 1885, p. 433) says : " The cicatrix also presses on the terminal nerve- filaments in the cervix, chiefly in the upper angle of the rent, and, through communication with the sympathetic system, produces reflex neuroses in the pelvis, down the thighs, along the back, and in different distant portions of the bodv." And on page 438 of the same work he says : " The dense cicatricial substance, by compressing the termi- nal nerve-filaments, gives rise to multitudinous and diverse reflex neuroses in other parts of the body." But no one speak8#.so positively in regard to both the presence of a mass of cicatricial tissue in the angles of the original tear and its Levitra Online Us Pharmacy influence in perpetuating the anaemia and causing the varied reflex nervous phenomena as Dr. T. Addis Emmet. On page 468 of his last edition he says : " We frequently meet with cases where nature has at- tempted to repair the injury and to prevent the gaping of the flaps, in a double laceration, by filling in the angles on each side by granulations as the parts have healed. The result is that a dense cicatricial plug remains. When this condition exists, there is often- much reflex disturbance of the nervous system, and frequently it is the exciting cause of neuralgia in other parts of the body." Again, on page 486 : " We can not ignore the clinical fact . . . that, after nature has repaired the injury by partially or completely filling the gap between the flaps by cicatricial tissue formed in the process of healing by granulation, marked reflex dis- turbances will sometimes Levitra Online Us Pharmacy be established." That any experienced gyntecologist should doubt that a mass of hard, fibrous, in this case cicatricial, tissue (the • "cicatricial plug" of Emmet) is to be found deep in the angles of many cases of neglected lacerated cervices, seems to me strange, as frequently it is Levitra Online Us Pharmacy perfectly easy of demon- stration. In a number of cases I have removed Levitra Online Us Pharmacy tissue as characteristic as that reported upon by Dr. Garrigues (Em- met's "Principles and Practice of Gynascology," 1880, p. 491), hard and gristly to the Levitra Online Us Pharmacy feel, which, when dissected out, left a bed of smooth, apparently normal, uterine tissue. This plug always, so far as my experience goes, extends much more deeply on the inner surface of the uterus, often quite to the internal os, the original laceration extending obliquely outward and involving the whole thickness of the cervical wall only in its lower or outer portion. This makes its complete removal, Levitra Online Us Pharmacy without marked danger of serious 98 M08ELEY: CICATRICIAL PLUG. [X. Y. Med. Jocb., haemorrhage, much easier than would be possible did it ex- tend farther out toward the attachments of the broad liga- ments. I think a principal cause of misunderstanding in regiird to this "cicatricial plug" is, that we do not distin- guish between those cases of deep laceration in which the healing process has taken place as described by Dr. Emmet, and subsequent contraction Levitra Online Us Pharmacy of the cicatricial tissue has drawn the cervix into a comparatively natural shape, leav- ing the tissues of the anterior and posterior lips in a practi- cally normal condition, and those in which the changes subsequent to the laceration have so altered the tissues of the whole cervix as to render it a hard, fibrous mass. We see that opinions on this subject differ very widely, ranging from a denial of the existence of anything like a cicatricial mass to a very positive affirmation, not only of its existence, but of its direct causative influence in bring- ing about the numerous neuroses mentioned, and it oc- curred to Levitra Online Us Pharmacy me that, in this very mixed state of affairs, you might feel an interest in the recital of a few cases which seemed, to my mind, to demonstrate that this same " cica- tricial plug " or mass of hard, fibrous tissue was, not only the offending member, but the only factor playing the part of a direct cause which could be found, and that its removal was followed by a change in the nervous symptoms, too sudden to be accounted for by the slow changes which would result from simply an improved state of nutrition. Case T. — In June, 1879, I was called upon to assist a medi- cal friend in a tedious and difficult case of labor, anil, by means of forceps, delivered Mrs. 0. of a large, dead male child. From tliat time I lost siglitof the lady until the early autumn of 1880, when I was asked to take charge of her as a gynsscological pa- tient. At this time she complained of general weakness, and ir- regularity of menstruation, the flow being accompanied by pains in both ovarian regions and back. She was somewhat aniemic and generally run down. Examination showed a double laceration of the cervix which was somewhat granular; a slight laceration of the periniBum, an anteflexion of Levitra Online Us Pharmacy the funJus, and some tenderness in the region of both broad hgaments. She Levitra Online Us Pharmacy was put upon hot douches with applications of Churchill's tincture of iodine and glycerin pads prepar.itory to repairing the cervix Levitra Online Us Pharmacy and perinieum, but before that could be done she w:is taken down with a double pneu- monia, during her convalescence from which I left home and entered the Woman's Hospital. During ray atisence from home ray patient continued the hot douches, and had applications made by a medical gentleman, who finally pronounced her well and insisted that there was no occasion for an operation. On April 23, 1882, a few days after my return from New York, this p.itient came to my office, and on that day I recorded the fol- lowing history: Mrs. C, aged thirty, married eleven years. Has bad two abortions (at Ave months and six Levitra Online Us Pharmacy weeks, respectively), but fol- lowed by no unpleasant symptoms. One labor at term three years ago, hard, tedious, and completed by forceps. She dates her sickness from the labor three years ago. Since that time she has had attacks of menoi-rhagia with leucorrhcea most of