Whatever method is used, the patient should be carefully watched to note the degree of improvement, or at least to see that she gets no worse. If, after several months, the patient is not on the high road to recovery and the abscess can not be safely opened through the vagina, laparotomy should be done. You have not lost anything by your delay, the patient being in better condition for the operation and is almost sure to make a brilliant recovery; for laparotomy, under these conditions, is a safe and sure means of relieving and curing your patient. I say safe, for I believe if the plan of treatment I have indicated is followed out, the mortality from the removal of pus sacs from the pelvis by this method will be almost nil, and the abscess being well defined after such treatment, all offending material can be removed and the patient be well after getting out of bed. I wish to refer to three cases illustrating what can be done and the dangers of puncture through the vagina. Lucy R., married, suffers with very great pain in lower abdomen, temperature 103° F., pulse 130. Examination shows a large abscess pointing in Douglas's sac. A generous incision was made at the softest point and a quart of very offensive pus evacuated. A T-shaped rubber tube was introduced just long enough to protrude from the vagina. The cavity was flushed daily with a one to four solution of hydrogen dioxide. The pain ceased after eight hours and in two months the examination showed the uterus movable but not entirely free from adhesions. Unfortunately, I was not able to examine this patient again, but when I last saw her she was perfectly well and robust. Mary G., married, has suffered with great pain in the lower abdomen for more than a year. Examination shows a tumor as large as a cocoanut, just protruding above the pelvic brim. Douglas's pouch was pushed down low in the vagina and fluctuation was distinct. The tumor was irThe tumor was ir regular in shape above and adherent throughout the entire pelvis. The usual incision was made through the posterior cul-de-sac and about a half-pint of a whitish fluid escaped. As the tumor was still in situ, except for the bulging in the vagina, I decided it was a multilocular ovarian tumor and that I had punctured a cyst. Laparotomy was done and two large abscesses were removed. The space I had to open into was a cavity of the perineum walled off by the abscesses and containing a partially coagulated peritoneal fluid. If I had pushed my knife up a little further I would have gone directly through an intestine. Caroline J. entered Columbia Hospital to the service of Dr. Stone. She was suffering with great pelvic and abdominal pain and seemed to be almost in extremis. A large mass was found filling the pelvis and pointing to the left and a little behind the cervix. I punctured this through the vagina and a pint of foul-smelling pus escaped. The usual tube and flushing were practiced. The improvement was very rapid, so that from an emaciated-looking old woman she became quite plump. A few days after the puncture a small mass was detected to the right and somewhat anterior to the uterus; this was diagnosed as a pyosalpinx. Laparotomy was advised, but the patient concluded to go home to attend to some business and did not return for two months and then was brought in the ambulance. The temperature was 105° F., pulse 150; abdomen showed general peritonitis. I opened the abdomen and flushed with hot water. The pyosalpinx was found ruptured within the abdomen, causing the peritonitis. The patient died in about ten hours, not having rallied at all after reaching the hospital. OBSTETRIC CASES INVOLVING CERTAIN MECHANICAL DIFFICULTIES. By J. Edwin Michael, M. A., M. D., Professor of Obstetrics at the University of Maryland. CASE I. Decapitation. Seen with Dr. J. D. Iglehart. Robust young primipara. When first seen by Dr. Iglehart labor had been progressing for several hours without coming to an issue. The waters had broken and upon examination Dr. Iglehart found a hand in the vagina, the uterus much contracted, waters gone and child dead. Several attempts at version resulted in failure and fracture of the presenting arm. When seen by me the case had reached a truly critical stage. The pains were regular, frequent and powerful. The presenting shoulder was forced well down into the pelvis, the os was well dilated. Palpation showed a firmly retracted uterus, pressing firmly on its contents, head to left, dorsum anterior, small parts not palpable, no cyst tension, waters having escaped, contraction ring well up above pubis, lower segment thinned out to a perilous degree. We concluded that further attempts at internal podalic version would endanger the integrity of the uterus, already under a distinct threat of rupture. Other methods of version were of course out of the question. Decapitation was therefore selected as the proper operation. This was accomplished by the use of Braun's decapitation hook, an instrument of most unprepossesssing appearance, but of decided. value. The neck being severed safely by repeated tractions and rotations of the instrument, the body was easily delivered by slight traction on the prolapsed arm. The head, from which some difficulty was expected, followed readily, the finger having been placed in the mouth and hypogastric pressure having been applied. In this case I firmly believe that had another attempt at version been made we should have had a rupture of the uterus. The dangerous thinning of the lower segment, the retraction of the uterus and the loss of the amniotic fluid had produced a state of affairs in which an attempt at increasing the contents of the womb by the introduction of the hand would have been disastrous. The case also illustrates the value of hypogastric pressure in controlling and extruding the head. The recovery of the patient was uneventful. A CASE II.- Falciform Contraction. robust Irish primipara was pregnant of twins and in charge of an ignorant midwife. Upon the birth of the first child, which she said presented by the vertex, a fluid drachm of extract of ergot was administered. After waiting a considerable time and becoming alarmed at the delay in the birth of the second child, a call was sent to the Free Lying-in Hospital and Dr. Hargrove, then Senior Resident Physician, responded. found the second fetus presenting by the breech, the os somewhat rigid, the child dead. Having dilated, etc., sufficiently, he brought down the feet and delivered the buttocks and trunk. The arms caught at the brim and were with some difficulty brought down. At this point He the uterus became tetanic and all further attempts to deliver failed. The various methods - Veit-Smellie, Goodell, etc.were tried in vain and every attempt to apply the forceps to the after-coming head miscarried. It was not possible to get the blade of the instrument in position. Upon my arrival I found the following state of affairs: Woman's general condition good, uterus firmly retracted over the retained head, child's neck much drawn out in the attempt to deliver. The uterus seemed to hold on to the head with the grip of a bull-dog. The examining finger passed easily into the cervix, but just within encountered a sharp, tense margin of tissue as much like a steel band as human tissue could be. The finger, even with the exercise of as much force as could be applied, failed to make any impression upon this constriction. I could not, with the use of any amount of force I considered safe, get the forceps blade past this band. Profound anesthesia made not the slight est impression on it. The neck had been nearly pulled in two, the jaw had been broken in the previous attempts to deliver. I worked over the case for more than an hour without having made any impression whatever upon it, so far as I could determine. I was considering the advisability of trying to incise the band when finally, by the exercise of powerful supra-pubic pressure by my assistant, Dr. Hargrove, the head was forced through the retaining band and delivered. The surroundings of the case were filthy, the midwife was dirty and ignorant and the husband drunk below stairs during the labor. As was to be expected, the case became infected and the patient was ill, but finally made a good recovery. CASE III.- Seen with Drs. B. F. Leonard and A. Atkinson. The patient in this case was a primipara, aged 30, of very unusual physical proportions. She was about five feet, four inches in height, and weighed 280 pounds. Her mammary glands had been so enormous in size and weight that Dr. Leonard had amputated them some time before. After amputation they weighed twenty pounds, so that if she had not been delivered of those appendages her weight would have been 300 pounds. When first taken in labor Dr. Leonard, whose patient she was, had found, upon examination, a very narrow vaginal orifice and had with great difficulty been able to reach the os uteri. Only after mechanical dilatation had he been able to make a diagnosis. The thickness of the abdominal walls had precluded a successful palpation. When a sufficient dilatation of the os had been made attempts at delivery with forceps had failed. Dr. Atkinson was then called in consultation and craniotomy was decided on. This operation was successfully done so far as perforation and crushing of the head were concerned. Delivery, however, could not be accom Suf plished. I was then added to the consultation and requested to bring instruments for delivery. Upon my arrival chloroform was again administered by the patient's mother, a task which she carried out with such an exhibition of coolness and judgment as I have seldom seen in a non-professional person. ficient dilatation and indeed laceration of the vagina had been produced in the former attempts at delivery, to allow me plenty of room. I applied the crushing blades of Tarnier's basiotribe easily, but was unable to accomplish delivery, the blades slipping off as fast as I put them on. The vault of the cranium had been crushed and partly removed and the mechanical conditions were such that such traction as I could make would not bring down the fetus. The night was extremely hot. My confrères had about completely exhausted themselves. My own efforts were beginning to express themselves in a perspiratory form. With much chagrin I finally had to admit that I could not deliver with instruments. I then addressed myself to internal podalic version. With a patient who was a veritable mountain of flesh, whose abdominal fat prevented any material aid from the external hand, this was no easy task. Having gained entrance to the uterine cavity with my left hand I grasped an arm. Its size left little doubt in my mind that it was a leg. Not willing to trust to size alone, however, I followed it down to an extremity and was astonished to find a hand. hand and arm were much compressed and beginning to weaken. Finally, however, grasping a foot, I sought to bring it down, and succeeded after what might legitimately be called Herculean labors. The uterus was firmly retracted, the waters had long ago escaped, the immense fetus was wedged down tight and the external hand was practically useless. A fillet being attached to the foot, the other foot was found and brought down. At this point I felt that I had conquered the mechanical difficulty in the case and took a short breathing spell. Both feet being now included in the fillet, as the uterus made no progress in expelling the fetus, I My Minus made a powerful traction and made but little progress. Gaining little by little, however, the body came down until the shoulders became engaged. Then the arms went up and another problem had to be solved. With the body of an ordinary fetus, in the birth canal it is usually no very easy matter to bring down the arms. In this case it was almost impossible. I finally succeeded, however, just as I had about determined to dismember the child and remove it piecemeal. The child was a male and the largest I had ever seen. brain, all of which had been removed, and a large part of the skull, it weighed thirteen pounds and a half. Its length could not be taken on account of the loss of so large a part of its skull, but it was rather short. In fact in regard to its proportions, it was a counterpart of its mother. This task required about an hour and three quarters of the most severe muscular exertion that I have ever found it necessary to use in any medical or surgical act. The patient was naturally exhausted, as were all concerned, but she soon revived and made a recovery, which was free from any alarming complication. The perineal laceration was considerable, but in my opinion quite excusable. CASE IV. Seen with two physicians who shall be nameless. Young negress about 22 years of age. Of very small stature; had been in labor about four days. Waters broke three days before I was called. Attempts to apply forceps had failed and efforts to turn had left two hands and a foot at the brim. Patient very weak, with hot, dry skin, feeble, rapid pulse, slight delirium and every evidence of exhaustion. Tem perature not taken. A nasty brownish, fetid discharge issued from the vagina. Upon examination, besides presentation of two hands and a foot, it was discovered that we had to deal with a flattened pelvis with a conjugate of less than three inches. Palpation showed head in left flank, with crackling bones, indicative of the fact that death had occurred some time previously. It was evident that the patient's condition would admit of no delay; in fact her Af death was practically a foregone conclusion. I did not think it wise to send for instruments for dismemberment. I had been called from the University Hospital and did not have my obstetrical bag with me and thought I could force the softened head through the contracted pelvis. Turning was no easy task, although one foot was in reach. The uterus was firmly contracted, the fluids gone, the child firmly impacted by previous misdirected attempts at version, and epidermis of the extremities soft and loose; I succeeded, however, finally, in bringing down the pelvis, trunk and arms. Then by the use of most positive supra-pubic pressure the softened head was squeezed through and the woman delivered. ter delivery the head showed plainly the imprint of the sacral promontory and was mashed in such shape as would, I think, have been fatal to living child, even if it could have been delivered at all after the manner used. The uterus and vagina were douched with a sublimate solution. The woman died a few hours after delivery. This case illustrates better than any with which I have come in contact the necessity of careful examination of the pelvis before labor and at the onset of labor. A most superficial examination of this case would have shown the danger ahead and warned the accoucher to be prepared for it. It is not proper at this time to discuss the various methods of meeting the dangers of contracted pelvis of various grades, but the accurate knowledge of the difficulties which lie before us is the only basis on which we can act. To allow a woman with a conjugate of less than three inches to lie in labor until her child dies and she is moribund presupposes a degree of obstetric ignorance at which one is surprised and shocked. And even in the absence of knowledge of the means by which such information may be obtained, one would suppose that in a case where no progress is made and all attempts at operative interference fail, a consultation should be called. The case also illustrates in a very forcible manner the extreme value of supra-pubic pressure as an aid to delivery when vis a fronte is not capable of reaching the desired end. It CASE V.-Dr. Billingslea. Mrs. C., aged 40. Something over a year ago had shown such symptoms of kidney trouble during the latter part of her first pregnancy that artificial delivery had been determined upon and successfully accomplished. Pregnant about eight months. Organic heart lesion demonstrable. Amblyopia marked. Dr. Murdoch had already diagnosticated albuminuric retinitis. Headache with tendency to coma. Pulse irregular and somewhat feeble. Albumen in urine in large quantity. We put her on eliminative treatment at once. In twenty-four hours not only was there no evidence of improvement, but the comatose tendency deepened and the blindness increased. was evident that we were losing ground and we concluded that rapid delivery would be our only chance. Manual dilatation and accouchement forcé was the plan decided upon. Under chloroform and with strict antiseptic precautions, a finger was passed with some difficulty through the os. Then a second finger. Finally four fingers, the os yielding steadily, but slowly. At this point Braxton Hick's bi-polar version was easily accomplished. The feet being caught, the membranes were ruptured and the legs brought into the os. So far things had gone as well as could be expected. Here, however, set in a state of affairs which gave us much trouble. The os assumed a rigid, tetanic quality which absolutely hindered further progress. The margin presented a rigid, hard edge comparable to a steel band upon which the fingers of the operator had little or no effect. It was absolutely unyielding. After many exhausting and somewhat forcible efforts which gained nothing, I determined to make multiple incisions in the cervix. With a curved, probe-pointed bistoury laid flat on my finger, during the introduction, I incised the cervix in many places. With the powerful space thus gained, the child again began to advance under traction by fillet fastened to the legs. The trunk and upper extremities being delivered, the cervix again con tracted around the neck, and it was only by the use of the most vigorous traction together with the Veit-Smellie method of extraction and supra-pubic pressure that the dead child was delivered. It had been alive at the beginning of the operation and but for the tetanic behavior of the womb, would have had a fair chance for life. The recovery of the patient was prompt and uneventful although of course her organic heart and kidney lesions remained a source of trouble and apprehension. CASE VI.-With Dr. Hill. Mrs. L., aged 21. Primipara. Dr. Hill had recognized a presentation of the face R. M. P. and asked me to see the case with him. Dr. J. M. Hundley kindly assisted in the case and agreed to the diagnosis. As no descent had been made we concluded that manual substitution of vertex for face presentation ought to be attempted. Under chloroform and with antiseptic precautions this was easily done, the result of a very simple manipulation, pushing up the chin and bringing down the occiput being to reduce. the presentation to L. O. A. This being done, it was a question as to whether we ought to deliver with forceps or leave the case to nature. We concluded to resort to forceps, since the patient had already suffered a good deal, showed some signs of exhaustion and was already anesthetized. We expected no difficulty whatever. The Tarnier instrument was easily adjusted and traction begun. Under the exercise of but moderate power the instrument slipped off. I was surprised, as this is not the usual behavior of the instrument. Adjusting it again with special care, I again began traction and was again chagrined by the instrument slipping. After many failures, the head still being high and having made no progress, we determined to try version. With little or no difficulty this sometimes trying operation (internal podalic) was successfully done and a dead fetus delivered. I was then and am still at a loss to account for the fact that the forceps would not remain fixed on the head. They were easily and well placed. In fact we apprehended no difficulty whatever, but could not deliver |