long as possible in such cases, and believes that rapid delivery is only indicated in those cases where, in spite of the tamponade, the hemorrhage is free.

E. H. G.

2. Benicke: Conception after Curetting of the Uterus (Ztschrft. f. Geb. und Gyn., XI., 2).-It has been made an objection to curetting of the uterus, that thereby conception is rendered difficult, if not impossible (B. Schultze). Düvelius has reported sixty cases where, after curetting, conception did ensue, yet, in the discussion of his paper, no others were familiar with similar cases. B. has, therefore, carefully gone over his records, and is able to report ten cases where conception followed on curetting. Of these ten cases, the operation was undertaken once for the cure of endometritis hemorrhagica, and in nine for the removal of retained membrane. In three of the cases, the operation was repeated, so that altogether it was performed thirteen times. In five of the cases, the conception ended prematurely, but this was not a result of the curetting, seeing that the patients had the habit of aborting. In two of these cases, conception ensued four and five weeks respectively after curetting; in the others, 2, 3, 4, up to 17 months after. B.'s conclusion is that the fear lest curetting should interfere with further conception is absolutely groundless; indeed, that in many cases it is an excellent method of preparing the endometrium for a new conception.

E. H. G.

3. Schroeder: A Contribution to the Physiology of the Second and Third Stages of Labor (Ztschrft. f. Geb. und Gyn., XI., 2).—The conclusions deduced by S. from this study are, in brief, the following: during the stage of expulsion, the energetic action of the abdominal muscles is very essential, and, therefore, narcotics, since they calm excitement and diminish pain, are the best promoters of labor. Ergot and its preparations are, as a rule, contra-indicated, since the muscles of the uterus contract of themselves sufficiently. During the third stage of labor it should be remembered that the mechanism through which the placenta becomes detached and is expelled from the uterus is a precise one, whilst the expulsion of the placenta from the vagina is not. The control of the uterus by means of the hand after the birth of the child is, therefore, unnecessary. The placenta will, normally, be soon expelled from the uterus through its contractions, without much hemorrhage. We know that this has happened when the uterus becomes smaller and its lower segment swells out over the symphysis. Then by simple manual pressure, above the placenta in the neighborhood of the contraction ring, we may easily, and without danger, completely expel the placenta. In typical cases, the rational and best method of conducting the third stage of labor is to wait until the placenta has been expelled from the uterus, and then resort to manual pressure. When the placenta is expelled after the manner described by Duncan, then the hemorrhage is apt to be greater, and manual pressure not so effective or simple, since the upper border of the placenta often remains for a time attached at the fundus. E. H. G.

ITEM.

DR. E. H. GRANDIN has been appointed Obstetric Surgeon to Maternity Hospital, in place of Dr. Mundé, resigned.

THE TREATMENT OF PELVIC ABSCESS IN WOMEN BY INCISION AND DRAINAGE.

WITH REPORTS OF TEN CASES.

BY

PAUL F. MUNDÉ.

In bringing so well-worn a topic as the operative treatment of pelvic abscess in the female before the profession, I am well aware that I have but little to add to what other authors have already here and there taught, or what has been practised by many surgeons, gynecologists, and general practitioners. Still, I am induced to believe, from cases which I occasionally see reported as more or less extraordinary, and from a certain confusion of statements as to the dangers of interfering with pelvic abscess by free incision, as it is practised elsewhere in the body on generally recognized surgical principles, that there yet exists a doubt as to the proper manner of treating these cases, especially among those of the profession who follow a general line of practice, and see such conditions but now and then. It is, therefore, the object of this paper merely to reiterate and recapitulate the general principles on which cases of pelvic abscess in women should be treated, and to place on record my own individual experience.

In doing so, I distinctly disclaim any attempt at an exhaustive treatment of the subject, or an intention to detract in the smallest degree from the merits of those who have preceded me in the same line of inquiry.

By far the larger proportion of cases of pelvic peritonitis and cellulitis terminate in a gradual absorption and ultimate complete disappearance of the exudation, leaving either no traces whatever, or merely a more or less limited mobility of the uterus, or a vague fulness of the parametrium. This process of absorption may extend over months, and even years, severely taxing the endurance of the patient and the resources. of the physician.

The rapid breaking down of the exudation and the formation. of an abscess is comparatively rare, and may be considered decidedly the exception. It is most liable to occur when the exudation has formed very rapidly and is very large, and when the recuperative powers of the patient are below par. Suppuration occurs by far more frequently in cellulitic exudations than in those caused by pelvic peritonitis, and is most commonly met with when the cellulitis came on after parturition at term or after an abortion. In cellulitis, it is self-evident that the exudation and, eo ipso the abscess, is extra-peritoneal. In peritonitis, the pus, of course, lies in the peritoneal cavity; but the rapid formation of adhesions between adjacent folds of intestines and neighboring organs and tissues closes the abscesscavity, and separates its contents from the rest of the abdominal cavity almost as securely as when the abscess is extra-peritoneal. This point is of considerable practical importance in deciding as to the safety of tapping or incising a pelvic abscess; for, if the adhesions which shut off an intraperitoneal abscess from the rest of the serous cavity are sufficiently firm, and if the wall of the abscess is adherent to the abdominal wall, there is no more risk in opening such an abscess than if it were actually extra-peritoneal.

Fortunately, the necessity of making the differential diagnosis between these two conditions does not often occur, since cellulitis far more frequently terminates in suppuration than peritonitis.

In looking over the question of the frequency of pelvic abscess, I have made use of four hundred cases (stopping when I

reached that round number) of pelvic peritonitis and cellulitis, which I found recorded in my private, hospital, and clinical notes. (For assistance in compiling these records, I am indebted to Dr. E. H. Grandin, instructor in my service at the New York Polyclinic, and to Dr. E. Sanders, who succeeded me in the department of diseases of women at the Mt. Sinai Dispensary, when I became gynecologist to the hospital.)

Among these 400 cases, there were 48 of pelvic abscess, or exactly 12 per cent. I think this proportion large, but its size is accounted for by the fact that many of these cases occurred in the practices of other physicians and were only seen by me in consultation, and were therefore selected cases; thus 21 were consultation cases, and 27 occurred in my own practice.

Of these 48 cases of abscess, 23 opened spontaneously (14 into the rectum, 5 into the vagina, 3 into the bladder, and 1 through the abdominal walls); 16 were diagnosed and successfully treated by aspiration; 1 was diagnosed by aspiration, but passed from under my care before free evacuation of the pus could be accomplished (she went to a hospital); and 8 were treated by free incision and drainage, 6 through the abdominal wall, and 2 through the vagina. In three of these last cases, abdomino-vaginal drainage was instituted, a vaginal outlet being added to the abdominal incision. All of the cases which were operated on recovered. Indeed, I have seen but one case of pelvic abscess, a forlorn case to which I was called many years ago, and which is not included in this list because I never learned its sequel, which I considered fatal. Some were incurable, chiefly old abscesses with high rectal perforations which it was impossible to reach; others dried up temporarily only to refill at slight exciting causes; but none of the patients seemed to me in danger of their lives from the abscess, except the lady referred to, whose pelvis was literally honeycombed with sinuses, which opened into the vagina, bladder, rectum, and through the abdominal wall, gluteal, and femoral regions. The lady, I was told, had been given up by Dr. Sims and other eminent gynecologists, and I do not see how her system could stand the strain and waste much longer.

Three of the abscesses which opened or were opened in the vagina proved to be suppurating dermoid cysts of the ovary. When I suspect suppuration in a pelvic exudation, which I

do either because the swelling persists undiminished, long after nature should by rights have absorbed it, or because it becomes puffy, doughy, and boggy to the touch, or because distinct fluctuation can be felt, I first proceed to verify my suspicion by the aspirator, and having discovered pus, if the quantity is presumably small, attempt to remove it all by aspiration through the vagina, where the suspicious point is usually most prominent. I have had an aspirator made, with a long metal tube provided with a stop-cock, to which tube I first attach a hypodermic syringe, and when pus is found, close the stop-cock, and substitute for the hypodermic a larger syringe holding about one ounce; opening the stopcock, I then withdraw all the pus by repeatedly filling the syringe, if necessary. If there are a number of small abscesses, so-called multiple abscesses, repeated introduction of the needle may be required (I have done so seven or eight times) at different spots, in order to remove all the pus. I read a paper on this subject, the cure by aspiration of small doubtful pelvic abscesses, before the Academy of Medicine of New York, in December, 1880 (see Seguin's Archives of Medicine, December, 1880), in which I reported eight cases of obstinate pelvic exudations, with small multiple abscesses, cured by vaginal aspiration alone. Since then, I have doubled that number, and have had no occasion to regret my action, if I took care to confine myself strictly to small abscesses containing less than two ounces of pus. In no case did I observe an unpleasant reaction follow the aspiration, and in every case where pus was obtained, and in a few where it was not, the exudation made a rapid progress to complete absorption.

To insure success by this method of simple aspiration (without incision and drainage, understand), it is absolutely neces sary that the abscess cavity be so small as to permit of its contracting and closing when its contents are removed.

CASE I.-Pelvic Abscess. Unsuspected Dermoid Cyst; Aspiration. Refilling of Abscess. Finally, Cure by Vaginal Incision and Drainage in Woman's Hospital.

Only once have I had occasion to regret having neglected this rule, in a case of unsuspected dermoid cyst of the ovary, which went to a hospital before I had the opportunity to make a large incision. In that case, detecting fluctuation in the vaginal vault, I aspirated, and at once found pus. I