quently I tied it above and below, and divided it between the ligatures. The opening in the abdominal walls was, however, too small for manual exploration, and the incision was extended upwards. The bowels, large and small, were greatly distended with wind, and in some places were of a deep-red color, but had not lost their shining lustre. The exact seat of the stricture was hard to find out. I thought I felt a constriction in the descending colon in the left lumbar region, and as this was below the cæcum I determined to make an artificial anus in the cacum. The abdominal cavity was, therefore, carefully sponged out, and an incision about three quarters of an inch long was made in the cæcum, and the edges of this opening were carefully stitched to the parietal peritoneum and to the skin. Great care was taken that none of the fæcal contents should enter the abdominal cavity. I placed nine soft sponges around the cæcum, and Dr. M. H. Richardson and F. B. Harringtou succeeded perfectly in preventing the entrance of any fæces while I was passing the sutures. Much embarrassment was occasioned by the great distention of the coils of intestine, and it would have been better to have made the opening quickly without searching for the seat of the stricture; however as the obstruction might have been from a band or a twist it was natural that I should have sought for it. The operation was a long one (an hour and a half), and the weather was intensely hot. When the patient was placed in bed her pulse was rapid, but she was otherwise in fair condiWind and fæces came out through the opening in the cæcum. Hot bottles had been put at the patient's feet, and I left her in charge of Dr. Nichols. The following is his farther account of the case:

tion.

"Directly after the operation a copious discharge of semi-liquid fæces set in. Upon coming out of the ether she complained of great pain, and was extremely restless. Her pulse soon showed signs of weakness, and she succumbed to the effects of general shock five hours after the conclusion of the operation, the severity of her suffering during the last two hours requiring a resort to ether.

66

At the autopsy, made by Dr. W. P. Bolles, the same evening, there was found an annular cancer (scirrhus) in the descending colon, about eighteen inches from the orifice of the rectum, occluding the intestine so completely as to prevent the flow of even water. Below the stricture the intestine was completely empty. Above there was found small, scattered masses of fæces, but the great bulk of the contents had been expelled from the artificial opening. There existed no signs of inflammation of the intestine above

the seat of the stricture."

I

It will be seen that the result in these two cases was different, but in both the operations adopted were logical and proper. In the second operation there was much more handling of the bowels than in the first, and it was very difficult to manage the insertion of the sutures and to keep the bowels from protruding between them or being wounded by the needles. believe that Mr. Lawson Tait thinks it better surgery to open the bowel at any point you happen to strike (that is, to pull out the first loop that presents itself and open it) than to search for the obstruction. In our second case that mode of proceeding would have been the best. I present these two cases to the Society as a contribution to the study of the treatment of intestinal obstruction.

THE TREATMENT OF RETAINED SECUN-
DINES AFTER ABORTION.1

BY JOHN W. BRANNAN, A. B., M. D., OF COLORADO SPRINGS.

THE management of incomplete or imperfect abortion has excited renewed interest and discussion during the past year. The gynecologist on the one hand and the general practitioner on the other have expressed their respective views with much warmth and earnestness of conviction. The gynaecologist insists upon the immediate removal of the retained membranes and placenta by manual or instrumental means; the general practitioner, while admitting fully the desirability of the complete emptying of the uterus, believes that this is nature's task, and that the physiciau should not interfere unless the symptoms are urgent. The former fears the present risk of hæmorrhage and the future risk of septicemia; the latter fears inflammation as a result of uterine manipulation. Such is a brief statement of the points at issue between the disputants.

Let us suppose, for example, a case of abortion at the third month of pregnancy; the foetus has come away, the secundines are retained, the cervix uteri is more or less contracted, the woman is comfortable, there is no hemorrhage or offensive discharge. The gynæcologist would at once proceed to extract the membranes and placenta, using the finger, curette, or forceps, according to the state of the cervix; if the cervix is tightly closed, he would dilate it with tents or metallic dilators, and then extract as before. The more conservative general practitioner, however, would preserve an expectant attitude, contenting himself with giving full doses of ergot, and possibly tamponing the vagina; should alarming hæmorrhage or symptoms of septicamia supervene he would then, but not before, feel called upon to empty the uterus in the manner described above.

4

5

On consulting the obstetrical literature of the last twenty-five years we find the same difference of opiuion that now exists in the profession. The earlier writers of this period, however, are agreed in advising the expectant treatment of retained portions of the ovum. Tyler Smith and Bedford assert that in such cases there is not the same tendency to decomposition and its dangers that there is in the case of placenta at full term. Meigs prefers to leave such occurrences in the hands of nature, and believes that there is no danger in so doing. Ramsbotham relies upon the vaginal tampon and the use of ergot when the membranes cannot be reached with the fingers in the vagina. Hodge says that "the extraction of the retained membranes certainly ought not to be attempted by manual or instrumental measures if there be little or no bleeding, especially as the os and cervix generally contract, and the membranes are closely adherent." Churchill believes that we are not to interfere when the membranes are retained, unless there is hæmorrhage or evidence of irritative fever. He concludes as follows: "Larger experience has made me less fearful of leaving these cases to nature, and more unwilling 1884.

6

1 Read before the El Paso County Medical Society, January 7,

2 Lectures on Obstetrics, 1858.

3 Principles and Practice of Obstetrics, 1863.

4 Obstetrics, the Science and the Art, 1863.

5 Principles and Practice of Obstetrical Surgery, 1865.

6 A System of Obstetrics, 1866.

7 Theory and Practice of Midwifery, 1866.

to interfere hastily." Leishman1 advises us to preserve an expectant attitude if the membranes are retained, unless the hemorrhage be alarming. In the latter case he tampons the vagina. While admitting the danger of blood-poisoning from a putrefying retained placenta, he adds that such poisoning is rare.

2

We now approach the period in which modern gynæcology has made its greatest advances, and its influence upon its kindred branch of medicine, obstetrics, is at once seen. The more a given writer is occupied with gynæcology and the less with the general practice of medicine the greater is his activity in interfering with the processes of nature. Barnes says that the first indication is to " empty the uterus." If the os is open he at once removes the whole ovum with the finger, breaking up the decidua if necessary. If the os is closed he immediately dilates the cervix with laminaria tents, and then removes the membranes with the finger as before. He does not use ovum forceps. He condemns the vaginal tampon as "unscientific and illusory," claiming that it neither stops the hæmorrhage nor favors the dilatation of the cervix. Playfair 3 tampons the vagina and gives ergot in cases of alarming hæmorrhage or of undilated os uteri. If the os still remains closed he employs sponge tents for its dilatation, even though there be no urgent symptoms. He then removes the ovum with the finger. He admits, however, that "cases are frequently met with in which any forcible attempt at removal would be likely to prove very hurtful, and in which it is better practice to control hæmorrhage by the plug or sponge tent, and wait until the placenta is detached."

4

Prof. A. R. Simpson blames the authors of our obstetric text-books for failing to state clearly how we can best secure complete evacuation of the uterus in cases of abortion. He advocates the use of a sponge tent, previously disinfected, as soon as the abortion appears unavoidable. He also gives ergotine hypodermically. When the cervical canal is dilated he removes the ovum from the uterus with the fingers. In order to render the uterine cavity accessible to the exploring finger he either pushes down the fundus uteri from above or drags down the cervix from below with vulsellum forceps. He deprecates the use of instruments for the detachment of retained portions of the ovum.

Schroeder employs the tampon if the hæmorrhage is alarming or the ovum is retained. He claims that the tampon always checks the hæmorrhage, and as a general rule effects the expulsion of the ovum from the uterus. In case some portions of the ovum are still retained by a contracted os, he dilates the cervix with sponge or laminaria tents, and then empties the uterus with the fingers. If any placental fragments cannot be reached by the hand he employs forceps for their extraction. Angus Macdonald is more conservative than the He says: four preceding writers. My opinion, therefore, is that in the ordinary run of cases, in which the hæmorrhage is not specially profuse, we ought to trust to ergot by the mouth, or ergotine subcutaneously,

6

1 System of Midwifery, 1875.

2 Obstetric Operations, 1874.

66

8 Treatise on the Science and Practice of Midwifery, 1876.

and that we shall most probably find that all will go on all right, except that we shall have to hurry the conclusion of the case with slight manipulation, and that wholesale imperfect plugging of the vagina is to be strongly deprecated." If, however, hæmorrhage is severe, or symptoms of septicemia arise, he takes "active measures to empty the uterus tuto, cito, et jucunde." If the os is open he removes the uterine contents with the fingers. If the os is closed he introduces a sponge tent and leaves it in situ from two to four hours. He then clears out the uterus, as before, with the fingers. Macdonald opposes the use of abortion forceps for the removal of the membranes, and also considers it an unnecessary and dangerous procedure to drag down the cervix with a vulsellum, as recommended by Simpson.

Lusk endeavors to empty the uterus as soon as possible. If the cervix is patent he removes the membranes from the uterus with the finger. If the cervix is closed he employs the tampon, giving it three trials, each tampon being left in the vagina for twelve hours. If, after the removal of the third tampon, the cervix is still undilated, he resorts to sponge tents. He prefers to use the tampon before the sponge tent, as the former stimulates the uterus to contract, and promotes the separation of the membranes, even when it fails to secure their discharge. Lusk fears the results of putrid decomposition of the retained placenta. At the same time he admits that "fatal results are rare, as decomposition is usually a late occurrence, setting in, as a rule, only after protective granulations have formed upon the uterine mucous membrane, and after the complete closure of the uterine sinuses.

8

T. Johnson Alloway, of Montreal, agrees with Simpson in his criticism of text-books on obstetrics because in them "insufficient stress is laid upon the importance of removing at once a retained placenta after abortion." He himself advocates the immediate removal of the secundines with the curette, not the finger, either with or without previous dilatation of the cervix. He maintains that, as a rule, it is impossible to remove the membranes with the finger unless the uterus is forced down in the pelvis to a dangerous degree.

Dr. Mundé gives it as his opinion that "the future safety of the patient demands that the secundines should be at once removed after expulsion of the fœtus in every case of abortion in which such removal can be accomplished without force sufficient to injure the woman.” His manner of operating is as follows: If the cervical canal is sufficiently patulous he detaches and removes the placenta with the fingers of the right hand while crowding down the fundus uteri with the left hand.

If, however, the abdominal walls are fat or tense, or if the cervix is not sufficiently open to admit the finger easily, he employs the curette and placental forceps for the detachment and removal of adherent portions of membrane. The uterus is then washed out with a two to five per cent. solution of carbolic acid, the water used being either very hot or very cold. If there is the slightest suspicion of septic infection he swabs out the uterine cavity with pure tincture of iodine. Should the cervical canal be too narrow to admit even the curette it is at once dilated

7 The Science and Art of Midwifery, 1882.

179.

8 American Journal of Obstetrics, February, 1883. Ibid.

vagina and removed. Placenta could be felt within internal os. No hæmorrhage or discharge. Pulse 120; temperature 102° F. Treatment, one drachm of extr. ergot. fl. and one sixth grain morph. sulph. subcutaneously.

March 12th, A. M. No change in placenta. Pulse 72; temperature 98° F. Ergot and morphia as yesterday. P. M. Placenta still felt within os; hæmorrhage slight. Pulse 96; temperature 99.5° F. Swept my finger once around the circumference of the internal os, between it and the placenta, otherwise no manual interference. Ergot and morphia continued.

March 13th, A. M. Was told that placenta had come away twenty minutes after my visit of preceding evening. Pulse 90; temperature 98.5° F. Patient made rapid recovery.

CASE II. July 25, 1883, six A. M. Mrs. M., multipara, aged twenty-six, four months advanced in pregnancy. Occasional pains in back for last two weeks, with considerable flowing. Lost much blood yesterday, and early this morning a solid mass came away. A four months' fœtus, somewhat macerated, found in the basin. No placental fragments. Examination showed the placenta to be still within the uterus, the os being closed firmly around the umbilical cord. No hæmorrhage. Temperature and pulse normal. Twenty minims of laudanum and one drachm of ergot given. At ten A. M. vagina carefully tamponed with wads of cotton soaked in glycerine. Ergot repeated. Six P. M. Tampon removed and vagina washed with two and a half per cent. solution of carbolic acid. No change in state of cervix. Ergot and laudanum repeated.

July 26th. No change. Tampon again used, removed in evening. Ergot and laudanum continued. July 27th. No change. Tampon omitted. Ergot and laudanum continued. Vaginal injections of two and a half per cent. solution of carbolic acid to be given twice daily.

July 28th. No change. Medicines omitted. July 29th, P. M. Placenta expelled entire, no offensive odor whatever to it. Rapid recovery. CASE III. August 20, 1883. Mrs. W., multipara, aged forty-seven years. Sufferer from repeated abortions since twenty years of age. Menses ceased ten weeks ago, patient supposing that she had reached the climacteric. Has not felt well for a week. Yesterday had pain in back, and slight flowing. This morning severe bearing down pains, and passed large amount of clots, together with foetus and after-birth in fragments. Patient thinks that everything has come away. Nothing found on examination except a hard cervix fissured in various directions, with os tightly closed. Uterus appeared to be about normal in size. Fifteen minims of laudanum and one drachm of ergot given twice daily and carbolized vaginal injections. Nothing of note occurred in the case until August 22d, two days after the abortion, when at my usual visit I was shown a fragment of placenta, about one and a half inches in diameter, which the patient said had been expelled that morning. The mass had scarcely any perceptible odor. From this time on the patient progressed rapidly to perfect recovery.

The above cases caused me no little anxiety at the time of their occurrence. Their fortunate termination, however, would warrant me, I think, in pursuing the same course in similar cases in the future.

We know and may admit freely that the retained placenta does occasionally give rise to hemorrhage or

to symptoms of septicemia. Mundé's own cases, however, show that forcible removal can even then be effected with good results. In fifty-four of his fiftyseven reported cases the placenta had been retained for a period varying from a few hours to two months. And yet recovery of the patient followed the removal of the placenta in all but one of these cases. On this point Muratoff,1 of Moscow, who employs Sims's uterine dilators in all cases of neglected abortion, expresses himself as follows: "The presence of inflammation in the uterus or in its vicinity does not contraindicate the use of metallic dilators; on the contrary, it vitally indicates instrumental dilatation. In the great majority of my cases, dilatation, with subsequent emptying of the womb, was immediately followed by a marked improvement both of the local and of the general conditions; the patient's temperature steadily and quickly fell to the normal level, rigors and pain disappeared, the uterine discharge rapidly lost its offensive odor, and the uterus underwent uninterrupted involution." Muratoff, after dilating the cervix, does not at once introduce the curette or forceps or the hand into the uterus. He first tries bimanual expression of the uterine contents. Should this fail, the membranes are removed by one or two fingers. Besides Munde's cases, I have collected thirty-two other published cases of forcible removal of long-retained placenta (one retained for 115 days, another for six months), and in all of them the patient recovered. We thus have a total of eighty-six cases, with but one death. Would the fatality be as small if physicians, however lacking in technical skill, were to proceed to dilate and extract in every case of abortion as soon as the placenta showed a tendency to delay ?

Having argued to prove that active interference in abortion is as a rule unnecessary and dangerous, it follows that I agree with those who favor the expectant plan of treatment. This does not mean, however, that abortions should be "neglected," as the gynecologists express it.

The following outline of treatment would seem to me judicious, and as auswering all the indications in a case of abortion in which the secundines are retained after the expulsion of the foetus: If the membranes are lying loose in the open cervix, they should be removed by the finger. If, however, they are still within the cavity of the uterus, no attempt should be made to remove them, whether the cervix be open or closed. Full doses of ergot should be given, and the vagina should be carefully tamponed. The ergot and tampon will check whatever hæmorrhage there may be, and will also serve to excite the uterus to contract and thus effect the separation of the membranes. Two or three tampons may be used, each being le ftin situ about twelve hours. The vagina should be well washed with a two and a half per cent. solution of carbolic acid at each removal of the tampon. If the membranes still remain within the uterus, and there be no hæmorrhage or evidence of blood-poisoning, we may leave the case to nature, merely continuing the ergot and carbolized vaginal injections for a few days. Besides enjoining the rest usual after all abortions, the physician should keep the patient under observation for a few weeks, if possible. If at any time serious and repeated hæmorrhages should occur, or symptoms of septicemia manifest themselves, these steps should be taken to London Medical Record. The Medical Gazette, December 1.

1883.

should

She grew drowsy and heavy. The progress of the labor her no farther concern. gave If addressed, she could be roused to make answer, but soon fell off again. The pains became slow and ineffective. The pulse was at between sixty and seventy, full and laboring. Her hands, held by her husband looked almost black under his pressure. Fifteen minutes af ter the third dose of chloral I ruptured the membranes; and twenty-five minutes later, not quite two hours from the first appearance of pain, a male child was slowly extruded into the world. The surface of the child was excessively pale, and from head to foot it was besmeared with meconium. After very moderate efforts, however, it began to breathe and cry; but it did not for several hours regain its natural color. The placenta was soon expelled, though without any portion of the membranes. One drachm of fluid extract of ergot was twice given, and a half ounce of brandy. An hour after the birth the mother was in fairly good condition, and both she and thec hild made a safe recovery.

If now I add, that it would be hard to name husband and wife more widely known in the community where this occurred, or more deservedly admired and honored, I may emphasize for some readers the story of personal distress.

Heports of Societies.

SUFFOLK DISTRICT MEDICAL SOCIETY. SECTION FOR CLINICAL MEDICINE, PATHOLOGY, AND

HYGIENE.

ALBERT N. BLODGETT, M. D., SECRETARY,

IN MEMORIAM. -DR. CALVIN ELLIS.

JANUARY 9, 1884. The meeting was called to order at eight o'clock, DR. R. T. EDES in the chair. A summary of the proceedings of the last meeting was given by the Secretary.

Upon motion of DR. GEORGE B. SHATTUCK the business of this meeting was suspended as a token of respect to the memory of the late Dr. Calvin Ellis, formerly President of the Suffolk District Medical Society.

DR. EDES, in announcing the result of the motion, made some very appropriate remarks relating to his early acquaintance with, and life-long esteem for, Dr. Ellis, a man whose character would long be a living influence in the medical element of Boston. Dr. Edes then called upon Dr. George C. Shattuck, who spoke as follows:

DR. SHATTUCK said that he could not refuse an invitation to say a few words at this time, and to bear his testimony to the worth and excellence of our late associate, Dr. Calvin Ellis. It certainly is well for us survivors, after the departure of a highly esteemed associate, to meet together and put on record our appreciation of worth and skill and our sense of loss. Excellence and distinction in our profession are the result of original endowment, of industry in training faculties, in acquiring knowledge, and of fidelity and A medical man must skill in the discharge of duties. devote years to preliminary education, and then must be constantly studying and training his powers of observation and reasoning, as well as adding to his stores of knowledge. There are those here who were associated with Dr. Ellis in his early years and will tell us of the qualities for which he was remarkable as a young man and a student. I became associated with him when he had already acquired reputation as a teacher and practitioner, and was looked upon as on the sure road to distinction. I noticed, and admired, his knowledge and skill as the pathologist of the Massachusetts General Hospital and instructor in clinical medicine in the

Medical School.

His ability, knowledge, and fidelity were recognized by professors and students. He was evidently the coming man in his department. And yet he worked patiently in subordination, was always kindly and courteous, and ready to carry out the plans of those who had the direction of affairs. When his predecessor in accordance with his own wishes and ideas of duty retired, Dr. Ellis was chosen professor of clinical medicine and visiting physician of the hospital, without any solicitation on his own part or from his friends, but because those who had the appointing power recognized that he was the fittest man to discharge the duties. The wisdom of the appointment was shown by painful illness to retire from work, those who apby many years of successful work. And when obliged pointed him, those who worked with him, and those for whom he worked, preferred to wait for three years in the hope that his health and strength might be renewed so that the same skilled labor might still be at the service of medical science and instruction.