At the same time the appendix came into view. The part that had protruded from the anus was the cecum, and the opening, as noted peculiar in shape and looking forwards, was the ilio-cacal. The entering layer was a portion of the ilium; the returning layer was the ascending and a large part of the transverse colon; the sheath was the remaining part of the transverse and the descending colon. The color of the gut was good and the adhesions had been so slight as to be barely noticeable. The gut was placed in normal position and the wound closed. Before the dressing was completed, the distension of the abdomen was perceptibly lessened. Within an hour there were discharged small quantities of dark mucus with particles of fecal matter. The general condition was as good as could be expected. There was no vomiting. Water was retained, and, during the night, brandy and small quantities of breast milk. Gas was passed freely and much mucus and some feces. Evidently the intestinal canal was unobstructed and peristalsis was active. There was, however, great restlessness. The rectal temperature varied during the night from 105° to 107°. Symptoms of collapse were marked ten hours after operation. The usual means for maintaining vitality were tried, but without avail. Death took place from surgical shock fifteen hours after operation.

This case is of special interest on account of the length of time the true condition remained undiscovered; the amount of intestine involved and that obstruction was not complete.

To the delay in discovering the intussusception and promptly interfering surgically the life was doubtless sacrificed. Let me here say that when hydrostatic treatment does not promptly reduce the intussusception, abdominal section should not be delayed. The conditions found will then indicate whether reduction shall be attempted, there shall be excision or anastamosis, or relief shall be obtained. from a coloctomy hoping that the invaginated gut may slough away and thus nature perfect a cure as she sometimes does in these cases. Certainly one should not think of returning the protruding gut within the rectum and keeping it there by means of a candle or other substance plugging the anus, as has been done by surgeons of repute. That the obstruction was not complete is readily accounted for by the fact that the sheath, composed of the colon, was of so large calibre as to cause no appreciable pressure upon the smaller invaginated gut, the ilium.

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SURGICAL FEATURES OF OBSTETRICS.*

BY BENJAMIN HARVEY OGDEN, M.D.,

St. Paul, Minnesota.

HE art of midwifery is like an obelisk. It has many different view points. There are the therapeutic, physiological, mechanical and surgical aspects. It would be extremely foolish for one to stand before any one of these sides and extol its advantages to the exclusion of the others. There is danger that the exclusive surgeon may place too little value upon therapeutic measures, and there is equal danger that the general practitioner will ask an impossible task of his remedies because he fails to appreciate the value of mechanical and surgical assistance. Inasmuch as midwifery is conducted mostly by general practitioners, it seems to me the latter is the greater danger. At our last annual meeting we listened to an excellent paper upon the uses of drugs in obstetrics; to-day I wish to stand before the other view points and emphasize, as strongly as I can, the importance of a thorough knowledge of and training in surgical technique and mechanics as of paramount value in the successful conduct of labor. I am the more anxious to do this because every little while someone writes an article ridiculing and belittling the painstaking methods now advised, and pointing with pride to a large number of cases conducted successfully without them. It is undoubtedly true, and fortunately so, that the majority of labors will terminate themselves without assistance of any kind, mechanical, surgical or medicinal, but such cases cannot be said to reflect any particular credit upon the physician unless it be his wisdom and tact in remaining "masterly inactive."

It is when he anticipates, prevents or corrects a condition threatening the life of mother or child, through his knowledge of symptoms of renal insufficiency, or of pelvimetry or of manipulation and mechanical assistance in malpositions, or of aseptic technique, or of control of hemorrhage, or lastly, and by no means least, by his ability to diminish suffering and lessen the hours of nerve and body strain which unaided nature would cause-it is the successful conduct of such cases that may properly make him proud of his calling— masterly inactivity up to a certain point; but beyond that the most masterly activity. This is no place for Laissez Faire doctrines; and Read before the Minnesota State Homeopathic Institute.

the saying "leave the case to nature" often covers a weakness of the attendant. If this paper were prepared for specialists in surgery I would need to emphasize more the value of remedies in obstetrics; but prospective mothers go to the family physician, and rightfully so, for counsel and help in their travail, and for such it seems to me the emphasis should be placed upon the mechanical or surgical features of the obstetric science. Let me briefly consider some of the most common phases of obstetrics for which such knowledge and training are essential.

Ist. The prevention and treatment of infection.

2d. Cases requiring mechanical interference such as eclampsia, pelvic deformities and abnormal or unfavorable positions and presentations.

3d. Treatment of hemorrhage and lacerations.

4th. Involution or the restoration of the uterus to its normal size and position.

It is pretty generally understood by the physician and to a large extent by the laity that the maintenance of asepsis is the guarantee of the best results in obstetrics. For the surgeon with abundance of assistants, this is almost a second nature; but for the average practitioner who contends often with unfavorable surroundings, poor and untrained assistants, or often none at all, it is a different matter. There is danger that these very difficulties may make him careless and thus fail to do the best he could, unless he holds before himself an ideal technique and follows to a large extent a routine method. To take up this subject in detail would make a paper in itself. I only wish to emphasize the value of habit. Cultivate the aseptic habit. Make it a part of your being. Do not scoff at, but study, the painstaking methods of the surgeon; make them your own, and you will have acquired a habit whose value cannot be measured when dealing, not only with obstetrical cases, but with all classes of troubles.

He who follows rigid aseptic methods will seldom have to deal with cases of septic infection during the puerperium from his own practice; but, from other sources, and occasionally from his own, such cases will come for treatment. Here again there is an increasing belief in which I fully concur, that the most important part of the treatment is surgical. Dr. Danforth, in a most excellent paper upon puerperal sepsis read at the American Institute of Homeopathy, says of treatment: "It is mainly surgical." This in italics. Intra-uterine douching; curetting and packing of the uterus; opening through the mucous membrane of the post-vaginal fornix into the lymph spaces of the cul-de-sac and packing with iodo

form gauze, thus draining away the poisonous lymph; in very profound cases intravenous injections of normal salt solution; opening of pelvic abscesses and occasionally complete hysterectomy are some of the procedures which may be found necessary, any one of which will require considerable surgical skill and dexterity.

Again the numerous deviations from the normal position are to be overcome by mechanical means, and are therefore surgical in nature. A prolapsed arm or cord, transverse or face presentations, occiput posterior positions, in fact, almost any cause of dystocia, are to be overcome or treated by mechanical assistance; and he only is qualified to meet these conditions, who has a thorough knowledge of mechanics, and can make for himself an accurate mental picture of the relation of the child to the parturient canal in any given position, and the evolutions necessary for birth.

Advance in obstetric surgery has been such that it is now an open question whether one is ever justified in deliberately destroying the life of a viable fetus to secure its delivery. The induction of premature labor in moderately contracted pelves, symphyseotomy or the performance of Cesarean section, not only saves the life of the child, but gives equally as good chances for the mother. Even eclampsia, for which remedies are indispensable, finds most valuable assistance from emptying the uterus as rapidly as possible, and possibly blood letting and intravenous injection of the normal saline solution.

Hemorrhage is one of the serious and dangerous complications liable to occur at any labor, and at almost any period of gestation. Ectopic gestation, placenta prævia, uterine inertia, and severe lacerations are conditions which demand quick diagnosis, calm, cool judgment, and masterly activity. I am strong in my belief that the immediate control of hemorrhage in all of these conditions is mechanical and surgical, and that remedies, whether in high potency or dram doses, are of little value. Now do not misunderstand me. You will note I emphasize the word immediate. In dealing with hemorrhage incident to ruptured tubal pregnancy, or of placenta previa, there can be no question regarding this statement; only the most prompt and skilful surgery can save lives in such cases; but with reference to post-partem hemorrhage, there will, no doubt, be those who differ from me. Hemorrhage from the uterus results from failure of the uterine muscle to contract and shut up its sinuses. Ergot induces uterine contraction, but even when given hypodermatically, requires from twenty to thirty minutes in which to act. Belladonna, ipecacuanha, china and sabina are polychrests whose

value no one would doubt or gainsay; but I do not believe these, or any other, are equal to the task of immediate control. This, I repeat, is a mechanical process, and is accomplished mainly by compression. With one hand grasping the uterine fundus through the abdominal wall, and pushing downward and forward against the symphysis pubis, and two fingers of the other hand placed in the posterior vaginal fornix pushing the cervix upward, the uterus is bent upon itself and a compression secured which rarely fails to stop hemorrhage until muscular contractility is restored by natural means or the administration of the indicated remedy. In more desperate cases, the contraction may be stimulated locally by the use of very hot douches, or the bipolar faradic electrode, and, finally, the more lasting compression of gauze packing may be resorted to.

Hemorrhage is not always from the uterine sinuses, but may come from a badly torn cervix or vagina. Within a month I have attended a case in which bleeding continued profusely in spite of a firmly contracted uterus, and was found to come from a deep rent in the side of the upper vagina, the tissues having simply burst open from the tension caused by a large head. A few sutures sufficed to stop the hemorrhage, and at the same time made certain a good repair of the vagina. Not all lacerations cause much hemorrhage, but their repair is an important factor in securing a good recovery from confinement. It should be the routine habit of everyone who attends such cases to examine carefully for, and repair immediately in a scientific manner, all vaginal and perineal laceration, though it is yet an open question whether this duty extends to cervical tears.

The physician's duties are not completed with the third stage of labor, or even with the safe conduct of the woman through the first week following. He should see that the generative organs are restored to their normal positions and proportions. This is of vital importance for the future comfort and happiness of the mother, as well as the enduring reputation of the physician. Here, indeed, is a grand field for therapeutics; but there most also be a thorough knowledge of the mechanism of uterine support and the processes of involution. We must consider such subjects as posture in bed, condition of the bowels, proper dress and exercise, at times the use of vaginal tampons and, perhaps, temporarily, a pessary.

In writing upon such a subject as this there is always danger of being misunderstood. I have the utmost confidence in the proper use of the indicated remedy. It is this very esteem which makes me unwilling to bring it into disrepute by asking of it impossibilities -things for which it was never intended. We would not think