After two such and, when labor

extosis on the sympyses pubis, and craniotomy had to be performed when the head was the presenting part. disastrous labors, one again became pregnant, came on, a foot presented, with the result of a child born alive. without mechanical interference. The other case was nearly identical with this one.

During the early history of the forceps, when it was little known, when it was roughly made and ignorantly used, it is not to be wondered at that its use was postponed until the last moment, even until the mother and child were nearly moribund, and if death subsequently ensued, the cause was naturally enough ascribed to the forceps, when, had it been earlier brought into requisition, such disastrous consequences need not have ensued. Absolute cleanliness, and the use of disinfectants, should always be strictly observed when these instruments are used; and when these conditions are present, they are, in the hands of a skilful operator, the means of saving the child-bearing woman an incalculable amount of suffering, saving hours of pain to the woman, and hours of anxiety to the friends. From 1790 to 1864, the average use of the forceps in the continental hospitals of Europe, according to Charpentier, was one in thirty, the minimum being Osiander, who used it only once in 291 labors, and the highest, Hohl, who used it once in every three labors. In Great Britain, from 1803 to 1863, John Clarke used it once in 3,878 labors, and Moore, of London, once in 291 labors. It is noticeable that Osiander, who used the forceps once in 291 confinements, did the work, upon which his statistics were based, between the years 1792 and 1822, and Hohl, who used it once in every three cases, from 1840 to 1857, showing a tendency, as time advanced, to use it more frequently. A plea for the use of the forceps somewhat earlier than formerly, may be found in Harper's tables, taken from Charpentier's work on obstetrics:

R. L.

A. H.

As there is at present a tendency among the profession in general to a much more frequent use of the forceps than formerly, I have tried to ascertain the number of times they are used in proportion to the number of cases attended, from a number of medical gentlemen in this city, with the following result: Banta, 1-10; A. H. Briggs, 1-6; F. W. Bartlett, 1-6; Crawford, 1-10; A. Dagenais, 1-12; E. T. Dorland, 1-6; C. C. Frederick, 1-8; Geo. E. Fell, 1-50; M. B. Folwell, 1–8; B. P. Hoyer, 1-4; M. Hartwig, 1-20; H. D. Ingraham, 1–11; Thos. Lothrop, 1-15; G. E. Mackey, 1-10; W. W. Potter, I-41; De Lancey Rochester, 1-23; Chas. E. Stockton, 1-20; E. Tobie, 1-11; W. H. Thornton, 1-15; C. C. Wyckoff, 1-10; J. J. Walsh, 1-2; W. D. Greene, 1-12—an average of once in about eleven and one-half cases. I regret being unable to obtain the deathrate also, whereby to make the statistics more complete. It is an undoubted fact that a great source of infant mortality, as shown by statistics, up to within eight or ten years has been the indiscriminate use of ergot. The physician had been taught that the use of forceps was wrong, except in extreme cases, but he had not been taught that the free use of ergot was also wrong, and therefore gave it ad libitum. After the uterus had been in tonic contraction for hours, it cannot be wondered at that a dead child was born, with or without the aid of forceps. I recognize the fact that, from not using the forceps often enough, we may err by going to the other extreme, and yet my own experience teaches me that using it once in every twelve or fifteen cases in a series of say 500 labors, is not too often. If no ergot whatever is given until labor is terminated, and the forceps used in delayed cases, I believe the infant mortality will decrease and the maternal mortality will not increase. It occurs to me we have struck a happy medium between two extremes. We should not use it as often as once in two or three cases, nor yet so seldom as once in 3,878 labors, neither should we employ the forceps without the use of germicides in the fullest sense of the word. In short, employ every means to potect mother and child; employ disinfectants, employ precaution, and above all, employ good judgment and common sense. 444 ELK STREET.

I.

In consultations chiefly.

Translations.

"OPERATIONS FOR EMPYEMA, PARTICULARLY THEIR AFTER-TREATMENT. BY PROF. HUGO HOLSTI, OF HELSINGFORS (ARCHIV. FUER KLINISCHE MEDICIN, No. 42, 1886)-"SHOULD THE PLEURAL CAVITY BE WASHED OUT." BY M. M. BASIL (MED. CHRONICLE, AUGUST, 1887) — "WHEN IS INCISION TO BE AVOIDED IN PURULENT PLEURITIC EXUDATIONS"? BY PROF. O. FRAENTZEL (CHARITE ANNALS, 1888). TRANSLATED FROM THE Norwegian Medicinsk Revue.

BY HERMAN MYNTER, M, D., Buffalo, N. Y.

Professor of Surgery, Medical Department, Niagara University.

Most authors seem at present to agree. that an empyema may only exceptionally be absorbed by Nature's own help, that no medical treatment has any effect, and that we do not definitely cure a patient by puncture, with or without aspiration, at least not in adults, but that the radical treatment, a thoracic fistula, becomes necessary.

About the operation itself there is still some disagreement, but everything seems to indicate that resection of a costa, with subsequent opening of the pleural cavity in the lateral region, will be considered the most proper operation.

There are still different opinions about the after-treatment. Bartels and Kussmaul use daily irrigation, which was used in Helsingfors till 1883. The results were not satisfactory, particularly with regard to the permanent fistula, and Professor Runeberg commenced, therefore, after 1883, to use the method recommended by König, Wagner and others, to irrigate the cavity once immediately after the operation. This method was given up from the Fall of 1885, and in seventeen cases since treated no irrigation has been used. The occasion for the change was a case in which a communication with the bronchi was evidently present. The irrigation was omitted in order not to expose the bronchi to the irritating effect of antiseptic fluids. The case terminated favorably, and the stinking pus lost, in a few days, its fetid character.

The author has treated twenty-seven cases, of which ten were irrigated once, immediately after the operation. Of these, one died, a man sixty-three years of age, who suffered from valvular disease of the aorta, and died of pneumonia; two left with a permanent fistula,

and seven recovered. Of the seventeen treated without irrigation, one left in five weeks (on his own demand) with a fistula not perfectly healed; all the others recovered. Recovery occurred in an average of seventy-one days after the operation; the shortest time was five and one-half weeks; the longest, five and one-half months.

Most authors are inclined to believe that the longer the empyema has lasted before the operation, the less prospect is there of an early recovery. The author does not agree with this statement. Of the twenty-three perfectly cured patients, nine were operated prior to one month's duration of the disease. Of these, only three were cured in the course of two months; with the others it took longer time—in two cases respectively, 157 and 166 days. If the disease had existed two to three, or even five to six months, the recovery took place earlier. With a duration of from nine months to several years, the recovery took longer time.

The patient's age may have some influence on the duration of the convalescence, which probably is shortest in childhood. The average duration in nine patients operated in 1884 and 1885, was thirty-eight days; in fourteen patients in 1886, sixty days, and in the last seven, forty-five days. It looks, therefore, as if the duration had gradually been diminished, and as if the omission of irrigation, to say the least, had had no unfavorable influence on the recovery. Complications, such as communications with the bronchi and fistulas, have had no evident influence on the duration. When tuberculosis was present, no operation, save a simple puncture, has been performed.

The author does not consider it improbable that repeated irrigations may occasion a permanent fistula. Even if done carefully, it cannot be avoided, that thin, commencing adhesions are torn over, by which the growing together of the opposite layers of the pleura is made more difficult. Carbolic acid, besides, has a bad influence on the process of granulation. In most cases of empyema, it is difficult to show the cause; once in a while it may be a trauma, but it is, probably, oftenest the result of a pneumonia. Both are found most frequently on the right side. The operation has generally been made in the lateral region, between the axillary and mammilary line, where there is less of muscular tissue, and where the operation may be done without placing the patient on the healthy side, which often may occasion a dangerous attack of dyspnea. It has been argued that retention of pus occurs easier with the fistula here than on the back.

This does not agree with the author's experience. He recommends, to be sure, that the patient lie on the operated side as much as possible, which, as a rule, is done without difficulty.

If the collection of pus is circumscribed, the fistula, of course, must be made where it is necessary. The operation is always combined with the resection of the sixth costa, sometimes, besides, of the fifth and seventh. We gain by that a better drainage without prolonging the operation or making it much more difficult. The fear of deformity of the thorax, as a result of the operation, is only of a theoretical nature. The operation is easy to make. Sometimes, in going through the pleura, some bleeding may occur. It may be parenchymatous, from the newly-formed vessels in the pleura, and need not indicate that the intercostal arteries were injured. If this should happen, it may become necessary to plug the opening with sublimategauze for a day. After the pleural cavity has been opened, it ought to be evacuated slowly, to avoid too quick changes in the intrathoracic pressure.

The most important thing in the after-treatment is to make provision for perfect evacuation of pus. This may be difficult if the fistula becomes so narrow that no drainage-tube can be introduced, while there still is found a pus-secreting cavity behind. It is therefore necessary, if fever should occur, to examine the condition of the fistula and, possibly, make a counter-opening. A question of importance in regard to the after-treatment is, when the drainage-tube ought to be removed. It ought not, as a general rule, to be removed too early. We must convince ourselves, as near as possible, that no cavity exists behind the fistula, which is best done with a long, flexible, well-disinfected probe; for instance, a uterine probe. Being in this way convinced that no cavity longer exists, the drainagetube may be removed.

It happens quite frequently that the cavity ceases to decrease in size. This may be found out by injecting a weak solution of corrosive sublimate. The amount of fluid used indicates the size of the cavity. If the cavity ceases to decrease, injection of tincture of iodine may stimulate the process of granulation. If we do not succeed by this method, we may have to resort to extensive resections of costæ. M. Basil has mostly the same opinion as Professor Holsti, with the difference that he, as a rule, irrigates the cavity once, immediately after the operation, particularly if fibrinous