cian stated that the curette had passed in at least six or seven inches. In order to determine the exact condition the abdomen was opened by an incision through the anterior fornix, and it was demonstrated that the instrument had entered the Fallopian tube and had not perforated the uterus or Fallopian tube.

DR. FRANK T. ANDREWS.-These cases are more common than we have formerly supposed. I myself have seen three cases of perforation of the uterus. One of them I saw in consultation in a hovel on Indiana Street, the patient being in collapse. The attending physician said that the patient herself had passed a wooden meat skewer into the uterus with the intent of producing an abortion, and the physician in attempting to deliver the abortion had pulled down a considerable quantity of bowel into the vagina and had lacerated the bowel to a considerable extent, and shortly after I saw the patient she died. She died within an hour. Nothing could be done for her.

In a second case the patient was brought into the hospital, in which a Goodell dilator had been used to dilate, not perforating the uterus, but tearing the uterus into the broad ligament, and the sound, as was proved by laparotomy, passed alongside of the uterus and perforated the top of the broad ligament just behind the Fallopian tube. In this case I stitched up the peritoneum, put in a slender vaginal drain into the rent in the broad ligament, and the patient made a complete recovery.

In a third case the patient was brought into the hospital, the physician stating that he was the second attendant in the case; that he was called in after another physician had produced an abortion, and had attempted to pass a uterine sound, which was sucked up, so that it slipped away from his hand, and he was fearful he was going to lose it. I did not pay much attention to this explanation. At any rate, he sent the woman to the hospital. I made an incision in the abdomen an inch or more in length, closed the perforation which I found in the top of the uterus, and the woman made an uneventful recovery.

DR. CARL WAGNER.-In regard to such cases where a doubt exists as to whether the uterus has been perforated or not, I like to take exception to Abrams, who teaches to laparotomize in each case. Because the curette may pass into the tube only and thus simulate perforation, or as Bieder proved in his experiments the curette can even traverse the tube and enter the peritoneal cavity. In some cases the uterus may suddenly be converted into a flabby bag through a sudden paralysis of its muscular substance, and in this way through elongation allow the curette to enter to a perplexing depth. Furthermore, the application of large ice-bags upon the abdomen in perforated uteri has given very frequently very satisfactory results, as the literature of late proves

abundantly.

DR. EFFIE L. LOBDELL.-In my own practice I recall one, a puerperal case, which developed a temperature about the fourth. day. The family becoming alarmed called in a near-by physician,

who promptly proceeded to give an intra-uterine douche. I happened in while he was attempting to introduce the Kelly intrauterine instrument through a vaginal speculum. After considerable manipulation in introducing, he turned the inserted portion so that the tip presented anteriorly, causing a perforation directly into the bladder, resulting in a permanent vesico-uterine fistula. The second case was one in which I had been called in consultation. My diagnosis was retroversion with pelvic abscess. The physician believed the condition to be one of retained decidua, as there was a history of abortion two or three months prior, and to confirm his diagnosis introduced a small curette to explore. My hand was placed lightly over the lower abdomen, when suddenly I felt the tip of the curette with only the abdominal wall between it and my hand. It was immediately withdrawn. A postcervical incision was made, an immense abscess emptied and drained and at no time was there complication from the accident of perforation.

I would like to call attention to the fact that in both cases there was retroversion of the uterus, which was not recognized nor regarded by the physician previous to his manipulations. DR. WM. M. THOMPSON read a paper on

DERMOID CYSTS OF THE OVARY COMPLICATING LABOR.1

DR. JUNIUS C. HOAG.-I was much interested in the report of this case, because it is similar to one which I reported to this Society a number of years ago. Dr. Thompson, in his case, had the advantage of dealing with a small fetus, rendering palpation an easy matter. When I reported my case, I remember that Dr. Bacon asked the question why it was we did not drain the tumor at the time, rather than do a Cesarean section, as was done, and in the discussion I recall I forgot to answer his query, and although ten years have elapsed, I can now answer his question. We did not drain the tumor because we could not make out definitely what the tumor really was. There were a variety of opinions expressed regarding the tumor. Three men examined the patient. One thought there was a monster with two heads; another thought there was a bony growth attached to the pelvic wall; and a third, I think, expressed no opinion. What we found when I made the Cesarean section was a well-developed child and a large dermoid cyst. The patient made a good recovery, and about three months later she returned to the hospital and Dr. Watkins, who was also present at the first operation, removed the tumor through the vagina. The operation at that time was not difficult. At the time the woman was in labor I think it would not have been judicious to have opened the tumor; at least, it did not appear to be so at the time, because we could not decide what the tumor was or outline it well. The tumor was quite large, and what rendered the diagnosis particularly difficult was the fact that in the sac of the tumor 'See original article, page 87.

there was a large flat bone, and in the bone were some soft places, defects so to say in the bone, covered only by the membrane that formed the sac of the tumor, so that the feeling was that of another head. The soft part of the bone appeared like a fontanelle in a child's head. This piece of bone was about three inches in diameter, and contained on the inner surface a number of teeth.

DR. C. S. BACON.-I do not criticize the management of this case as it was undoubtedly the proper management, but I would like to ask what methods were taken to replace the tumor. I have seen three cases of ovarian tumor complicating labor, and in all of them it was possible to replace the tumor. In one case the tumor was ruptured during the effort at replacement, and the It was other two were replaced without rupture of the tumor. necessary in all these cases to put the patient in the knee-chest position and introduce the whole hand into the vagina and make considerable effort in the replacement. Ordinarily in such conditions as were present in this case I should suppose it was desirable to use every possible method to replace the tumor before opening or removing it.

DR. HENRY F. LEWIS.-In noticing the literature for the past five or six years on this subject, it appears that there is a growing tendency not to use obstetrical treatment in these cases, but to come more and more to surgical treatment. There are a great many excellent authorities who recommend Cesarean section as the proper treatment for all these cases, where we make a diagnosis of dermoid complicating labor. A few years after Dr. Hoag reported this case, I reported before the Chicago Medical Society, a case of dermoid cyst complicating labor, in which, because I had not arrived at the state of knowledge that is now possessed by us, I replaced the tumor manually, with recovery of the mother and child. The tumor was proved to be a dermoid afterwards by Dr. Henrotin, who, a year or so later, removed it.

DR. THOMPSON.-Dr. Bacon's remark about replacement of the tumor is timely; but as this woman had been in labor so long and was exhausted, I did not continue my attempts very long to I thought it was cystic; further than that replace the tumor. I could not tell. It bulged the recto-vaginal wall so much that I could not see the cervix; it took up all the space. It was comparatively easy to make an incision and draw it into the wound, and the fact that the patient was exhausted, and the surroundings were not favorable for opening the abdomen, I made the operation I did. I believe from the cases I have read about and from the literature I have seen, that Cesarean section is the proper operation when the patient is seen in time.

RUDOLPH W. HOLMES, M.D..

Editor of the Society.

TRANSACTIONS OF THE
WOMAN'S HOSPITAL SOCIETY.

Meeting of October 25, 1904.

The President, DR. J. RIDDLE GOFFE, in the Chair.

DR. CARMALT reported a case of

COMPLICATED UTERINE FIBROMYOMA

OPERATION

RECOVERY

PREGNANCY.

This case is reported as illustrating the difficulties and uncertainties of pregnancy complicating uterine fibromyomata, the value of myomectomy even in cases with very large tumors and the complications of that operation. The case has been observed by me over six years, and therefore the history is rather complete. Mrs. C. R. P., wife of a physician, 32 years old, 5 feet 9 inches; weight, now, 196 lbs.; married twice; American, of New England and New York Dutch ancestry, all long-lived somewhat neurotic, red hair, blond coloring; family and personal history negative save for present complaint.

In December, 1899, I curetted her for endometritis following an incomplete abortion at the third month, the second she had had. The anterior wall of the cervix was much thickened and the uterine cavity four inches deep. In 1900 she apparently had a third miscarriage, and the uterus was much larger, giving evidence of a tumor in the lower segment. In November of 1901 her husband and I decided that she must be pregnant, from the rapid increase in the abdominal tumor, the enlargement of the breasts, slight nausea and a violaceous tint to the vagina, despite a menorrhagia still continuing. She was put to bed at the time of menstruation and given opiates, but did not really become pregnant until May, 1902. By that time it was apparent that there was a large, rapidly-growing fibromyoma, or myomata, in the anterior wall of the cervix and lower uterine segment pressing upon the bladder as well as filling the upper vagina so completely that the cervix could not be reached.

The patient declined to have labor induced, and we decided to do Cesarean section whenever labor commenced, the period of pregnancy being very doubtful. Preparations were made and labor commenced, but before the arrival of assistants the uterine contractions lifted the tumor out of the pelvis and drove the child down to the perineum. Although this took place in less than half an hour, the length of the vagina was so great that the child was asphyxiated before I delivered it. Faithful artificial respiration, hot and cold water and stimulation failed to restore the

breathing. The placenta was retained behind the tumor and I had to remove the placenta manually. Her convalescence was uninterrupted and the tumor (apparently the size of a child's head) shrank to less in size than a small egg.

During the following summer she had several attacks of menorrhagia, possibly abortions, and the tumor again grew to a greater size than ever before. It filled the vault of the vagina and apparently mechanically interfered with conception. Her apparent sterility began to prey upon the patient's mind. She declined to consider hysterectomy at all, and knowing the risks, decided upon an exploratory celiotomy with probable myo

mectomy.

October 25, 1903.-Gas and ether. Ordinary preparations. Assistants, Drs. A. V. S. Lambert and Charlton Flint. Incision from above umbilicus to pubis. Tumor occupied anterior wall of uterus, encroaching upon bladder below and extending into left broad ligament. There was no pedicle. An attempt to split the peritoneum over the mass met with such furious bleeding it was discontinued. Around the base of the tumor sutures, including the peritoneum and large vesse beneath, were passed and tied. More than fifty of these were used, and the peritoneum toward the tumor was incised, bleeding points tied while the mass dissected free from bladder below was removed, together with the anterior wall of the uterus. The mucous membrane of this anterior wall was not entirely removed. The raw surface thus made was brought together with two tiers of mattress sutures as would be the rent of a Cesarean section, and when the peritoneum was closed the wound looked like that of a Cesarean section with an incision extending down on to the peritoneum behind the bladder. The abdominal wound was closed in tiers and the patient put to bed. Operation, two hours. General condition rather poor; pulse, 120. She had been infused just before close of operation. Loss of blood considerable.

Her convalescence was uninterrupted until the 28th day. Primary union in wound. This day she was allowed to sit up at my suggestion. It was the day her menstruation was due. That night she had a temperature of 104° and great pain on the left side over region of the left ovary, apparently. No mass could be felt. Two days later that left thigh began to swell and a diagnosis of left iliac phlebitis was made. Four weeks later the same condition developed in the opposite leg and side, and alternately the kidneys apparently ceased secreting; the edema extended as high as the axilla. The edema subsided, and in six weeks the patient was well. In the next few weeks the patient became pregnant and I delivered her on September 15, 1904, of a 104-lb. boy after a labor of two hours all told. In my anxiety to get a live child I permitted the head to tear the perineum, which was immediately repaired, and healed well, save for continued swelling of legs from former phlebitis. She is nursing her baby without difficulty.