hours without any progress; said she was overdue several days. On examination the position and presentation were found normal, but head not engaged. The cervix was practically effaced, and dilatation the size of two fingers. There was some degree of hydramnios. She was having pains every half hour. These pains continued for twenty-four hours longer without any progiess, and finally after a dose of one-quarter of a grain of morphia stopped altogether. In two weeks I was called again; the same condition was found; she had had pains for nearly twenty-four hours, and they ceased again. Finally, I was called a week later, and she continued having pains every half hour or every twenty minutes for nearly thirty-six hours, after which time I made an examination and found the head still not engaged and dilatation the size of three fingers. The cervix was entirely effaced, and the os rather rigid. In the examination I accidentally ruptured the membranes, and, roughly estimated, over a quart of fluid escaped. She had half a dozen severe pains, and a normal child was born in seven minutes after my examination. The questions arise whether the moderate amount of hydramnios could have been the cause of the inefficient pains, and by what mechanism did the os dilate so rapidly?

The other three cases are cases of premature detachment of the placenta, one in my own practice, and two that I saw abroad. In the first, the patient, a multipara, had been in labor for several hours, and had several fainting spells before I saw her. I found her unusually pale, with a pulse of 110 or 120; the abdomen very tense, and extremely tender to touch; no fetal heart sound could be heard. The patient felt faint with each pain. Dilatation being complete, the membranes were ruptured and forceps were applied. No blood escaped even then. The baby was delivered rapidly; it was dead. The placenta followed instantly, and with it a large mass of clots. The uterus failed to contract in spite of all the means I used, including packing, and I nearly lost the patient.

The second case came to the hospital with a history of bleeding through the entire day. She had been given whiskey in order to sustain her strength, and was in a half intoxicated condition. But she looked very pale; her pulse was 120; the abdomen was tense and tender to touch; fetal heart sounds could not be heard. Placenta prævia was excluded, and a diagnosis of premature detachment of the placenta was made; a dead child was delivered by version and extraction, within half an hour. The placenta followed immediately, and with it many clots. In this case, too, the uterus failed to contract, in spite of all the efforts that were made, including packing. The patient died in a short time.

The third case was a primipara. She had been having slight labor pains for twenty-four hours, but was feeling well. It was accidentally discovered that she was bleeding, and after a very careful examination, resulting in a diagnosis of premature de

tachment of the placenta, the cervix was rapidly dilated and a living child delivered by version and extraction. The placenta followed at once, and then a considerable hemorrhage. There were no lacerations of the cervix, yet the bleeding continued, because the uterus could not be made to contract. Finally, a vaginal hysterectomy was resorted to, for the patient was rapidly failing, but she died.

It would seem that the danger of premature detachment of the placenta is not only great before delivery, but that the atony of the uterus that follows is just as dangerous to the mother's life.

DR. CHARLES B. REED.-I would like to inquire of Dr. Yarros if in the first case the contractions of the uterus which the woman experienced, were attended by definite, real labor pains! And, secondly, if they were, what effect, if any, they had upon the cervix, and whether the cervix was entirely effaced in the dilatation of the os or whether there was effacement of the cervix with the two and three-finger dilatation she spoke of? Also, in the second case, whether any attempt was made at packing the uterus to stop the hemorrhage?

DR. GUSTAV KOLISCHER.-The first case reported by Dr. Yarros is quite interesting in that it shows we cannot violate elementary rules in obstetrics without endangering the life of the child, and eventually the life of the mother.

It is a well-known fact that if hydramnios exists in a multipara, one of the things we have to do if the head or face (after labor has set in) has become engaged in the pelvis is to rupture the membranes. If we do not do this, we may commit another error-leave the patient after the membranes have ruptured spontaneously. The fundus of the uterus and the lower uterine segments represent one tube. Although the external os is not entirely dilated, it will dilate at once at the slightest pain if the membranes are ruptured. We know, as a matter of experience, that if in a multipara pain sets in, and the membranes rupture, delivery of the child is expected immediately. We know that we expose the mother to grave danger if we leave her unattended with hydramnion, because the overdistended uterus is very liable to postpartum hemorrhage on account of insufficient contraction.

So far as premature detachment of the placenta is concerned, we know that if a woman is exsanguinated by any cause, she is liable to have atony of the uterus. We must be prepared for that. I cannot conceive how any person with obstetrical judgment can go to work and perform vaginal Cesarean section on account of premature detachment of the placenta. It is beyond my con- . ception. I can understand how one can perform vaginal Cesarean section in a case in which he wants to empty the uterus as soon as possible.

DR. YARROS.-Vaginal hysterectomy.

DR. KOLISCHER.-An attempt at hysterectomy in such a case is also beyond my conception.

There is one other thing I want to emphasize very strongly, and

it is this we have to be concise, definite, and accurate in our obstetrical statements and teaching. It is absolutely wrong for a statement to go out to the profession, endorsed by this Society, that if there is post-partum hemorrhage, we have to do all sorts of things. It is such ideas that will. We have to do certain things; we should not waste time and waste the blood of the woman trying to do other things. That is not an obstetrical indication; it is not the way to act. There are three things to do; pull down the uterus as far as you can, compress the uterus bimanually, or pack the uterus, and exert counter-pressure over the abdomen to prevent the uterus from rising again.

DR. RACHELLE S. YARROS.-In answer to Dr. Reed's question, I would say that at the first examination the cervix was almost effaced, and that during the pain the os became much more tense, and that the uterine contractions could be felt distinctly. Packing was used in every case.

In answer to Dr. Kolischer, I would say that he surely does not mean that the membranes should be ruptured in every case of hydramnios. There did not seem to me any justification for such procedure in this case; so long as mother and child were in good condition; the mere fact that it was inconvenient for us and the patient to have the labor drag on did not warrant the hastening of the labor.

As to vaginal hysterectomy for post-partum hemorrhage, he surely knows there are cases on record where the mother's life was saved by this operation. The only difficulty is to know just when to do it; that is, not to do it too soon, and not too late. Discussion on the paper of Dr. Heliodor Schiller.

THE TREATMENT OF VAGINITIS BY YEAST.*

DR. JOSEPH B. DE LEE.-I would like to ask Dr. Schiller whether the use of yeast would be admissible during pregnancy? DR. GUSTAV KOLISCHER.-I have had a little experience in the treatment of chronic gonorrhea with yeast, but it has not been satisfactory. It is true that during the time of treatment the secretion diminished, but we were always able to find gonococci such as were found previously. There were some cases in which the clinical symptoms pointed to a uterine gonorrhea, but we were unable to find gonococci. We stopped our experiments because in a few patients the yeast set up symptoms of inflammation around the appendages and in the parametric tissue. Of course, we can hardly attribute this to the administration of yeast alone. Almost any interference during a gonorrhea may lead to involvement of the appendages, or of the parametric tissue.

So far as the disappearance of gonococci from the vagina is concerned, we must bear in mind one thing, that certain conditions which primarily are due to gonorrheal infection may be kept up, and maintained, and we are absolutely unable to find any gonococci, so that among the men who do most research work in gonorrhea, there is still discussion as to whether certain secretions *See original article, page 635.

coming from the cervix or uterine cavity previously infected by gonococci are still infested with those germs, or whether the conditions are due to other causes.

We did not use yeast in the way Dr. Schiller has reported in particular, nor did we do anything to improve the soil for the yeast as he did. It is to be hoped that something will be gained by this method of treatment, because in these conditions mentioned the treatment itself is one of the most thankless jobs that the gynecologist can be called upon to perform.

DR. J. CLARENCE WEBSTER.-Some time ago I studied the literature of this subject somewhat, in order to try to form some idea as to the efficacy of yeast in such conditions as have been described by Dr. Schiller, but I was not persuaded that this treatment was any better than any of the other methods already in use. The use of yeast for medical purposes is not at all a recent innovation. In France, in 1852, Mosse described its employment by workers in breweries, especially in skin diseases, furunculosis, acne, etc. It was found by the employees that they were benefited from rubbing the yeast into the skin in these conditions. Lassar, a well-known dermatologist, has also experimented along these lines. Others have administered yeast internally as well as externally, and have claimed to have obtained benefit from it. Some interesting experimental work has been done with yeast by Sergent. The staphylococcus aureus was used to inoculate rabbits; after their ears had been shaved and scratched, and after a certain length of time the yeast was rubbed in, and it was claimed that recovery took place much more quickly than in the control experiments. But it was always found that if the inoculation was severe, the rabbit died, and the yeast exercised no antagonistic power whatever.

With regard to the use of yeast in the vagina for the cure of gonorrhea, Cronbach claimed that he got no better results with it than he did with ordinary antiseptic treatment.

There has also been carried out some experimental work with regard to immunization, the yeast being administered to animals some time previous to the inoculation. Some claims have been made that a certain degree of immunity can be obtained. I feel, at the present moment, that the proof, that gonorrhea can be treated by yeast more satisfactorily than by the antiseptic method, is not very certain.

DR. SCHILLER (closing the discussion).-In answer to the question of Dr. De Lee, as to whether yeast has been used in pregnancy, I have to say that Dr. Plien used rheol bacilli in the cervix of pregnant women with good results. Rheol is a combination of living yeast and asparagin, kept in paraffin oil, with some boric acid. He used this with good results.

I would like to mention that yeast is used by some surgeons as a preparatory disinfection of the vagina before vaginal operations and since they have used it they have had better results and no infection.

Yeast in the vagina can be used in pregnant women, and I would

not hesitate to use it if there was a severe endocervicitis or chronic vaginitis.

As to Dr. Kolischer's remarks concerning parametritis and salpingitis, I will say that cases of salpingitis have been reported after the use of yeast. All the cases of Plien, who saw salpingitis were acute cases of gonorrhea which he treated with rheol bacilli in the cervix.

Olshausen and Eberhardt, and some others, explained the bad results which Plien obtained by stating that he used bacilli of rheol in the cervix in acute cases of gonorrhea and say that no other results could be expected. It is hard to believe how yeast could set up a salpingitis if used only in the vagina. The second explanation which Dr. Kolischer gave, that salpingitis is the consequence of an ascending process of gonorrhea, and not due to the yeast treatment, is much better.

I understand that Dr. Kolischer used plain yeast, with no results.

Concerning the use of yeast in other diseases, such as diabetes, constipation, and auto-intoxication from the intestinal canal, furunculosis, etc., I will say that some favorable results have been reported.

The work concerning immunization of yeast was done by an American author whose name I do not recall. With it he secured an increased resistance against infection.

Cases of

ABDOMINAL AND VAGINAL CESAREAN SECTION

were reported by Drs. RUDOLPH W. HOLMES,* Jos. B. DE LEE, C. B. REED, CHAS. E. PADDOCK, C. S. BACON, F. B. EARLE, J. CLARENCE Webster.

SECOND CASE OF CESAREAN SECTION FOR FUNNEL PELVIS.

DR. CHARLES B. REED, M.D.-Cases of Cesarean section are not very unusual, but the one herewith presented possesses a few points that are possibly of general interest.

The patient's first labor resulted in a craniotomy with difficult extraction of the crushed head, and her second delivery was by Cesarean section, which I have already reported.

She is now 22 years, and shows the following anatomical characteristics:

The patient was 158 cm. high, with large, full and mature breasts, noticeably slight in figure with narrow hips and strongly converging genitocrural folds. The physiologic lumbar lordosis is diminished, no kyphosis, no rostration of symphysis, iliac venters rather straight and no evidence of early rachitis.

External measurements with tape and pelvimeter give sp., 19.0 cm.; crests, 22.0 cm.; troch, 26.0 cm.; Baudelocque, 19.0 cm.; *See original articles, pages 732 and 738.