teen months prior to her admission. Her labor and puerperium were normal. She remained in bed ten days. Her second child was born six weeks prior to admission to the hospital. She was delivered instrumentally by a physician. The placenta and membranes came away intact. Four days after her labor she developed a high fever which continued for two weeks. She had no chills. From the beginning of the fever she suffered from severe sharp shooting pains in the lower left quadrant of the abdomen with marked tenderness. This continued until the physician covered her abdomen with a black salve (Crede's ointment), which relieved her so that she was able to be out of bed in a few days. Three weeks before her admission, that is, after she had been up and about for a week, the pains from which she had suffered after the birth of her child returned. They gradually increased in severity, being worse at night, were of a sharp shooting character and were located in the left iliac region. This pain is the only thing which she complains of.

Physical examination shows marked rigidity, tenderness and muscular spasm in the left iliac region. Vaginal examination shows the uterine body enlarged and crowded over to the right by a large tender mass at its left side. The blood count showed 18,000 leukocytes with 85 per cent. of polymorphonuclear cells. The cervical and vaginal smears were negative as to gonococci. Operation March 23, 1910. Median incision, omentum much thickened and adherent over uterus, especially over left side and over left broad ligament. On separating the omentum an abscess was found in the upper left side of the fundus of the uterus dissecting anteriorly between the folds of the broad ligament to the abdominal wall. The uterus was freed and the abscess evacuated, the cavity of the abscess being lightly curetted and cauterized by pure carbolic acid followed by alcohol. Drainage was established by means of rubber tube and cigarette drains brought out at the lower angle of the abdominal wound. The patient made an uninterrupted recovery, the sutures being removed on the eighth day and the patient being discharged on the eleventh day following the operation (Figs. 5 and 6).

CASE IV. Puerperal abscess of anterior uterine wall (streptococcus), dissecting between uterus and bladder. Anterior colpotomy, vaginal drainage, recovery.

Mrs. F. F., twenty-five years old, was admitted to my service at the Har Moriah Hospital on October 12, 1910 with the following history: She is the mother of nine children, eight of whom are alive and well. All of these were delivered normally without instrumentation. The puerperium was normal in each case until the last labor which occurred four weeks before her admission to the hospital. On the fourth day following a prolonged labor the patient experienced severe cramp-like pains in the right iliac fossa. This pain was distinctly localized and was practically continuous up to the time of admission. At the outset of the pain the patient had a severe chill followed by fever and sweating.

Since that time she has had several similar attacks of chills, fever and sweating. She has had no vomiting. Her bowels have been constipated.

FIG. 7.-CASE IV. Abscess in anterior uterine wall. Dissecting between bladder and uterus. Anterior colpotomy. Drainage. Per vaginam.

Physical examination shows tenderness over the entire right half of the abdomen more especially in the right iliac fossa where an indurated mass can be felt filling up that quadrant of the

pelvis. Vaginal examination reveals an enlarged tender uterus drawn over toward the right side. Blood count, W. B. C. 22,000, polymorphonuclear cells 91 per cent. Urine showed evidences of an acute nephritis. Cervical and vaginal smears negative for gonococci.

Temperature on admission 103°, pulse 112. On October 25, 1910, the day of the operation, the temperature was 100.4° F. and pulse 100. At this time the abdominal mass had become more defined locally and vaginal examination revealed a soft bulging fluctuating tumor in the right vaginal fornix. On opening the posterior culdesac a small amount of clear serum was discharged and a fluctuating tumor in the right anterior wall of the uterus could be made out. This was incised freely, thoroughly irrigated, and drainage established per vagina by means of a large rubber tube and gauze packing.

The patient made an uninterrupted recovery and in four weeks was discharged well. Physical examination at the time of discharge showed that the uterus had returned to its normal size and was freely movable. The adnexa were normal and the urine contained no evidences of nephritis which existed at the time of operation (Fig. 7).

CASE V. Intramural abscess of uterus (streptococcus) the result of puerperal infection, incision, drainage, treatment by autogenous streptococcus vaccines, recovery.

Mrs. A. K., forty-two years old, was referred to me on March 10, by Dr. Samuel Millbank, and on that date was admitted to Bellevue Hospital with the following history: During a married life of seventeen years the patient had been delivered normally of ten children until the last confinement which occurred fifteen days before her admission at which time she was attended by a midwife. Prior to her last confinement she has had no complications of labor, getting up on the tenth day, well.

Fifteen days before her admisson she was delivered by a midwife of a full-term child. Her convalescence seemed normal until the third day postpartum, when the patient passed several large foul-smelling clots. She felt chilly and was markedly feverish following the chilly sensation. On the fifth day she was curetted by a physician, and the symptoms from which she had suffered disappeared. On admission she complains only of a feeling of nervousness and mental unrest. Physical examination is negative except for tenderness and muscular spasm over the iliac regions, more markedly on the left side. Vaginal examination shows old, deep lacerations of the perineum and extensive recent lacerations in the same regions. There is a mass in the left fornix, firm and tender. The uterus is enlarged, soft and tender, especially in the left anterior portion, its mobility being limited. The left tuboovarian region shows a distinct tender mass, some tenderness in right vaginal fornix. Vaginal and cervical smears negative for gonococci. March 20, leukocytes 21,500;

polymorphonuclear cells 87 per cent. April 11, leukocytes 16,000; polymorphonuclear cells 84 per cent.

On admission the temperature was 97.4° F., pulse 84, respira

FIG. 8.-CASE V. Drainage of abscess cavity by rubber tube; neighboring peritoneal are by cigarette drains. Left tube and ovary removed.

tion 20. The same afternoon the temperature rose to 100.8° F., and on the day of the operation, March 23, the thermometer registered 104° F., with a pulse of 102 and respiration 26.

Operation. Median incision, omentum found widely adherent