abdomen was somewhat distended, and the muscles resistant over the right half of the abdomen. Per vaginam the uterus was mobile, but pushed over to the left side by a somewhat elastic mass on the right side of the pelvis, situated apparently between the layers of the broad ligament.

In the vaginal wall, running from the base of the right broad ligament, starting from a spot slightly to the right of the cervix, there was an elastic ridge, somewhat irregular in outline, which passed forward and toward the middle line, becoming lost a little to the right of the urethra, about three-fourths of an inch behind the vestibules. The orifice from which the discharge came was not found.

A fortnight later the patient suffered severe throbbing pain and the temperature rose nightly to 101° or 102° F. The vaginal ridge had become larger, tenser and more elastic, and evidently contained fluid reaching very nearly to the vaginal outlet in the middle line of the vaginal roof.

The patient was examined under ether, and the vaginal cyst was found collapsed; the broad ligament tumor was very distinctly made out, and was thought to be a broad ligament parovarian cyst, the vaginal cyst being presumably a patent Gärtner's duct communicating with the cyst cavity. As the patient was regaining consciousness, she coughed, and bore down strongly, causing a quantity of yellow, offensive pus to come out of a minute hole not previously seen, just beneath and to the right of the urethral orifice at the base of the vestibule. A small probe passed down this abnormal orifice for three-quarters of an inch, and the passage was laid open as a rectal fistula would be. The openings of Skene's ducts just within the urethral orifice were quite perceptible. main vaginal cyst was then opened about two inches up the vagina but it was not possible to pass a probe for any distance either backward or forward. A few days later I succeeded in passing a probe along the whole canal from the anterior orifice, and subsequently a director; and under anesthesia, freely laid open

The

the vaginal cyst with a Paquelin's cautery, letting out much pus, which welled freely out of the upper end of the incision at the base of the broad ligament. The duct thus laid open was lined by a smooth membrane. A sound passed into this upper opening near the cervix went a distance of five inches upward and outward and was evidently inside a cyst cavity in the broad ligament. The opening was enlarged to admit the finger, which could be passed into the cyst behind the vagina, and could make out that the lining membrane was smooth and that the cyst was between the layers of the broad ligament. The cavity was washed out with iodized water and a

drainage tube inserted. The patient completely recovered. Routh believes

this to be a case of distended Gärtner's duct where the contents finally suppurated.

CASE II. In 1881 Watts reported a case of cyst which bulged from the anterior vaginal wall in the position of a urethrocele. The urethra was, however, quite normal. He laid open the cyst per vaginam, and to his surprise was able to pass a probe several inches without resistance. Watts thought the probe penetrated the peritoneal cavity but Routh thinks it pretty clear that as in his own it was really between the layers of the broad ligament.

CASE III. Veit's case (1882) was that of a married multipara, aged 47, who had a large vaginal cyst, which made micturition difficult owing to pressure upon the urethra. The cyst bulged out between the labia majora as large as a child's head. The uterus was pushed over to the left side by a tense elastic swelling in the right broad ligament, which clearly communicated freely with the vaginal cyst. the vaginal cyst. The case was treated by incision of the vaginal cyst, draining both it and the broad ligament cyst, and by cutting out a large piece of the lining membrane of the vaginal cyst to prevent reclosure. The finger could be passed into the broad ligament and the ovary felt on its posterior and outer surface.

Mr. Melton of Cairo reports the case of an Egyptian fellah woman aged 30

'who from her earliest recollection had been subject to a watery vaginal discharge. At the age of 13 she married and became pregnant, and was delivered of a healthy child, the discharge continuing during pregnancy. On vaginal examination, a very minute orifice, admitting only a catgut guide, was found on the vesico-vaginal septum, a little to the right of the middle line, and half an inch posteriorly to the vesical extremity of the urethra. From this issued, drop by drop, a pellucid fluid, to the amount of about two ounces per diem, having a specific gravity of 1026 and containing much albumen with some sodium chlorides. Urea and urates were absent. A fine urethral bougie, introduced with great difficulty, passed directly backward along the vesico-vaginal septum, and then following to all appearance the line of the ureter, penetrated to the whole of its length in the direction of the right kidney.

This was undoubtedly a patulous

Gärtner's duct. An opening was made in the bladder and the duct turned into it. There was no further vaginal discharge, but the woman had a permanent albuminuria.

Tait was consulted by a patient aged 60 who had had a profuse watery discharge from the vagina for 30 years. He discovered that the fluid came from two small apertures, one on each side of the urethra. Temporary closure of the canals by Paquelin's cautery caused much pelvic distention, which was relieved when the accumulation of fluid reopened the closed orifice. The discharge continued until the patient was 70 years of age.

Rauth concludes that it is established that in some cases Gärtner's ducts are patulous from the parovarium to the vestibulum, and that an obstruction in such a duct in the broad ligament portion will produce a parovarian cyst, and that an obstruction in the vaginal portion may cause a vaginal cyst, or both.

Her

Urinary analysis developed the following: Albumen 50 per cent.; epithelial and granular casts; specific gravity 1006; acid reaction.

(The percentage of albumen referred to in this paper represents an ocular estimate of the bulk of coagulated albumen in a given quantity of urine after boiling.)

Eliminative treatment consisting of pulv. jalap. co. 3j every morning; potass. acetate, gr. xx every two hours, and

an absolute milk diet, was instituted. The following day labor pains increased in severity, with a corresponding increase in uremic manifestations, headache, persistent nausea and vomiting, nervousness, and marked restlessness, slight edema of the face, although none in the extremities. Vaginal examination showed an obliterated cervix and dilatation of the os to the extent of a five cent piece.

Upon consultation with Professor Michael, it was decided to interfere and terminate the labor as rapidly as possible. The patient was anesthetized, and dilatation of the os by the fingers begun, after the completion of which, forceps were applied to the slightly engaged head, which had not yet undergone moulding nor flexion, two conditions operative in causing the for

ceps to slip. After repeated efforts along this line, accompanied by as many failures to deliver, I turned the child, pulled down the feet and thus delivered the breech, only to find the arms extended above the head. They were, however, brought out after considerable difficulty, without fracture.

The Veit-Smellie method was then applied to the after-coming head, but signally failed. Then the Goodell method was substituted and this, aided by supra-pubic pressure, proved efficient. The child, as was anticipated, was asphyxiated, but after an hour's work was finally resuscitated. There was a considerable post-partum hemorrhage owing to uterine relaxation and retained placenta, which was tightly adherent to the fundus of the uterus and had to be scraped away. Ergotole was then administered hypodermically and uterine douches given.

The perineum sustained a laceration of the third degree, extending partly into the rectum. This was hastily repaired owing to the condition of the mother, which was rapidly approaching collapse.

After the operation, the patient rallied although uterine retraction was so tardy as to necessitate stimulation by the Credé method and repeated doses of ergotole for the following twelve hours. Immediately following delivery, all uremic symptoms subsided and there was also such a rapid diminution in albumen that it, together with the casts, had entirely disappeared from the urine in the course of thirty-six hours. Eliminative treatment was discontinued after the first week. Patient passed an uneventful puerperium, the temperature at no time ranging above 100°. Discharged in good condition.

CASE II.-J. W., white, primipara. Pregnancy advanced to eighth month. Brought to Maryland University Hospital, March 10, 1895, in complete coma, having had seven convulsions during the twenty-four hours preceding her arrival. She was given pilocarpine muriate gr. 1, strychnine and nitro-glycerine hypodermically, and toward evening emerged to some extent from the comatose condition, although her intellect was very

much clouded. After transfer to the Lying-in Hospital about 8 P. M., she was examined and found to be in labor, the os being but slightly dilated. To ward off any convulsive outbreak, she was given morphia sulph. gr. hypodermically.

Urinary analysis. Albumen 80 per cent.; specific gravity 1030; acid reaction; numerous epithelial, granular and hyaline casts; blood casts and blood corpuscles. Arterial tension very high; respiration slow and somewhat stertorous; on the whole, her condition was such that Professor Michael advised immediate emptying of the uterus. She was anesthetized, and dilatation of os completed by the fingers, after which forceps were applied to the floating head and child delivered. From this time she showed marked improvement, the pulse becoming soft and regular, respiration approaching the normal, the intellect became clearer and continued to improve, being completely restored on the following day. The child was born asphyxiated, but was resuscitated and lived seven hours.

After-treatment of the case consisted in stimulation by whiskey hypodermically, absolute milk diet, elimination being accomplished by pulv. jalap. co. 3j, every other morning. Infusion of digitalis 3 iij every three hours. Also four dry cups. The urine gradually cleared up, as indicated by the following analyses:

One hour post-partum, 60 per cent. albumen; epethelial granular hyaline casts; acid reaction; 1022 specific gravity.

Twelve hours post-partum, 20 per cent. albumen; hyaline casts; acid reaction; 1020 specific gravity.

Twenty hours post-partum, 10 per cent. albumen; hyaline casts; acid reaction.

Forty-two hours post-partum, trace of albumen. Amount of urine passed daily averaging forty ounces.

Albumen and casts gradually disappeared, patient passed a normal puerperium with the exception of nausea and vomiting on the third day and was dismissed in good condition.

Cases of uremia occurring at different periods of and complicating pregnancy necessarily require individual consideration regarding their treatment. In the two cases just reported, the indications were practically the same, each having entered the first stage of labor and their respective conditions of such gravity as to make operative interference not only justifiable, but absolutely necessary in the interest of both mother and child. That such was the proper course is clearly shown in the fact that the cause possibly producing and certainly perpetuating the conditions having been removed, all uremic symptoms subsided and rapidly disappeared. As uremic cases do not present such grave and urgent conditions, the treatment instituted should be based upon a knowledge of the viability or non-viability of the fetus. Should the fetus be viable and the conditions cited in the foregoing cases exist there is but one rational course to pursue, i. e., immediate evacuation of the uterus.

It is therefore to those cases in which the fetus is non-viable that attention is especially directed. The question that now presents itself is, "Shall these cases be treated conservatively or radically?" Regarding the conservative measures, hygienic or medicinal, it would be superfluous to review them in detail, their employment being especially indicated where the result of chemical and microscopical examination of the urine, together with the lesser uremic symptoms, suggest it. On the other hand, if such measures fail and the condition increases in gravity, or in the event of not having seen the patient sufficiently early to invoke proper eliminative treatment, and cerebral symptoms develop, in my opinion, as Professor Lusk tersely expresses it, "the time for folded hands has passed." It will be held by some that even at this stage of uremic intoxication, the conservative measure of elimination by the steam bath or hot pack, with free use of cathartics, diuretics, etc., would be most efficacious and the proper course to pursue. Possibly, yes; probably, no. However, if such measures be employed, no one is in position to say with any de

gree of certainty that should the patient emerge from her comatose condition she would not return to it after a variable time. On the contrary, even though elimination of the toxines producing the uremic condition were accomplished through other channels than the kidney, i. e., skin and bowels, and the crippled kidneys restored to some extent by use of mild diuretics, and especially by the withdrawal of nitrogenous food favoring the production of the toxines, still the causative agents are but partially removed, in that double work is still imposed on the kidneys, viz., the elimination of excrementitious principles of not only mother but child as well; and, added to this, there is still the continued high blood pressure, causing constant congestion, and hence the greater liability to acute nephritis should any agency influencing such inflammation present itself.

Hence in the event of restoration through conservative measures, I think at best it would only be temporary, the uremia probably appearing later with graver manifestations, if not fatal result.

Before outlining the treatment, it should be noted that in uremic patients, labor, either as a result of uremia or precipitated by convulsions, may occur prematurely and result in spontaneous delivery, or again the same conditions may be present without exciting the least uterine contraction, and it is in this class of cases that interference is especially indicated. Treatment, therefore, necessarily depends on existing conditions and their consideration, and compels the obstetrician to weigh carefully each case before proceeding, the number of cases being too few and statistics too meager to lay down any fixed rule in reference to operative interference. I think, however, after a careful study of the subject in all its bearings, preference would be given to operating as soon as cerebral symptoms develop.

In the induction of premature labor, the principal means at our disposal are, (1) the introduction of an aseptic bougie between the membranes and the uterine wall, or (2) by dilatation of the cervix by Barnes' bags, or fingers and then

or

delivering by forceps or version. The bougie is of value in those cases the conditions of which admit of delay, but in threatened eclampsia it is of doubtful utility owing to the time required for its action, generally twenty-four hours, even longer. For should the case present indications necessitating interference, the method employed should be such as to secure immediate evacuation of the uterus. Hence to temporize with

the bougie is only to expose the patient needlessly to the results of increasing intoxication and to sink her more deeply into profound and possibly irremediable coma. Rapid delivery is then the only safe and rational course to pursue and this is best accomplished by rapid dilatation either by Barnes' bags or the fingers, preferably the latter, and then by application of forceps or performance of version, according to position of the fetus.

THE more ready accessibility of the pelvic organs to sight and touch naturally led to the exercise of abdominal incision as the usual method of procedure in removal of the uterine appendages.

The facility of such operations has been greatly enhanced by the introduction of the Trendelenburg position, in which the light falls into the pelvis, while the intestines fall away, or are held out of the pelvis with but little difficulty. If the object is removal, these positions leave little to be desired.

The important question, however, is, do we always desire to remove organs which the symptoms and physical signs demonstrate are the seat of serious inflammatory or suppurative disease?

Certainly not, if any procedure will afford a restoration to health with their retention. In other words, no organ should be sacrificed which can be saved. The careful study of suppurative processes which result in rupture of a tube and the formation of an abscess sac in the broad ligament, or Douglas's cul-desac, demonstrate the wisdom of affording a vent through the vagina, even should the condition be such as to render it certain it would be necessary subsequently to resort to abdominal operation for more radical relief. Nature is very careful to protect vital structures

by plastic exudation, thus affording a barrier against further encroachment. A large collection of pus thus becomes a localized abscess, excluded from the peritoneal cavity. In such a case an abdominal incision means the breaking. up of Nature's fortification and the possible infection of the entire peritoneal cavity.

Such a collection may be limited to either the inferior or superior position of the broad ligament, Douglas's cul-desac, or in front of the uterus, between it and the bladder. In all these positions the abscess may be incised, its contents evacuated, and the the cavity drained. through the vagina.

Such a procedure is not necessarily attended with serious danger, even in the gravest cases. Indeed, in many cases the choice of this procedure may result in recovery, when the exercise of the more radical operation through the abdomen would necessarily result fatally. It is objected that the operation is not thorough, that diseased tissue is left. While it is true that the removal of the organs is not as thorough as in the radical removal through the abdomen, yet the prime consideration is the cure of the patient and that with as little mutilation as possible. The surgeon does not remove the entire tibia because a portion of it is diseased, nor does he dis