and she passes bloody urine. For six pass the catheter, and, like the ostrich months she has had a purulent leucorrhoea; sticking his head in the sand, they shut she has a lacerated cervix, and complains their eyes to the danger and say, “We'll of pain whenever the bladder is touched. wait awhile;" perhaps they leave it twentyShe is still suckling the child. The urine four or thirty-six hours, and often an inhas been examined, and contains albumen curable cystitis follows delay and timidity and pus. The albumen, however, betokens nothing grave, for it is not large in quantity, and is dependent on the presence of pus and blood.

of this kind. Never have any hesitation about using a catheter; you can pass it along your finger, as I have described to you before, or, if you fail, boldly call for a light. A woman who has been pregnant once, and has had the walls of the bladder over-stretched after a tedious labor, by neglect of this precaution, is never the same woman again. When a patient of yours complains after labor that she wants to pass water and cannot do it, do not delay relief. If you practice in the country, and are perhaps four or five miles away from your patient, and apprehend any difficulty of this kind, you can insert a SkeneGoodman self-retaining catheter. By attaching it to a piece of tightly-fitting gumtubing, and controlling the escape of urine by means of a clip, you can have her water drawn at stated intervals, without making a special journey for that purpose.

This woman has passed through an energetic course of treatment, both local and constitutional, adapted to modify the condition of the urine, but she has found no relief. She says that she has to get up very often to pass water-every half-hour, according to her statement, but that I can hardly believe; were it every hour at night, that would be a great tax upon her strength. You know how difficult it is for a man to walk a thousand miles in as many hours; the broken rest, far more than the continued effort, is very exhausting to the whole system. In this woman's case, the strain of nursing, added to the loss of rest, is altogether too much for her. Why did labor cause this cystitis? It is possible that, during delivery, the traction | A suppository containing one grain of the of the forceps was not made in the axis of aqueous extract of opium and one-third of the superior strait, or in that of the pelvic a grain of the extract of belladonna, and a curve; but we cannot say that the instru- broad poultice, placed over the bladder, ments were improperly used. The slow you will find to afford your patient great passage of a large head bruised the neck comfort in acute cases of catarrh. of the bladder and the urethra; as a consequence, the parts became swollen, stenosis of the urethra occurred, and she had a stoppage of the urine. Not only this, but the walls of the bladder were paralyzed by pressure; the walls of the abdomen were weakened and tired out by bearing-down pains, and so the abdominal muscles, which you know are the best and most effectual to expel the urine-being, in point of fact, the true detrusor muscles-from sheer fatigue allowed her water to accumulate.

I shall now gently examine this woman's womb. As I touch the cervix, I find a tear on the right side, extending down to the junction of the vagina. There is also a laceration on the left side, but it is not so bad as the one on the right. There are evidences here of a previous inflammation; plastic matter has been thrown out, and the vagina seems to have lost its elasticity. I wish to see now if the uterus is pressing in any way on the bladder. I find it, however, in good position; neither the fundus nor the cervix is pressing upon that organ. Often and often, after hard labors, As I find no extrinsic cause for this irriwomen are not able to empty their blad- table bladder, I am going to dilate the ders, and it is necessary to catheterize urethra. But I wish to do it with clean them. Young men, however, dislike to hands; I do not care to carry any vaginal

1

IS CONCEPTION POSSIBLE AFTER DOUBLE OVARIOTOMY. 235

discharges or other poison-germs into the bladder. So I shall use soap and a nailbrush.

The first thing to be done after the patient is completely etherized, is to pass in a uterine dilator-Ellinger's is a good one for this purpose-and gently stretch open the urethra, as I am doing. This mode of treating cystitis is a very successful one. It is, to be sure, not infallible, but succeeds in a large majority of cases. A case in which this operation failed-in fact, the worst case of cystitis I ever saw, was due to a single over-distention. The subject, a lady, had traveled a whole day in a stagecoach, and from motives of delicacy did not empty her bladder. By and by, on reaching her journey's end, she found that she could not pass her water, and had to call in a physician to draw it off. On that day troubles began which have lasted many years.

I think the most grateful man in the world is the man who has just been relieved by the catheter of over-distention of the bladder. So, on one occasion, a poor widow who had been relieved by me of an irritable bladder, insisted on giving me more than the amount of my bill.

I now withdraw the dilator and introduce my little finger, which is well-oiled. By a slight rotary motion I slowly pass it

in.

I

icles find their way thence into the Fallocaused it? There has been a slight lateral tear. In my book I say that you can dilate to the size of your forefinger. Perhaps I shonld modify that statement. have had, in one case, a loss of control of urine, but that is unusual. Now, my forefinger is of medium size. It is not large, nor yet is it particularly small. I think that if your index finger is of large size. you had better not use it as a dilator, but limit yourself to your little finger. I once operated upon a lady whose physician, in dilating the urethra, had used his thumb, by means of which the part was overstretched, and loss of control of the bladder followed.

I think that I have dilated the urethra sufficiently to introduce my forefinger. It goes in very easily, and will sufficiently stretch it. I am now able to feel the inner sufrace of the bladder, which is very much. roughened by contraction. This bladder is a pus-secreting surface, and it is denuded of its epithelium at points. I can feel granulations.

You should always take

this opportunity to examine the bladder. Rest, washing, and cleanliness are all that is now required.—Ex.

IS CONCEPTION POSSIBLE AFTER DOUBLE OVARIOTOMY ?-Dr. Boisliniere (St. Louis Courier of Med., April, '82) says that he knew of three cases where conception and safe delivery had occurred after double

I have often slightly torn the anterior margin of the meatus, and in one instance, quite a large amount of blood escaped. ovariotomy. The Fallopian tubes, or one The patient came into my hands while she of them, may remain after the operation, was pregnant. There was a slight rent of and may be connected with a portion of the meatus. I endeavored to stop the the ovarian stroma also remaining, so that bleeding by a piece of absorbent cotton ovulation and menstruation may continue. moistened with Monsel's solution, but no It is said that each ovary contains 350,000 astringent that I applied seemed to be of Graafian vesicles capable of becoming imany service, so I passed in a needle deep pregnated when they come to maturity, so down to the bone, and closed up the that a woman with both ovaries contains wound by a stitch. In pregnancy all the enough possibilities to populate a city veins in this portion of the body are en- larger than this. It is not only the stroma larged and engorged, so that the slightest that contains ova, but the ovigenic layer rent may encourage troublesome bleeding surrounding the stroma, and a part of this There is some blood here; the urine is layer might be left after the operation of slightly tinged with blood. What has double ovariotomy and the Graäfian ves

pian tube. Dr. Maughs had stated that he obstacles to the removal of the placenta, did not believe that he had removed all the or portions of it, we may desist from immeovarian tissue in his cases, and it was quite diately removing it in consequence of the possible that Dr. Engelmann had not re- condition of the patient: as, for instance, moved all the tissue, as he scooped it out in a patient hovering between life and with his hand. Then there was always the death from sudden or abrupt hæmorrhage possibility of the presence of supernumer- already arrested. In cases where bleeding ary ovaries. Of course if the Fallopian is still continuing, it would be unwisdom tubes were all removed entire, there would to wait, because the shock of operating be no opportunity for the ova to enter the will not affect the system so much as the uterus and conception would be im- the loss; whereas, if the bleeding have possible, unless the spermatozoids had been checked, besides saving the patient reached the ovary through the duct of from the shock of handling, it will be an Gartner this duct is always found in the sow, and occasionally in the human female.

advantage to wait till the shock of the hæmorrhage has passed off, and the general balance of the circulation is restored, and the heart has received blood from the outlying smaller vessels of the extremities, etc.

A certain number of cases of retained portions or whole of the placenta having Occurred to me, I have thought it may be useful to give a brief account of some of them, in order to show that, whenever the removal of the placenta is not carried out,

REMARKS ON CASES IN WHICH THE WHOLE OR PART OF THE PLACENTA WAS RETAINED FOR A LONGER PERIOD THAN USUAL AFTER DELIVERY OF THE CHILD: REMOVAL OF THE RETAINED PORTION BY HAND, WITH REMARKS. By J. BRAXTON HICKS, M.D. Lond., F.R.S., F.R.C.P., etc., Obstetric-Physician and Lecturer at Guy's Hospital, etc.-Lancet. a very proximate and positive danger is The very important rule, of long standing that the placenta, if retained, should always be removed, is now, almost without exception, so implicitly followed, that its great value can scarcely be fully realized Certain conditions, however, do from time to time arise, where it is very difficult, and in some instances impossible, to follow this rule absolutely; and some cases occur in which there has been a difficulty in recognizing the fact, that either a fragment has remained behind, or a secondary lobule has been formed outside the area of the apparently normal placenta.

impending. I have not included cases of abortion before the fourth month; but in all cases, at all periods of pregnancy, I consider the rule above referred to holds good-namely, to endeavor to remove the portion of placenta retained. Yet, in abortions, if the os uteri have contracted rigidly, it may be wise to wait a day or two to see what nature may do; for I have seen the placenta expelled the day after vigorous, though ineffectual, attempts at removal had been made, and this, no doubt, is the experience of many practitioners; but, having also seen, not only severe and proThe circumstances which will prevent tracted hæmorrhages, but still worse, many our removing the placenta, or portions of times, fatal pyæmia follow on the detention it, are either the firm closure of the uterus, of the secundines in both early and late or the firmness of the adhesion. It is gen- abortions, I consider it safer by far if, after erally in cases of premature expulsion of waiting a day or two without result, we the fœtus that the uterus closes so firmly pass a sponge-tent, or some form of dilator, as to prevent our entering. Seldom it is in and remove the adherent portion. After the fully developed organ that we are una- the fourth month or so, the os is more dilable, at any rate with the assistance of table; and, generally speaking, we may chloroform, to pass our hand sufficiently enter two or more fingers, without much far to empty the uterus. Besides these trouble, with or without dilatation. In all

It

cases, greater facility is obtained by the and extending amongst the villi-which are assistance of an anesthetic. occasionally met with at the seat of the adMost of the cases here related were hesion. It is better to gently detach all attended by what has been called "secon- the healthier parts, and to bruise down with dary hæmorrhage;" and in all the cases of the finger tips all the softer portions besecondary hæmorrhage I have attended, tween the nodules, and then to remove the two only were not owing to the presence of loosened pieces, than to forcibly tear away the whole or a portion of the placenta. the nodules or the firmly attached stems of These I have added at the end of this the villi. If we leave these behind, they paper. And, again, in all the cases of re- do not putrefy, but slowly disintegrate. tained placenta, offensive discharges were s best to wash out the uterus, after the present, except in one. Hence, in cases of above process, with either a weak solution hæmorrhage occurring during the puerperal of iron or with some disinfectant; and to state, coupled with offensive discharges, repeat the latter every day for some days we may expect to find a portion of pla- The danger is great if we remove the nodules; we shall probably pull off some portion of the uterine tissue, and a fatal hæmorrhage will be the probable result. I have seen such a case.

centa.

In cases indeed of sharp and severe hæmorrhage, without offensive discharge, it is safest to explore the uterus; and, even where the hæmorrhage is not severe, yet repeated and fresh, it will be best to explore; and if continued offensive discharges occur, with or without hæmorrhages, it is also well to explore the cavity of the uterus. We shall be the more urged to carry out this, if, in addition, we find the patient feverish.

If difficulty be found for the finger to reach the fundus, though this is more common in premature expulsion than in delivery at full term, I need hardly remind my hearers that the hand, placed on the uterus, above the pubis, will generally bring down the fundus on to the tips of the fingers, and every portion of the cavity will be brought thus within its reach.

One remarkable case of secondary hæmorrhage was told me by the medical attendant, where, at the first monthly period after delivery, so much hæmorrhage occurred, and such a relaxed state of the uterus was present, that he was able to pass his hand into the uterus and remove the clots which filled it to the size of "a seven months' conception." There was in this case no remnant of placenta.

In our endeavors to remove the placenta or its fragments, it is never wise to remove the hard nodules-the products of an effusion between the uterus and the serotina

CASE I. Retained Placenta; Death from Hæmorrhage Fifteen Hours Afterwards.— This was a case attended by a most incompetent person, who permitted the placenta to remain in the uterus without any attempt to remove it. The patient had had a natural labor, but the placenta remained in utero, for what reason I could not find out

certainly it was not adherent. I was asked to see her twelve hours afterwards. She was nearly dead from loss of blood, which was still going on freely, and the discharges were already offensive. I passed my hand into the vagina, and without difficulty withdrew the placenta, which was still partially in the uterus. The placenta was quite offensive. She sank two or three hours afterwards.

CASE II. Complete Adhesion of Placenta at Abortion at Four Months' Pregnancy : Retained a week: Secondary Hemorrhage.-I was asked to see a woman who had borne five children, who had between the fourth and fifth months' pregnancy, suddenly expelled the fœtus, followed by a rather sharp hæmorrhage. Her medical man attempted to remove the placenta, but he found it impossible from the closed state of the os After much trial, he sent for me. I endeavored to pass one finger; but the passage was closed so firmly, that, even assisted by

firm counter-pressure from above, I could in every direction. I therefore pushed my

not succeed. She objected to take chloro- finger through the center of the placenta form; and, as hæmorrhage had ceased, it till I arrived at the uterine wall, the diswas agreed to wait, in hopes that the uterus tinction there being plain enough. Starting might relax and expel the placenta. Six from this, I separated the placenta till I days had elapsed when I was suddenly arrived at the margin, which then was not summoned to her, a most violent hæmor- very difficult to separate. I found the rhage having occurred. I found her membranes very firmly adherent, but deblanched, half collapsed, and torpid from tached them by care. But little bleeding anæmia. The os was more patent than occurred during the removal. She recovbefore; I could pass one finger through ered well afterwards. She came into the and feel the placenta. I found it, however, hospital to be delivered at her next as fixed as possible, very solid, and alto- labor. The same condition existed, gether tougher than normal. I could not but was not quite SO severe. At detach it in the usual way. I could only the third labor she was again admitted, and make an impression on it by pressing the so much hemorrhage occurred that I fundus down on to the tip of the finger thought she would die before I could reinside the uterus, and then break it up by fretting it away bit by bit, till by the same manœuvre I had brought every portion of the inner surface into contact with the finger. This, of course, was a work of much time The fragments were removed from the uterus. She recovered slowly from the anæmia, with some slight inflammation of the left femoral vein.

move the placenta, which was adherent as before. On the removal, however, the bleeding ceased. At the fourth labor there was but little trouble; but the fifth was similar to the first in character. Neither upon the placentæ nor their fragments was any sign of inflammatory change to be perceived, nor could any nodules be felt on the uterine surface at the time of their removal, nor any sign of inflammation of the chorion. It appears to me that the condition which gave us so much trouble was an imperfection of the natural process, by which the decidual membranes are shed from the uterine surface and fixed on the ovular membranes. This seemed retarded, and equivalent to the condition of two or three months' pregnancy.

CASE III. Complete and most Firm but Simple Adhesion of Placenta, at Full Term in Four out of Five Labors: Recovery.A primipara patient of Guy's maternity was delivered of the child, but the placenta did not follow, and the student in charge not being able to manage the case, sent for me. Three hours had elapsed before I saw her, without, however, any hæmorrhage. I attempted removal, but found it impossible CASE IV. Secondary Hemorrhage: Ad to distinguish the margin of the placenta herent Placenta: Portion of Placenta Refrom the uterine wall. Her surroundings maining after Removal of Greater Part: not being favorable for treatment, I had Recovery.--I was asked to see a lady, deher brought into the hospital. This was livered twenty-four hours; a constant and done; and, as no bleeding had occurred, free blood-loss had continued ever since, I waited to see what nature would do, and her medical attendant was anxious lest leaving instructions to send for me on the there were a portion of placenta remaining slightest occurrence of bleeding. About in the uterus. The labor, he said, was a twenty-four hours afterwards, some slight languid one, and when the child was born uterine action occurred, and with it some the uterus did not contract well, the plaloss of blood. I proceeded therefore to centa remaining within it. Friction, etc., remove the placenta. Passing my hand to remove it in the usual way, I found the same difficulty of distinguishing the margin

were employed, but hæmorrhage was the only response. He therefore proceeded to remove the placenta, but found it adherent