opened another at the extreme right of the vagina, she being anesthetized each time. Her temperature kept up all of this time, and just here she began to complain of pain above the brim of the pelvis in the left lumbar region. By bimanual examination a small enlargement could be felt high up in the pelvis. In about three days. this could be detected through the abdominal wall, which gradually enlarged. I then advised that she be brought to Atlanta, which was done, and she was placed in the Tabernacle Infirmary. The following morning the abdomen was opened directly over this enlargement, which was just above the brim of the pelvis. Upon cutting through the abdominal wall it was found that adhesions separated this enlargement from the peritoneal cavity. The left tube could be traced up to this mass, much thickened and inflamed. Upon opening this abscess, it was found full of very offensive pus. The cavity was thoroughly flushed with salt solution. Three rubber drainage tubes were left in and dressings applied, patient placed in bed on her side to keep up drainage. The external dressings had to be changed every few hours for the first three or four days. At this time I found another abscess between the bladder and vaginal wall, which was opened and drained. This case was treated with the normal salt solution, as suggested. She was confined to her bed in the hospital two months and ten days, when she was dismissed in good condition. I am informed that she is again pregnant.

Finally, the points that I wish to especially stress in this paper are:

First. The careful preparation of the bed and the wo-man before the birth of the child, with especial attention to hands and careful examination of the placenta and membranes.

Second. After birth of the child careful examination of perineum for tears, and if they are present repair them

at once.

Third. That in case there is a rise of temperature, that you should start at once with treatment.

Fourth. The importance of making careful digital examinations and the use of the dull irrigating curette early, where the temperature is not reduced by douches. The importance of the normal salt solution to dilute the toxines and aid absorption, and the strengths of bichloride solutions.

Fifth. The preference of tube drainage over gauze in these conditions, and the absolute avoidance of gauze in the uterus after curetting.

Sixth. The importance of opening and draining the abscesses as they form in the pelvis or any pelvic organ.

IMPORTANCE OF PROMPTLY REPAIRING LACERATIONS OF THE FEMALE GENERATIVE ORGANS AFTER LABOR.

By E. C. DAVIS, M.D., ATLANTA.

Having been forcibly impressed by the great number of women daily crowding our hospitals seeking relief for lacerations of the generative organs and their sequelæ, I have been constrained to direct your special attention to the importance of recognizing these conditions and promptly relieving them before almost irreparable damage has resulted, or before it has become necessary to sacrifice some of the appendages in order to restore the suffering to health. There are few subjects more important to the general practitioner than this, or that should be given more careful consideration, for upon his care at this time depends both life and the subsequent health of the unsuspecting patient.

Some lacerations occur with practically all primipara, these varying from a simple solution of the continuity of the mucous membrane to a tear entirely through the sphincter and into the rectum. They may be so superficial and trivial as to require no treatment except a careful avoidance of infection, or they may require the highest possible degree of skill, in order that they may be restored approximately to their original conditions. Many now present can recall the oft-repeated remark of the venerated old teacher of obstetrics, who annually proclaimed to his class that "in the many years of practice and in the hun(201)

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dreds of labors he had attended, he had never had a lacerated perineum." Unfortunately, several now present have had to repair lacerations in his patients in later years, overlooked by him. Between 25 and 35 per cent. of primipara are lacerated sufficiently to require attention after delivery. In multipara the proportion is markedly diminished, but even with them, approximately 10 to 15 per cent. will be found requiring surgical attention. The reason why lacerations are not attended to often is that the physician is worn out from prolonged attention, perhaps all night or longer, and, in addition, the patient is at home, with surroundings not conducive to aseptic surgical work, and in such instances it is often wiser to defer operative relief until suitable surroundings can be procured for a reasonable hope of success. Again, many physicians seem to forget that the anterior surface of the vaginal vault and contiguous tissues are prone to traumatic injuries and need surgical attention. As to lacerations of the cervix, I must confess that unless the tear is high up and some large blood-vessel invaded, I usually wait a reasonable time for involution to begin, and determine then the extent of the laceration and the needs for repair.

My usual plan to detect lacerations is to examine the atient carefully after delivery, and again when patient has been cleansed by the nurse; then if I find lacerations of the perineum or vagina to make proper repairs at this time. From four to six weeks after delivery I instruct my patients that they should again be examined, to determine whether there are any lacerations of the cervix, and to again see the results of the operations on the perineum, if any have been performed, and if there be existing lacerations to have them properly attended to at this time.

As to the prevention of lacerations, much can often be done if you can gain the perfect confidence of your pa

tient, and have her carry out your orders carefully. You should begin some months before the time of expected confinement, and advise her carefully about diet, exercise, baths, etc. To enter upon this is unnecessary before this body of physicians. The market is flooded with cheap oils, said to be specifics for easy and normal labors without lacerations, and inasmuch as one woman who used some special oil has had an easy time, she recommends it to all of her friends. These things we know have no virtue above that of a good massage with pure olive oil, and instead are often dirty, rancid and irritating oils, making the patient unclean and causing micro-organisms to adhere that would otherwise be easily removed. At the time of delivery we have valuable means of assistance at hand to avoid these occurrences in ether and chloroform and in manual resistance to the too rapidly descending head. Watch carefully the descent of the head and see that this is retarded until the maternal parts are dilated, and will permit the easy escape of the fetus. If the descent promises to be too rapid, I do not hesitate to have my patient inhale a little chloroform or ether, thereby in a measure controlling the pains as I wish. In cases in which the perineum shows that it will be torn, I unhesitatingly make lateral incisions in the vagina, in order to enlarge the opening of escape. These can readily be closed after delivery. Again, all supports to the perineum are worthless, but by simply pushing up the head over the perineum and under the pubic arch, much can often be accomplished toward the preservation of the perineum. Above all things, do not allow the head to escape until the perineum has been thinned and the parts dilated and dilatable. After the delivery of the head, in broad-shouldered children, we must watch that the shoulders do not increase a tear and convert a slight one into an extensive