costal pleura back into the thorax against the lung-which at every inspiration bulged far out into the wound—and working gradually down over the right anterior aspect of the ninth dorsal vertebræ, the forceps finally grasped the ball and it was withdrawn.

Of course the costal pleura was opened by the ball as it entered, so that there was a free communication between the pleural sack and the wound. Hemorrhage was well controlled, the patient lying on the left side,—the deeper tissues were closed by catgut, the skin with silkworm. The patient rallied well; the wound healed through most of its extent by first intention; the later removal of a spicule of bone, evidently from the end of a re-sected rib, was promptly followed by complete union.

My theory had been that if the pressure of the ball caused the nervous symptoms, its removal would do away with that source of irritation al least. But if the ball had driven splinters of bone into the cord, or caused a clot to press upon it, or from its impact had caused serious injury to the nerve fibres, there might remain a greater or less number of symptoms unrelieved. The subsequent history has confirmed the fear of other sources of nerve injury beside the pressure of the ball alone. While the symptoms changed in varying degrees after the formidable operation, the function of the cord has not returned at this date, May 17, 1898.

Doubtless if a trephining could have been performed at the same time, or even later, there might have been a possibility of further relief, but the woman passed out of my hands January 1, 1898, and nothing of a surgical character has since been attempted.

The case is worthy of record because it is interesting as a study to both the neurologist and surgeon. It confirmed the possibility of reaching the spine, for surgical operation, from the thoracic aspect and ought to suggest means of relief in such chronic conditions as Potts' disease and other spinal injuries and defirmities, besides the now common operation of trephining from the rear.

TWO CASES FROM PRACTICE.

D. W. HORNING, M. D.

MINNEAPOLIS, MINN.

A large part of our accumulated knowledge is drawn from the every-day, practical experience of ourselves and others. We rest in confidence on methods or therapeutics which we have successfully employed, or which have been so employed by others whom we admit to be acknowledged authority. We read clinical articles in our magazines, or listen to papers read at our various medical associations and institutes, and note how all record the unusual success of some operative or mechanical method or the rapid curative action of some therapeutic agent in given cases. While reading or listening, the elder in practice gives himself a self-congratulatory shake as he recalls similar successes of his own, or, perhaps, considers his own cases as one better in success than those of the narrator. On the other hand the young practitioner attempts to store the facts in his memory for future use, with the self-admonition to go thou and do likewise. May it not be that the careful report of partial or total failures will be fully as instructive, since after-sight is often clearer than fore-sight. From our failures may we not learn at what point, and in what manner, a possible failure may be changed to success, or avoid needless apprehension and anxiety because we find seemingly untoward conditions do not result in disaster.

As obstetricans we are advised that we should be so well informed, so accurate in judgment and so proficient in tactile sense that we are able to determine absolutely and exactly every position and conformation of the presenting child; every feature of pelvis or tissue that might retard delivery. This is a high ideal for which we should undoubtedly strive, but we fear many of us fall far short of its realization. Because of failure in some respects, we report the following:

Mrs. C., primipara, aged 23 years, had passed through her period of pregnacy with comparative comfort, and came to her confinement in the best of condition. She had been having quite regular pains for several hours previous to the time at which I was summoned. Examination showed

the os uteri far back and quite high in the pelvis, dilated to about the size of a half-dollar, the tissues soft and yielding. The presentation was determined as right occipito anterior. The curve of the presenting part, the dimensions of the pelvis, the condition of the os, and the character of the pains led me to anticipate a comparatively short labor, therefore, no interference was offered for several hours. At the next examination the os was more widely dilated and more accessible, but the head did not seem to crowd into it during a pain to the extent we would expect, but as the case was advancing, though somewhat slowly, we again waited for further progress. During this time the pains continued of good strength, but not so severe as to exhaust the patient. At the next examination, about two hours later, there had been marked descent, but not the radical result we would expect from the character of the pains, and in order to obtain greater expulsive force the sac was ruptured and a small quantity of fluid was discharged. Within half an hour we examined again to determine the effect of several rapidly occurring and energetic pains. During the interval the head seemed to retract to an extreme extent, leaving the os wholly flaccid. During a pain the anterior lip did not retract properly, and to add to my discomfort the presenting part seemed like a very blunt edge. My first efforts were toward retracting and dilating the anterior lip, in the meantime considering what could give such an outline to the presenting part. Becoming convinced that some part of the cranial vault was in advance, and having some success with the anterior lip I allowed an interval of rest, hoping the natural forces would take care of that lip, as well as of the other parts. In this I was disappointed, as while the head, or whatever it was that was advancing, had passed well around the curve of the sacrum, the lip

had returned to its former position. By using two and three fingres I drew it forward and upward, and held it above the inferior surface of the pubic arch, maintaining the support for nearly half an hour, only to find the effort utterly useless. By this time the presenting part came well down toward the vulva during a pain, without much pressure on the perineum, but the amount of retrogression, when the pain ceased, was so great that it seemed as if there must be some force or body acting against the expulsive effort. Considering the length of time during which there had been good, but only partially effective pains, the possibility of getting too long and undue pressure of the anterior lip under the pubic arch, the shape and action of the presenting part, we applied the forceps and soon delivered a living child, but also produced a lateral perineal laceration.

We naturally were anxious to know the cause of the delays and uncertainties of the confinement, and at the earliest moment examined the child. The head told part of the story at once. The blunt edge, which had caused so much uncertainty, crossed the vertex from side to side, terminaring a little in front of where the parietal protruberance should have been. From this ridge or edge, was a plane which passed downward anteriorly to the lower border of the broad and flat chin, and a second one extended posteriorly from the same point down to the junction of the occiput with the spine, and from this you will get a fair picture of that child's head. This perfect wedge readily explained why the anterior lip did not retract or remain retracted when made to do so mechanically, since there was no occipital ridge to hold it. The unusual retrogression was the result of the natural contractility of the tissues acting against the faces of the wedge anteriorly and posteriorly when the vis a tergo was removed, forcing the body backward and upward. With the exception of the head, the child was perfect, and within a week it had regained a normal shape. We have examined the mother several times since the confinement, but so far have

failed to locate anything, in or about the pelvis, to account for the peculiar shape of the child's head, and yet we feel certain that it was produced during the time of labor. the time I failed to detect anything to cause delay or anxiety, but I had plenty of both. I failed, during the later stages, to determine what exact part was presenting, or what sort of being would reward my efforts, but as success was the issue for both mother and child, another similar case will be watched with far less disturbance to myself, much more confidence as to the means to adopt and greater assurance as to results.

Before closing I will present another case, not as illustrating any lack of skill on the part of the operator, but simply to exhibit a peculiar condition attended with ill results. Mrs. J., in her fourth pregnancy; was of an extremely nervous temperament; and her surroundings were of such a character as to increase her natural tendency. She had progressed to somewhat over the sixth month with no unusual conditions, other than the extremely active movements of the child. If we grant that a pronounced temperament, tendencies and activities of a prospective mother will induce like characters in a child in utero, the vigorous movements in this case will be easily understood. At about the time mentioned, the mother became painfully conscious of even more than the usual commotion within the abdomen and uterus. The disturbance continued for about two days when she soon became aware that all movement had ceased, and there was a sense of weight and coldness in the abdomen. Within forty-eight hours from this time, labor pains came on, and the delivery of a dead child was accomplished. Examination showed the child perpectly developed for the time of the pregnancy, and its surface apparently healthy, but the evidence of the cause of death was plainly in the funis. There were no coils of the cord about the body or neck of the child, but it was twisted and knotted upon itself. With abundance of room in utero, a large amount of amniotic fluid, one end of the cord firmly implanted in the placenta and the other attach