was

the case with me, to consider the question of inducing labor. We found the patient having a copious flow of blood. The os slightly dilated and was completely covered by the placenta. The woman had no pain but was becoming faint from loss of blood. We decided to bring on labor at once. The patient was etherized, and the os dilated and three fingers passed through the substance of the placenta and found the fetus lying across the transverse axis of the brim of the pel vis. I succeeded in bringing down one foot and proceeded to deliver. There was no difficulty until the head became engaged, and it was with the greatest effort that we were able to extract it. The child was still-born owing to the length of time we were in extracting the head. We then delivered the placenta The uterus at once became firm

with ease. and hard.

The points of interest in this case were to me the central implantation of the placenta. Second, the fact that the hemorrhage began so early in pregnancy. Third, the difficulty in delivering the head, which I think was due to the placenta so filling up the pelvis that the diameters were so reduced as to materially retard the delivery of the head.

DR. LONGAKER remarked that the most favorable statistics show from forty to fortyfive per cent of children saved. Hemorrhage early in the pregnancy usually indicates a central implantation of the placenta and labor should be induced early in such cases. Immediate delivery by traction on the leg is to be condemned. The breech is a perfect. tampon and after one leg is brought through the placenta the case must be left to nature. The hand should not be passed into the uterus, but the placenta should be perforated by one or two fingers and bi-polar version effected. If traction on the leg and rapid delivery be effected a bad presentation of the head at the superior strait will result, and the cervix will not be sufficiently dilated by the body to allow the head to pass quickly, and the child becomes asphyxiated. The average result of rapid delivery is unfavorale. The maternal mortality is from ten to forty per cent.

DR. HAMILL did not think the delivery in his case too rapid, traction on the leg was made because nature was exhausted and was not able to deliver the child without assistance.

ACUTE PNEUMONIA IN UTERO. DR. B. C. HINST exhibited the specimens, and remarked that pneumonia during intrauterine life is rare but it has been observed: Dr. Stischan of Australia, Brit. Med. Jour. 1886, II p. 860, has reported a case and Dr. Sigl of Germany. Arch. f. Gynaek. Bd. xv. s.

384, has collected three others. Sigl's explanation is undoubtedly the correct one for this occurrence. If the fetal blood is not properly aerated, the respiratory center in the brain is stimulated to action by the excess of carbonic acid gas in the blood and the fetus makes inspiratory efforts, drawing into its lungs amniotic fluid, containing in these cases possibly meconeum, and a catarrhal pneumonia is the result ending usually in the death of the fetus, either in utero or shortly after birth. These cases are to be distinguished from these in which the fetus draws, into its lungs, amniotic fluid, mucus and blood during labor. The specimen which I exhibited to the society, has the following history. These lungs were taken from an infant which died twenty-two hours after birth, having been cyanosed from the first. The mother had had a large lumbar abscess for the past year, and when she came under my observation in the Philadelphia Hospital, in the sixth month of preg. nancy, exhibited all the signs of general septicemia. She gave birth to her child at the seventh month of gestation. The post mortem examination of the infant showed other cause for death except the pneumonia involving both lungs, which must have arisen in utero, as the labor was easy and rapid, and there was no reason to believe that the child made inspiratory efforts during its expulsion. The microscopic slides which are exhibited confirm the diagnosis. They show well marked catarrhal pneumonia.

DR. HIRST also exhibited an

ECTRO MELIC MONSTER.

no

This fetus expelled in the fifth month presents, if one adheres strictly to the classifica. tion of Geoff. St. Hilaire, is only a deformity by numerical diminution, consisting in the absence of the left femur and four toes of the left foot. Its appearance, however, is certainly monstrous, and I have ventured to classify it among the ectro-melic monsters (ectromelic-aborted limb).

DR. J. C. DACOSTA narrated a case of RAPID DEVELOPMENT OF A FIBRO-SARCOMA OF THE UTErus.

The patient came under his care three years ago for catarrhal metritis, the uterus being sharply retro-flexed, and the posterior wall being bulged as if an interstitial fibroid were present. These conditions were all cured by the use of sponge tents. About the middle of last May she was attacked with a profuse metrorrhagia lasting ten or twelve days; fungous vegetations were removed by means of the curette. The June period occurred normally on the 22, but a recurrence of the bulging in the posterior wall was noticed. She went to

the seashore, but returned on July 22, worn out, thin, and with white, anemic lips. She had had a sanious discharge from the vagina for the last twelve days. Her condition had been diagnosticated at the shore as "fibroid and ulcerated cervix." The os was large as a five cent nickel. The cervix was filled with a pultaceous mass which was extruded by the free use of ergot. On July 25, Dr. DaCosta❘ removed, from the body of the uterus, a tumor three inches long by two inches thick, a fibro-sarcoma, which had grown inside of thirty days. The patient recovered rapidly. DR. DRYSDALE thought this very rapid. These tumors were likely to recur.

DR. JOSEPH PRICE exhibited a specimen of ABSCESS OF BOTH OVARIES.

In his experience it has been a common condition. He has operated in four such cases within three months. This case had escaped unoperated upon from Birmingham. Pus was present in both tubes. The operation was a complete enucleation without ligation.

DR. PRICE exhibited a "cotton rope" or wick which he used in drainage tubes. It becomes filled with blood, serum, etc., and is replaced with a clean one two or three times a day. It keeps the openings clear and favors discharge of fluids.

W. II. II. GITHENS, Sec'y.

SELECTIONS.

AN ADDRESS.

BY ARTHUR V. MACAN, M. B. Master of the Rotunda Lying-in Hospital, Dublin; President of the Section.

Delivered at the Opening of the Section of Obstetric Medicine, at the Annual Meeting of the British Medical Association held in Dublin, August, 1887.

[CONCLUDED.]

The next point I would like to bring under your notice is our method of conducting the third stage of labor. As soon as the child's head is born the left hand is placed on the fundus, the ulnar edge being directed towards the vertebral column with the palm of the hand looking directly in the axis of the uterus. The child's eyes are then carefully wiped, and a finger is passed into the vagina to see if the cord be round the child's neck. If uterine action does not soon expel the child, or if it should make any effort at inspiration, showing a want of aeration of its blood, then pressure is made on the fundus, which is gener

ally sufficient to cause the body of the child to be expelled. If it does not do so, then gentle pressure is exerted on the child's head so as to push it backward against the perineum till the anterior shoulder descends with a well-marked jerk past the pubes, and the delivery is readily terninated by pressure over the fundus. As the child leaves the uterus the left hand follows down the fundus, and causes any liquor amnii that is still in the uterus to be expelled. The position of the hand must now be the same as before the child was born, that is to say, the ulnar edge must be directed backward against the wo man's spine, and the fundus should be pressed, if anything, forward against the pubes. The whole hand is now gently rotated, so that the tips of the fingers irritate the posterior surface and sides of the uterus, and more especially the points of insertion of the round ligaments. We can then follow and watch

over the alternate contractions and relaxations of the uterus, and judge whether it is becoming unduly distended with blood or not. In the meantime the nurse steadily ties the cord as soon as all pulsations in it have ceased, and then the uterus is never for a moment out of the direct observation of the msdical man in charge of the case. Should the child be bodily asphyxiated, that is, in a state of white asphyxia, the nurse should tie and cut the cord at once, and then take charge of the fundus of the uterus, while the medical man takes charge of the infant. When there is any considerable tendency to post-partum hemorrhage it becomes a very nice question whether the medical man should direct his efforts to resuscitating the infant or the stopping the post-partum hemorrhage. In any case of doubt the mother's care demands our first attention. If the discharge of blood re mains moderate, and there is no accumulation taking place into the uterus, we use gentle friction at intervals for fifteen minutes, and then make firm pressure on the fundus in the axis of the brim during the acme of a contraction. This is nearly always sufficient to expel the placenta both from the uterus and from the vagina. The hand still, however commands the fundus, and friction is again applied when we feel the uterine contraction beginning to relax. Should this interval of relaxation pass without any hemorrhage, then we wait for the next contraction, and apply the binder during its continuance. After the binder is applied the woman again turns on her back, and the hand is rubbed backwards and forward over the fundus till it is found to be in such a state of permanent retraction as

to exclude all danger of post-partum hemorrhage.

This is our method at the present time in the Rotunda Hospital, and it has, in all its essential points, been the practice of the hospital for many generations. Thus Dr. McClintock, when writing on this subject in his edition of Smellie's Midwifery says: "Following down the uterus with the hand, as the fetus is being born, and keeping up the pressure until the placenta is expelled and the binder applied, has been the course pursued in the Dublin Lying-in Hospital since the mastership of Joseph Clarke (1786-1793), and is now almost universally followed by all educated practitioners," (McClintock's edition of Smellie's Midwifery, vol. i, p. 236.)

A curious confirmation of this systematic use of pressure to expel the placenta has lately come under my own observation. For on looking over Dr. Charles Johnson's wardbooks I find, after a large number of cases entered as hemorrhage before the expulsion of the placenta, the whole treatment, compressed into the short and expressive formula the "Placenta pressed off." And so fully was this looked on as the ordinary treatment of the hospital that nowhere are any directions given as to how this is to be done. This was in the year 1843. A further point that I would wish to emphasize is that when the late Professor Spiegelberg visited the United King. dom in 1855, the points that struck him most in all that he saw were the use of chloroform in Edinburgh, and the method of conducting the third stage of labor in the Rotunda Hos pital. I give this on the authority of the present Professor Leopold, of Dresden. (Archiv f. Gynakologie, vol. xviii, p. 349.) Indeed, if we consult Spiegelberg's book on midwifery, we will find that he accurately discriminates between the then lately introduced method of Credé and the Dublin method, and gives his verdict entirely in favor of the latter. The late Professor Schroeder also, whose book on midwifery has gone through eight editions, and is the one universally read by students in Germany, accurately distinguishes the two methods, and adopts entirely the Dublin method. We have, then, the curious anomaly that whereas in Germany the highest authorities are in favor of the Dublin method, in the latest English textbooks the writers recommend Crede's method, or rather, I should say, while describing and recommending the Dublin method, call it Crede's method. As an Irishman, and as the present Master of the Rotunda Hospital, I cannot but hope that after this meeting of the British Medical Association we may find this

mistake corrected, and that, in future, this method may be known, after the town in which it first saw light; as the "Dublin" method.

This subject, which is, to me, a most interesting one has occupied so much space that a few words must suffice to draw your attention to our method of practising the "bimanual examination" of the female genital organs. And first let me protest against such terms as "brutal" or "indecent" being applied to any method of examination which has been adopted by the large majority of educated gynecologists of various nationalities as being the right one. Such terms, to say the least of it, savor somewhat of the legal principle, that when your have no case you must blackguard the opposite attorney; and there is also, in my mind, a strong presumption that those who make use of then do not themselves appreciate what the thereby condemned method has done for gynecology. It is not too much to say that this method of practicing bimanual examination has regenerated modern gyne cology, and raised the whole standard of diagnosis.

If we are agreed on this point, the only question remaining to be settled is how this method can be most accurately practice with least discomfort to practitioner or patient. We think that the method which best fulfils both these conditions is the examination on the back, the patient's feet being supported by suitable rest, another practitioner standing, so to speak, between her knees. One point that should not be lost sight of is, that the easier it is for the practi tioner to make the examination, the less suffering will such examination entail on the patient. The only argument that should be of any weight in considering this question is whether by this method greater ease or accuracy in diagnosis is obtained than by examining a patient on the side; and in answering this question, it is not sufficient for one or two specialists to come forward and declare that they can find out everything that can possibly be found out by examining the patient on the side, and that, therefore, the position on the back should be discarded. Even if this were true, which I must claim the privilege of doubting, it would not settle the question; for not only must we consider the final possibilities of any method of examination, but we must also consider the relative amount of experience and education each method requires to bring it to perfection; and, in comparing the two methods, those of us who advocate the examination on the back

have, at all events, this advantage over those

that we have tried both methods, while all who examin on the side, our opponents can claim is that they find no occasion to make any change. It would, It would, indeed. I think, be evident, from an unprejudiced survey of the mere mechanics of the question, that that position should be chosen which enables you to examine both halves of the pelvis equally; and this it can never be claimed that the examination on the left side does.

That the adoption of this method of cxamination on the back has led to enormously increased accuracy and minuteness of diagnosis must be apparent to anyone who has followed the course of modern gynecology both at home and abroad. Thus the determination of the normal position of the neterus, the palpation of the ovaries and their ligaments, as also of the posterior uterine liga ment and the normal Fallopian tubes, havein my opinion, by this method been rendered possi ble. That such accuracy of diagnosis is, how ever, still very rare in this country, may be gathered from a perusal of the ordinary periodical gynecological literature, in which snch a diagnosis as the exact size, shape, consis tence, tenderness, position, and mobility of the normal ovaries is rarely ventured on' though such expressions as "ovaries normal,', or "ovaries tender," are not uncommon. Indeed, except in such an assemblage of specialists as the presen the statement that one was able topalpate the normal posterior ligaments of the uterus, and trace the normal Fallopian tubes and round ligaments out wards for a considera-ble distance from each cornu of the uterus, and in cases of pregnancy trace of the course the ureters passing along the side of the cervix, to be lost above in the broad ligament, would be received with a smile of complacent incredulity. There is one point that I would like to emphasize, and that is that it is the position on the bac that renders some of the most imporoved modern treatments, such as the washing out the uterus in cases of endometritis, and the use of constant antiseptic irrigation in all operations on the cervix, vag ina, and perineum possible.

Here let me express my conviction, founded now on a considerable experience, that the enormous difficulties inseparable both to the teacher of imparting, and to the student of acquiring, an accurate knowledge of the diseases peculiar to women are materially lessened by the bimanual examination being made while the patient is lying on the back and the practitioner standing in front of her. In conclusion, allow me again to invite any member of the Association who may desire it to visit the Rotunda Hospital during his stay

in Dublin, and to assure him of a hearty welcome from myself and my assistants. -Brit. Med. Journal.

WITZEL OF INJURIES ON TENDONS AND THEIR TREATMENT.

A very complete study of the injuries of tendons and their proper treatment has been made by Dr. Oscar Witzel, and we give a brief résumé of his views. The greater part of injuries of tendons are complicated with wounds, and yet isolated cases of subcutaneous rupture of tendons do occur. Witzel thinks that there is always some pathological change in the tendon in these cases. previous tendo synovitis may cause the infil. tration of the tendon with serum, the tendon may be partly worn and raveled in hydrops of the sheath, or reduced to a third or a quarter of its diameter in hydrops with lipomatous degeneration of the sheath.

Α

The actual rupture may be caused by vigorous muscular action, but it is probably more frequently due to overextension of the tendon and its usually weakened muscle. Hence in every case of sprain of a joint, the examina tion should be sufficiently thorough to exclude this injury. The situation of the rupture can be detected by the finger, feeling the step-like gap between the ends of the tenden, as after tenotomy, the interval being filled with a soft clot of blood, which may give a crackling sen sation to the finger. The chief symptom will be loss of function in the muscle the tendon of which is ruptured. If the ends can be brought into close contact, and care is taken during the treatment that they remain in ap position, union may be confidently expected. If the ends can not be approximated by manipulation of the limb, incision and suture are indicated, as in fracture of the patella and olecranon. But it will be best to delay the operation until the first inflammatory reaction has passed, so as to avoid the presence of blood, so easily made septic in the sheath of the tendon.

One feature common to nearly all wounds with injury of tendons, is that they are directed more or less transverse to the axis of the limb and to the course of the tendon. The character of the instrument is of great importance, for clean-cut wounds heal much more rapidly than wounds with contused and lacerated edges, but the most important element is presence or absence of septic matter.

The prognosis is very uncertain and chiefly depends upon the condition of the wound with

regard to sepsis at the time when it first comes under treatment.

Secondary necrosis of parts of the tendon may follow if suppuration takes place, but this is much less likely to occur, or at least to be extensive, if the suppuration is not septic. As it is impossible to determine how septic the wound may be, if there is any doubt upon this point, the wound should be left open, since the amount of injury caused by the suppuration will be diminished by allowing free escape to the discharge. This must also be done if the tendon has suffered much contusion. Suture of the tendon can not be attempted in these cases, but an operation for suture can be done later, when the wound is granulating well, and all septic infection has disappeared (intermediate suture), or when the wound has entirely cicatrized (secondary suture).

That extensive exposure and isolation of a tendon in a wound will be followed by its mortification, is an old teaching. But if the wound is aseptic, gangrene will not occur so long as the nourishing covering of the tendon remains, and the blood-supply is maintained. If the blood-supply is cut off, the isolated part dries up, turns gray, and is thrown off by granulation of the edges.

Simple division of a tendon by incision is a small matter, for experience teaches that the uivided ends rapidly unite if kept in contact, dniting by first intention like other tissues. The material for this union appears to be supplied rather by the sheath than by the tissue of the tendon, and the two ends are joined by a mass of callus (like a fractured bone) which is at first adherent to the neighboring parts. These adhesions are separated by motion, and the exuberant callus wears off by friction, so that the point of union can not be detected even by a longitudinal section of the tendon.

The great difficulty in injuries of tendons. lies in the retraction of the divided ends-a separation which is greatest when the tendon lies in a long synovial canal. The two ends become adherent in this position of separation, and the muscle suffers atrophy from disease: even if the ends are united by the interposi tion of new tissue, the muscle loses in power. Whenever there is a possibility that tendons have been injured in a wound, especially upon the anterior surface of the hand and forearm, the action of every muscle should be examined. All the movements of the hand should be made, the fingers spread apart (loss of the power to separate the fingers indicating that the ulnar nerve has been injured), and the fingers flexed while separated, and due

allowance made for the action of auxiliary muscles. The projection of the tendons under the skin must be looked for. Another reason for thorough examination of the action of the muscles in fresh injuries is the great danger of overlooking some tendon when more than one have been injured.

In the examination of such wounds as full antiseptic precautions must be employed as in the examination of a compound fracture, anesthesia and Esmarch's method are very useful, the former assisting as much by relaxation of the muscles as by prevention of pain. By moving the limb in a direction opposite to that in which the affected muscle moves it, the retracted ends of the tendon can often be made to appear in the wound. Should this fail to bring the central end into sight, the muscle must be strongly compressed, and stroked downward from its origin toward the periphery by the hands of a strong assistant or by the rubber bandage wound from above downward. Some attempt to lay hold of the end of the tendon with forceps inserted into the sheath, but there is great danger of septic infection in this maneuver, as well as danger of tearing or contusing the tendon. It is far better to enlarge the wound at once. But by the old method of enlarging the wound, cutting directly down upon the tendon, it was often difficult to unite the skin over the tensely stretched tendon after suture, and the tendon was liable to become firmly attached to the cicatrix. Witzel prefers to make an incision in the skin, beginning at the wound, to one side of tendon and parallel to it, and to dissect up a flap until the tendon is exposed. The sheath of the tendon is then opened, if possible, on the side. This method also affords an opportunity to thoroughly drain and disinfect the sheath, which has almost certainly been rendered septic by the retracting tendon.

The needles of Hagedorn are best for suturing tendons, because they separate the fibers without tearing them. But the same object can be attained with the fine needles curved on the flat employed in operating for hare-lip, if they are passed with their greatest diameter parallel with the fibers. The best material for sutures is the bichloride catgut of Hagedorn.

A suture which is at all constricting will prevent union by cutting off the blood-supply, hence Nicoladoni's suggestion, to make the sutures of the most delicate material, and to relieve them of tension by passing an acupunc ture needle or a catgut suture through the tendon and the tissues overlying it at a distance of one inch above the point of division,