CANADA.

Posterior Positions of the Occiput.

K. C. MCILWRAITH (Canadian Prac. and Review, June, 1900) says that in spite of the forces tending to bring about the O.L.A. position at the brim, in certain cases the occiput is directed posteriorly; and in the majority of these cases the back is toward the right. In order that natural rotation should take place at all good flexion is necessary (unless the pelvis is very large or the head very small), because, as the occiput rotates from the rear to the front at some time during the process the long diameter of the head must be in the transverse diameter of the cavity. With good flexion the sub occipito-bregmatic, 334 inches, will engage. With poor flexion the occipito-frontal, 44 inches, will engage, which could not pass the transverse. Under these circumstances the occiput is rotated still further to the rear and the head has to be delivered in that position. Two lines of treatment offer: (1) Leaving the case to nature as long as possible, and delivery with forceps if rotation does not take place. (2) Manual rotation of the occiput to the front. The former is objectionable because the labor is long and exhausting, great force is required to deliver with forceps in this position, and the forceps are apt to slip. The forceps, moreover, tend to undue flexion, pressing the child's forehead against the symphysis. If forceps must be used, they should be of the axio-traction pattern, and should be drawn slightly posterior to the ordinary axis of traction.

A posterior position should be suspected whenever abdominal palpation shows the back is to the right, progress slow in spite of good pains, and the foetal heart unusually hard to hear. Certain diagnosis must be made before the head becomes fixed. As soon as the os is dilatable the patient should be chloroformed and the position determined by the hand of the attendant. If the occiput is posterior, dilate the os if necessary, push the head above the brim, and rotate it to the front by the internal hand, while the external hand pushes the shoulders around at the same time. Then apply forceps and deliver. The patient should be placed in Sims' position or the Trendelenberg to prevent prolapse of the cord.

Use of Ergot in Obstetric Practice.

CHAS. J. C. O. HASTINGS (Ibid.) says that the chief uses of ergot are (1) as a prophylactic given immediately after the birth of the child,

and (2) to make tonic the contractions produced by other means. Ergot has been accused of producing hour-glass contractions, but the only cases of hour-glass contractions, two in number, in the writer's experience, occurred in cases where no ergot had been administered. The great objection to ergot is that it is a drug over which we have no control after its administration. Its action begins in about twenty minutes from the time of administration, attains its maximum intensity in about half an hour, and lasts for an hour and a half. Its effect is tonic contraction of the uterus, and the question as to the time of its use is the question, "When is it safe to have tonic contraction of the uterus?" Certainly not before the birth of the child, for if the birth be delayed by any obstacle, there is danger to both mother and child. Quinine is a good substitute for ergot in the first or second stage of labor. As it requires at least twenty minutes for its action, it should be given immediately after the birth of the child, then in fifteen minutes begin to expel the placenta by Credé's method, if it does not come away before, and by the time the action of the drug is fully felt the uterus will be empty and contracted, preventing hæmorrhage. One reason that ergot is often condemned is the difficulty of obtaining a reliable preparation. Squibb's fluid extract is best.

GREAT BRITAIN.

Clinical Note on a Case of Vulvar Hæmatoma.

J. W. BALLANTYNE (Scottish Med. and Surg. Jour., June, 1900) says that cases of vulvar hæmatoma occur about once in 1600 labors. The writer was called to a case attended by a medical student, who stated that a swelling had suddenly developed in the left labia of a parturient patient. This was first observed at 5:15 P.M., and when seen half an hour later it was the size of a foetal head and increasing so rapidly that it could really be seen to grow. It was bluish-black in color, and the skin covering it was distended almost to bursting. Palpation could detect no pulsation in the mass, which was partly solid and partly fluid. The patient was a young primipara at full term. Labor had lasted about nine hours and had been perfectly normal. The membranes ruptured shortly before the appearance of the hæmatoma. The abdomen was

not pendulous, nor were there varicose veins in the labia. The patient was complaining greatly of pain in the left labium, was somewhat exsanguinated and oedematous under the eyes. Examination showed

cut tear.

the foetal head engaged in the O.L.A. position and well flexed. There was no contraction of the pelvic brim. It was decided to attempt to deliver by forceps. The head was easily brought to the perinæum, and just at the moment when it was being delivered the hæmatoma bulged into the fenestra of one of the blades and ruptured with a cleanA mass of blood clot, with some fluid blood and serum, was expelled. A good-sized male infant was quickly delivered, and the placenta and membranes removed manually. By this time the hæmorrhage from the hæmatoma had almost ceased, but the left labium was still enlarged, its tissues seeming to be infiltrated with blood. The parts were washed with a weak bichloride solution and the edges of the tear brought together as well as possible by four or five silkworm gut sutures. Owing to the thickened condition of the labium the wound gaped in the middle and was loosely packed with iodoform gauze, and some strips of gauze were placed in the vagina to prevent if possible, infection. Iodoform was liberally dusted over the labium. The patient was somewhat collapsed, but rallied and made a good recovery. Five months later the labium was of normal size and appearance. A trace of albumin was found in the urine during the first few days of the puerperium, but disappeared under a milk diet, as did the ædema of the face.

The case forms a characteristic instance of one variety of thrombus or hæmatoma complicating labor; that in which the blood escapes into the tissues of one or both labia and to some extent into the vaginal wall. A thrombus may also occur entirely in the vagina, and rarely within the pelvis. Thrombi usually form during the puerperium, occasionally during the second stage of labor, and very rarely during the first stage or in pregnancy. The etiology is most obscure. None of the commonly alleged causes were present, such as traumatism, twin-labor, large fœtus, excessive ossification of the foetal head or varicose veins. of labia or vagina. There was no reason to suspect a hæmophilic tendency. The transient nephritis may have predisposed to it. The pathogenesis is no less obscure. In a specimen examined by Perret a sliding or displacement of the layers of tissues in the pelvis, and more especially in the vaginal walls, had taken place, and into the space thus produced the blood had been poured. With the soft parts in situ, and with the pelvic canal wide above and narrow below, as the foetal head is pressed downward, the soft parts may be displaced downwards. in front of it, producing a separation of the strata of the vaginal walls and their immediate surroundings; into the space blood may be poured during labor or soon afterwards in the puerperium.

Three Cases of Puerperal Eclampsia.

FREDERICK SPURR (The Lancet, June 16, 1900) describes three cases occurring in his practice in a single year. The first case had been in excellent health throughout pregnancy, labor was rapid and easy, but the midwife noticed some twitching of the face and hands, and said that the patient seemed dazed. An hour after the birth of the child she was seized with a violent convulsion, and a physician was summoned. Five grains of calomel and forty grains each of chloral and bromide and "some digitalis" were administered by mouth. There was some quieting effect produced and a hypodermic of one-fifth of a grain of pilocarpine nitrate was given. Later in the day the convulsions returned, the intervals between the spasms being hardly perceptible. Chloroform, almost to surgical anesthesia, was persistently used, and bromide and chloral given. During the first twenty-four hours following the birth of the child she had about fifty convulsions. Urine and fæces were passed involuntarily about seven or eight times. The urine contained 30 per cent. of albumin. The patient remained unconscious for three days, and on recovery had no recollection of any events since about four hours before the birth of the child.

The second case had convulsions coming on after the birth of the child; the treatment was practically the same, except that two minims of croton oil was substituted for the calomel. The urine was repeatedly examined, but was perfectly normal before, during and after the eclamptic attack. The third case was less severe, as the patient had been on restricted diet and appropriate treatment for albumin for some weeks previous. The writer believes that chloroform, chloral and bromide is the best treatment in these cases, although in future he would use copious and repeated enæmata together with the purgatives by mouth.

THE

AMERICAN GYNECOLOGICAL

AND

OBSTETRICAL JOURNAL.

OCTOBER, 1900.

THE CONSIDERATION OF THE METHODS OF HEMOSTASIS IN ABDOMINAL SURGERY.*

BY E. E. MONTGOMERY, M.D., PHILADELPHIA, PA.

The evolution of abdominal surgery presents many subjects of the greatest interest to one interested in its development. From its origin, one of the most important considerations was the means for the control of hæmorrhage. As we study its evolution we witness the practice of various methods. McDowell ligated the pedicle, left the ligature long, and brought it without the wound, to be subsequently withdrawn. Nathan Smith early resorted to the animal ligature, using strips of kid. At the time I began the practice of abdominal surgery, the surgeons were just returning to the ligature from the use of the clamp upon the pedicle, as it had been employed by Atlee, Peaslee, and Spencer Wells. The ligation was being enthusiastically advocated by Lawson Tait, who was then appearing upon the horizon as an abdominal surgeon. Keith was employing the hot iron to the stump instead of the ligature. In recent years the ligature has been almost continually employed upon the pedicle after ovariotomy, but a great variety of ligatures, as silk, catgut, kangaroo, tendon, muscular tendons, silver and iron wire, have been employed. Many have been the methods for rendering the ligature sterile and inert. The greatest difficulty in the control of hæmorrhage was exhibited in the operations upon the uterus for fibroid growths. The earlier operations consisted in the amputation of the organ through the cervix using the latter as a pedicle. It was ligated en masse and occasionally dropped back, but unless the ligation was done with the elastic ligature, hæmorrhage subsequently was not infre*Read before the Philadelphia Obstetrical Society. October 4, 1900.