face to face with an emergency for which the authorities furnish neither precedent nor rules for guidance. Such an emergency was the one which Dr. Arms had just related, and such cases came under the recognized surgical principles governing the removal of foreign bodies. Cesarean section might become necessary from a number of causes, such as uterine inertia where the waters were all drained off, the os undilated and the vital powers of the patient were rapidly failing; where a lumbar abscess bulging out above the promontory of the sacrum forces the os uteri forward so that the head cannot engage; where there is dropsy of the fetus preventing the body's engaging in the superior strait; where, from uterine tumor or other causes, the womb contracts irregularly and the sphincteric action of the neck is strong while the expulsive effort is inert; where the fetus has died in utero and a post-mortem rigidity exists; or where the external parts are swollen and the vagina is hot, dry and partially occluded by tumefaction, edematous or inflammatory; in any of these cases, when the waters are all drained off, and the uterus closely oppressed to the fetus, every other obstetrical expedient may fail, and the accoucheur may be brought to the point where he must either perform Cesarean section or be compelled to see the patient die with the fetus or its mutilated remains still within her. In the case detailed to us he had advised Cesarean section because, in his judgment, it did not add one mite to her danger. Section was no more dangerous to this patient than evisceration, and much more certain to succced.

Dr. THAYER said they should have attempted to eviscerate, anyhow.

Dr. VANCE replied that he did not believe that any man could have eviscerated in this case, and hence did not advise the attempt.

Dr. ARMS said that in another case he should insert a drainage tube from the uterus through the vagina and wash out the uterus with disinfectants.

Dr. SAWYER said that two cases in his experience had made him more ready to decide in favor of section. He was called some years ago to an

Irish woman and found an arm down. He reached up and got a foot, but with external manipulation and all the pulling he dared do-the woman, of course, being under chloroform-he could not turn. The priest would not allow evisceration. Dr. S. went home for a short time and was sent for again in haste, and on his return found the baby in the bed. A stout Irish woman had, as she said, "Took hould and dhrawed it through" all doubled up, head extended upon the back, and both arm and foot down. The woman recovered without any ill consequence. He

learned from this that proceedings for which the books gave no authority were sometimes safe. In another case, where delivery was delayed, he, together with Dr. Bennitt, applied the forceps. Dr. B. pulled and he used pressure above, and then he relived Dr. B. at the forceps. The patient was finally delivered, but died in two or three days, and the whole lower part of the uterus was found sphacelated. From this case he had learned that a procedure for which the books gave the fullest authority might prove most disastrous to the patient. He asked if Dr. Thayer had ever eviscerated before the head was out of the way and the part to be eviscerated was presenting at the os.

Dr. PowELL stated that he considered turning, rather than forceps, as the operation of election where the presenting part failed to engage. He was asked if he had any authority other than his own for converting a normal head presentation into a breech presentation. He objected to Dr. Arms having performed craniotomy without consultation and professional assistance. He related a case which he recently attended where, after a labor of four and a half hours, the last half hour of which pains were unusually vigorous, but seemed to accomplish little, the head came down in the first position and he assisted it out by the aid of his finger in the rectum. He was obliged to give chloroform and deliver the body. He waited fifteen minutes for the afterbirth and used Crede's method and failed. After waiting half an hour he passed his hand in, following the cord, and it .passed up without resistance nearly to the umbilicus and he found the womb below his hand. He was in the abdominal cavity, his hand had passed through a rent in the utero-vaginal junction at the left side. There was considerable hemorrhage and shock, but no protrusion of intestines. He called Dr. Himes in council and he also passed his hand up, feeling the intestines, and finding that the rent extended half way round the cervix and had a ragged membranous edge. The placenta was delivered and the patient treated with stimulants, morphine and disinfectant douches. There was no peritonitis; temperature did not rise above 1011⁄2° F., but there was some pain and diarrhea. There was a bloody discharge for,awhile and a mass the size of a pullet's egg sloughed off. He had not dared make a thorough examination. Thought a fold of mucous membrane had been caught between the head and the left side, and torn through. He had not felt the intestines. possibly might have been a cyst.

It

Dr. VANCE asked if, after this case, he thought Cesarean section a dangerous operation.

Dr. DUTTON asked if he considered it justifiable to ask another man to put his hand through the rent.

Dr. POWELL replied that he always wished great responsibility shared, and so in all such cases it was his habit to call consultation.

Dr. ARMS stated that the work at the Retreat where this case occurred was peculiar. There was no compensation, and he did not feel like calling men unless it was absolutely necessary.

Dr. POWELL thought that should make no difference, and that any man would be willing to go under such circumstances.

Dr. DUTTON stated that once when Dr. Arms had called him they both felt they needed further advice, so they sent for the man whose experience gave them the greatest reason to hope for profit from his advice, and he refused to come because he was not to be paid.

Dr. HART called attention to the great advantage of the knee elbow position in turning, and cited a case of face presentation where he had turned by the aid of this position and where he felt sure he could not have turned without it.

Dr. WEIDENTHAL reported a case of twin labor where the first child was delivered by a midwife and forty-eight hours thereafter he was called. He found the head forcibly extended upon the back and the chin presenting. He finally succeede i in reaching a foot, and turned and delivered.

1

IT is a wonder that a competent, sensible practitioner has any respect for humanity at all. People are constantly revealing their nonssene in medical matters to him, and he has to grin and bear it as best he may. He finds himself supplanted by a man he knows to be a quack, and is assailed with a series of therapeutic experiences by a larger percentage of the elderly females he is thrown in contact with that is calculated to set an unhardened man crazy. The separation of the true from the false among physicians is truly one of the great social problems.—St. Louis Globe: Democrat.

OBSTETRICS.

POST-PARTUM HEMORRHAGE. (James F. Hibberd, M. D., in Amer. Practitioner.) The frequency of this alarming complication of labor is not well established. Churchill tabulates 66,699 labors, and reports this accident in 310 cases, and of these 20 were fatal, that is one death from this hemorrhage in every 3,335 labors; or, differently stated, one hemorrhage in every 215 labors, and one death in every 15 hemorrhages.

There is no accident of the lying-in chamber that demands of the medical attendant so clear a head on the instant as a sudden gush of blood in a large stream from a uterus that has just been emptied of a fetus. Most of the dangerous mishaps of this chamber allow time to call counsel or at least for the accoucheur to think over the problem involved and recall what others have done or taught or what he himself has experienced on like occasions in the past, and by a comparison of circumstances decide what is best to be done in the present. Should his patient fly into a convulsion, whatever he does within reason, she will come out of it alive after a while and he can prepare to prevent a recurrence; if the uterine wall splits open and the fetus passes out of the womb and in among the other viscera of the abdomen, the mother will live until the doctor's mind works out the best mode of proceeding; but if a woman who has just been delivered of a child has a torrent of blood rushing from the vulva, it must be arrested quickly, or she perishes, and if there be less blood escaping and more of it filling up an inert and expanding uterus death is equally imminent.

The accoucheur, therefore, whether a young or an old one, who does not in advance have his mind fully imbued with the principles that should guide him in such an emergency, and his wits in such command at the moment as to be able to efficiently apply these principles without hesitation, is in such condition that he may speedily become a moral homicide, for the person who undertakes to practice midwifery and through ignorance or misconduct permits a woman to die of hemorrhage that a competent practitioner would have arrested, is guilty of real, though perhaps not legal, homicide.

It would be an error in my judgment to suppose that in these cases the fault, if fault there be, always lies in not enough being done. I am apt to believe that often there is more done than is healthful; not necessarily. because the things done are wrong of themselves, bu beecause too much

has been done of that which was in appropriate measure good. It may be likened to the administration of morphia for pain. A quarter of a grain may be good and safe for enteralgia, but a quarter of a grain administered every fifteen minutes for an hour might be fatal. But the force of this argument will be more apparent after inquiry into the nature of this hemorrhage.

The anatomy of the uterus at term is not very clearly set forth anywhere within my knowledge, but it seems to be conceded that in the hemorrhage we are discussing the blood escapes from the uterine sinuses at the attachment of the placenta, which attachment has broken in whole or in part, leaving the sinuses open and pouring out their contents. These sinuses are a special development of pregnancy, are without valves, large and relatively straight before delivery, but when the womb has voided its contents and contracted to but a fraction of its former size they are twisted and doubled on themselves in such wise that their caliber is occluded, forbidding the exit of blood, and this is the safety state of the common puerpera, and it is only when this twisting and doubling fails to take place, or when from some cause they do not occlude the sinuses, that the hemorrhage we are considering occurs.

In the instances where there is hemorrhage from this source notwithstanding the contraction of the womb, if any such there be, the arrest of the flow must be accomplished by securing the plugging up of the open end of the sinuses by whatever means we have at hand, that will be efficient without being mischievous. The practicable plug is a clot of blood, and this is to be created by constringing the mouth of the vessel until the arrested blood coagulates, or by the direct application of a coagulating drug, as the salts of iron.

Supposing one has a puerpera who has bled freely, dangerously, and the womb was fairly contracted but has relaxed a little, and the woman is faint, gasping, or even in complete syncope, what is to be done? Shall we sprinkle the face with cold water, apply ammonia or other volatile pungent to the nostrils, chafe the limbs, and do other popular professional expedients to revive the patient? Apply cold to the hypogastrium and vulva, examine the uterus, which will be found filled with a coagulum, turn out the clot and insert ice, or inject hot water, or lave the whole interior wall with Monsel's solution? What would you do, my young friend, in such an emergency? The case is urgent, and you must meet its demands on the moment. There is no time to send for consultation. You must rely on yourself alone, and this under the fearful consciousness that