Diagnosis. The placenta not coming down as it should after the delivery of the child, if traction on the cord is employed it is found that it does not descend, but instead it lengthens from elasticity, immediately retracting on release. This shows that it is attached above. The continuance of this traction results in rupture. Should the examiner pass his hand along the cord he will, in the true hour-glass contraction, find the external os patulous and flaccid, often distorted, readily admitting the finger up to the internal os. Here he meets an obstruction complete or nearly so to further progress. One finds a large or small portion of the placenta below the constriction, or it can be felt by the finger-tip above the stricture. Its vascular ramifications, softer feel, elevation above the walls of the uterus, the, to the patient, duller sense of the accoucheur's touch upon it, in comparison with that upon the uterine walls, and, from bimanual examiniation, increased thickness, these symptoms all combine to make its differentiation from the uterine walls comparatively easy. Internally one finds those parts of the uterus above the constriction hard and firm. This can also be felt externally, and the constricting band can in many instances be made out. The uterus is found high up in the pelvic cavity and elongated with its transverse diameter diminished. Contraction is found rarely at the external os, and may occur at any other portion of the uterus. Pains and flooding are seldom present. The writer would urge upon the profession the importance of abdominal palpation as an additional means of diagnosis. An expert diagnostician should be able to make out the presence of hour-glass contraction through the abdominal walls. As aids in this department are recommended, "The Diagnosis and Treatment of Obstetrical Cases by External (abdominal) Examination and Manipulation," and "Minor Surgical Gynecology," both works of Paul F. Munde. Not only should the sulcus be determined by external manipulation, but also whether the uterus is contracting in the normal globular form or in the long, oval condition betokening hour-glass contraction. Where there is retained placenta, a bulging at that part of the uterus containing the placenta is palpable. It is affected little or none at all by pains. Irregular pains occur in the sacral region and neighboring organs, the bladder and intestines, colic, nausea and tenesmus also are sometimes present. Should all means of diagnosis present not be sufficiently conclusive, let the practitioner allow his hand to come within the spasmodic grasp of the uterus and he will think he has met an old classmate. The grip is crushing. Dr. Reamy says: "I willingly withdrew my hand, so painful was the grasp. If the con striction had surrounded the neck of the child it could not have survived longer than if it had been suspended with a noose around the neck." Dr. Nichols remarks: "On very many occasions my hands have been nearly powerless for days from the long and severe pressure they were subject to in overcoming hour-glass contraction." Prognosis. In this statistics do not come much to our aid, and we do not know a great deal concerning it. A prognosis is not so easy when nature clouds her future in such doubtful dimness. .In 33 labors in 30 women, where ante-partum hour-glass contraction occurred, reported by Smith, we find the appalling mortality of 8 mothers and 28 children; 3 mothers died undelivered; only seven were stated as primiparæ. Of those who died, 4 were primiparæ. In one case the mother had gone through 13 deliveries. As a Treatment. Remove, first, the spasmodic contraction, then remove the placenta if retained. Time alone will sometimes remove the constriction, though it may permit of its increase. There being no contraindicating implications as hemorrhage or lapse of time, one may quietly wait. Six or eight hours having passed by it is better to commence active measures. One may try to dilate the constricted orifice by inserting two fingers and opening them as a pair of shears; and by firm, steady, and continued, yet slight force, overcome the spasm, or, as it were, wear it out. preparatory measure, the fingers should be smeared with unguentum belladonnæ. In Scotland chloroform is much in use, having been highly recommended by Simpson. King, on the contrary, asserts that it is not affected by anesthetics. In attempting to introduce the hand into the uterus it should be placed in the most insinuating position in the shape of a cone. Opiates, decoctions of belladonna and hyoscyamus are recommended. Frankel recommends subcutaneous injection of morphia muriate, 0.015 0.003 gram. ; atropiæ sulph., 1 milligram. Dr. Richardson recommends amyl nitrite, gtt. iij.,,ether 3j.; inhale. This he says does not produce unconsciousness, but has an opposing effect to ergot. In it we have the epichontocic agent. Dr. Fancourt Barnes recommends inhalations of three drops of nitrite of amyl on a handkerchief. He has obtained flattering results. Johnson has had excellent results with hypodermic injections of belladonna, but it failed him once. Warm fomentations and irritations to the abdomen, sinapisms, turpentine stupes to hypogastric region, venesection when patient is plethoric, and warm baths. In the ante-partal variety, the upright position has been found to be favorable to delivery. Ramsbotham objects to large doses of opium. They may, he says, so paralyze the uterus that it will not again contract. Warm baths might produce hemorrhage, which might not be easily detected; hence they are not to be considered. If a small portion of the placenta is found to be below the constriction, it should be pushed up and the hand made to penetrate into the uterine cavity. If strangulated near the middle, one should pass the hand up and secure the part above. If the major portion is below the constriction this should be compressed, thus lessening that above and favoring delivery. It is claimed that traction on the cord to remove the placenta is sometimes good practice if it can be made perpendicular to the plane of attachment, not horizontal; the simile being the separation of two wet sheets of paper. The separation with the hand should be made by running the finger along as one should tear the uncut leaves of a new journal. Very tightly adherent pieces of placenta may be .loosened by a scratching motion of the ends of the fingers. Do not, however, be too eager to remove every bit. Several cases are on record of a fatal result from a too forcible removal of portions of the placenta. One may start. the detachment of a plate of the inner muscles of the uterus, which, becoming deeper and deeper may finally lead into the peritoneum and the usual results follow. The danger of allowing a portion of the placenta to remain are great; those of forcible detachment are greater. M. Dubroca, of Bordeaux, has introduced a new method, the method of erosion. When it is difficult to induce the dilatation of the stricture, he introduces one finger into the placenta, tearing it up and reducing it to fragments, which are afterwards expelled. He has found this plan useful. in cases in which he could not introduce the hand. One may inject cold water into the placenta, through the umbilical vein, with considerable force. This should be retained a few minutes by compressing the cord, then released, and the injection repeated. This has an effect both on the placenta and the uterus. If everything else fails, incisions through the stricture should be made. Care should be taken that the cut is made sufficiently deep. It should be made with the long blunt fistula shears. With the buttoned bistoury there is danger of cutting the walls of the vagina. Cesarean section has been seriously discussed as being a resort in the ante-partum variety. Many reliable authorities hold with reason that it is good practice. The following rules are given as to prophylactics : A. Avoid every cause liable to irritate the uterus. B. When ante-partal, avoid a too early rupture of the membranes. C. As far as possible remove all impediments to the expulsion of the child from the uterus. D. Assist with the forceps or by turning before the cervix becomes excessive. I will ask a careful consideration of all the above and then ask my readers to agree with me in the following conclusions: A. That the old-fashioned" Hour-Glass Contraction," "handed down by tradition," finds a place and a name still in a few of the “irregular contractions of the uterus." B. That its occurrence ante-partum adds greatly to the dangers incident to the mother and child in the parturient act. C. That the danger so far as the mother is concerned is but slightly lessened in the post-partum variety. D. It being possible to diagnose, through the abdominal wall, the sulcus uteri caused by the contraction, at least in many cases, this means of diagnosis should be resorted to more frequently. E. Flaccidity of the segment of the uterus below the stricture is the rule, thinning the exception. F. That hypotheses based upon assumed anatomical structure of the uterus and cervix are, at this time, not entitled to the weight of authority. There is a lack of harmony in the opinion of anatomists regarding them. They are unsupported by clinical observations. Hic jacet the views of Bandl. G. A treatment applicable to all cases, owing to the many and varied peculiarities attendant upon each, is at present impracticable, and each case must be treated, until we are further informed, p. r. n. H. The disheartening mortality in the ante-partal variety, renders the Cesarean section worthy of serious consideration and use as a means of safety to mother and child, especially the latter. LITERATURE. BANDL, LUDWIG.-Ueber rupture der Gebarmutter und Ihre Mes chanic. Wien, 1875; also, Condition of the Uterus and Cervix during Pregnancy and Labor. Schmidt's Jahrbucher, No. 4, 1878, and American Journal Obstet., July, 1878, and Gynecological Section German Con. gress of Physicians, Sept., 1878. BARNES, FANCOURT.-Hour Glass Contraction of the Uterus Treated by Nitrite of Amyl; Brit. Med. Journal, Lond., 1882, vol. i, p. 377; also, Med. Surg. Reporter, Phila., 1882, vol. xlvii, p. 44; also, Obst. Gaz., Cin., v, p. 205, 1882. BAUDELOCQUE.-Heath's Trans., vol. ii, p. 969. BLUNDELL.-Obstetrics, pp. 166-623-625, 1840. BALTZELL, J.-Ante-Partum Hour-Glass Contraction; Am. Jour. Obst., 1882, iv, pp., 300-302; also, Am. Med. Recorder, Phila., vol. iv, 1881. BURNS. Midwifery, 5th ed., p. 485. BRADLEY J.-Hour-Glass Contraction of the Uterus; Detroit Lancet, 1879, n. s, ii, pp. 95-101. BRIGGS, W. A.-—A Case of Ante-Partum Hour-Glass Contraction of the Uterus, with remarks; Pacific Med. Surg. Jour., San Francisco, 1878-9, xxi, 337-350; discussion, 398-401; also, Am. Jour. Obst., xv, P. 309, 1882. BOURNEVILLE And Vaulet.—De la Contracture Hysterique Permanenta, Paris, 1882. BRADLEY, W. L.-Ante-Partum Hour Glass Contraction of the Uterus; Med. Record, N. Y., 1882, xxi, p. 569. CAULKINS, J. S.-Some Remarks on Hour-Glass Contraction of the Uterus, Tr. Michigan Med. Society, Lansing, 1879, ii, pt. 3, p. 397. CAZEAUX.-Midwifery, 1870, pp. 870-879. CHARCOT.-De la Contracture Hysterique, Rev. phot. de Hop., Paris, 1871, xliv, pp. 557-561, Theorie de la Contracture Spasmodique Permanenta. Ibid, 1879, i, 11, 1132-1154. CHAPMAN. Med. Gaz., vi, p. 400. CAMPBELL.-System of Midwifery, p. 205. Cook, W. C.-Spontaneous Version, Hour-Glass Contraction, Evisceration, Tr. Med. Soc. State of Tennessee, Nashville, 140. CHATELLIN, H.-Enchatonnement incomplete du Placenta deliverartificielle precoce; guerison, France, Med. Paris, 1882, iii, ance 373-377. CHURCH, WM. H.-Ante-Partum Hour-Glass Contraction of the Uterus; Am. Jour. Obstet., xv, p. 305, 1882; also, Chicago Med. Jour. and Exam., 1866, iii. CURTIN, R. G.-Observations of Sulcus Uteri Transversus in Cesarean Section; Am. Jour. Obstet., N. Y., 1880, xiii, p. 397. DEWEES.-Midwifery, 1826, pp. 495-507. DAVIS, H. G.-Ante-Part. Hour-Glass Contraction; Am. Jour. Obstet., XV, 312, 1882; Phila. Med. & Surg. Rep., xiv, p. 484 and xxx, p. 115. DOUGLASS. Obs. Hour-Glass Contraction, 1820, p. 10, Trans. Royal Coll. Phys., vi, p. 393. DUDLEY, BENJ.-Lond. Med. Gaz., July, 1848, from Schmidt's Jahrbucher, lxiv, pp. 37, 49. DUNCAN, J. M.-Researches in Obstetrics, p. 389. ELLIOTT, GEO. F.-Ante-Partum Hour-Glass Contraction of the Uterus, three cases; Am. Jour. Obst., xv, p. 309, 1802; also, Obstetric Clinic, p. 188, 1858, chap. vii. FRANKEL. Ueber eine Uene Behandlung's Methode, Spastinches Uterus Stricture in der Austreibungs und Nachgeburts Periode Tagbl. d. |