whether it would not have been better to wait until just before the application of the forceps. Now let me recommend to you, gentlemen, as a habit of life, always to review your cases, be their termination favorable or unfavorable, and ask yourselves if the treatment might not have been improved. I was glad to hear the question I have mentioned, for it showed this habit; and now I will answer it. I think the early incision was not a mistake, but was the very best treatment; because, the longer incision was postponed, the greater would be the amount of extravasation, the greater the distention of the parts, the more extensive the laceration of their areolar tissue. The argument of Hunter, that the clot would act as a compress, a tampon, to arrest the hemorrhage, is, I think, altogether erroneous. In my own case, where I followed his plan, there was extensive sloughing, and the whole labium was lost. In this last case nothing of the kind has occurred; and so it was in both of Professor Sayre's. Incise at once, then-so as to relieve the parts from the pressure, and relieve the patient from the shock of the severe pain attending the tearing of the tissues, a shock far greater even than that of ordinary labor-pains (we can arrest the hemorrhage promptly and surely by applying directly to the bleeding surface the powerful styptic, persulphate of iron)-turn out the clots, find out the exact point of laceration, and apply this styptic.

The next question was between speedy delivery by artificial means, and waiting till the system should recover from the shock, and trusting nature to deliver the woman. I decided to deliver as quickly as possible with safety to the patient, and for this reason: I have already shown you that the accident is not due to varicose veins; but the exciting cause is arrest of the venous circulation by the mechanical pressure of the presenting part of the foetus. If this be so, the sooner the pressure is removed, the sooner will the danger be over, and the less will be the injury to the parts. Deliver as soon and as rapidly as possible, and be prepared to meet the great gush of blood, that you must expect as soon as this is accomplished, by the means adopted in the present case. Apply compresses of cotton batting, saturated with solution of persulphate of iron, directly to the bleeding part, and keep up pressure till the hemorrhage stops. This patient was reduced almost to the last extremity by loss of blood; but these measures arrested the hemorrhage, and whiskey and morphia brought back the pulse, which had become imperceptible.

Every author, I believe, directs that a tampon be applied. I must say, and with the strongest conviction that I am right,

that I consider this direction a very bad one. In the first place, there is no need of the tampon after once arresting the hemorrhage by the means I have described. In the next place, if the vagina is tamponed, you have all the lochial discharges retained in it to decompose; you have, moreover, pressure upon the urethra and pressure upon the other parts that have just been subjected to severe contusion. But the safety of the patient requires you to guard against every possible danger of sloughing; and against decomposition, whether of the discharges or of the blood effused, at a time when the system is especially liable to the absorption of poison. I think the greatest danger in these cases is from septicemia. So you make use of antiseptics. I was particularly struck by the fact that our distinguished countryman, Dewees, many years ago, recommended pyroligneous acid as an application to these cases of laceration, thus anticipating the antiseptic treatment by carbolic acid, now become so famous. My colleague, Professor Sayre, used compresses of oakum impregnated with carbolic acid, through which the discharges were allowed to ooze. We employed a wash of glycerine and carbolic acid, which protected the parts from fissure and excoriation by the irritant discharges or the

urine.

It is an important point in the dressing not to detach the coagulum formed by the persulphate. It presents a black, uglylooking mass, which you are strongly tempted to clear away; but you must never remove any part of it, except such as is completely loosened. If you avoid exciting it yourself, I think there is little danger of secondary hemorrhage. Still further to guard against such an event, this patient was not allowed, for some time, to evacuate the bladder spontaneously, but the catheter was employed. After the coagulum had become detached, the parts looked a little irritated, and an emollient was applied in the form of a poultice. The result you have seen.

In looking over the records of cases like this, I find they have been treated by bleeding and an antiphlogistic regimen. This case has been treated upon the principle, directly opposite, of restoring the exhausted vital powers as quickly as possibleby opium, the great restorative, alcohol, quinine, iron, and the most nutritious diet. I think she speaks well for the treatment.

Thus, gentlemen, I have occupied the hour in endeavoring to prepare you for an emergency which is not very rare, and may occur to any one of yon-an accident which has heretofore been attended with a fearful fatality, both to mother and child, but which I hope more enlightened practice may render less dangerous in the future.

DR. W. T. LUSK has kindly furnished the following translation and abstract from Scanzoni's Lehrbuch der Geburtshülfe, published in 1867, and our readers will be interested in comparing his views with those of Professor Barker.

Thrombus of the vulva, or labial hæmatocele, occurs oftenest during or shortly after labor. Rupture of small vessels and slight extravasations beneath the mucous membrane of the genital organs, and into the connective tissue of the vicinity, are the pretty constant accompaniment of every normal labor. In fifteen cases of thrombus vaginæ, only one was connected with varicose veins. Tumor increases slowly, if vessel alone ruptures, but much more rapidly where there is at the same time considerable separation of the contiguous cellular tissue. In Scanzoni's fifteen cases the tumor occurred eight times before expulsion of child, six times during the delivery of the placenta, and once, in a twin case, between birth of first and second child.

Scanzoni lost only one of his cases: viz., from puerperal fever. Dangers are from ichorous decomposition of the retained elots. Pyæmia may be predicted in extensive extravasations which are not evacuated in good season.

Treatment.-The speedy evacuation of the blood from the cavity is the best remedy to avoid interminable abscess-formation. Scanzoni applies forceps and delivers immediately, and only incises the tumor first where it is likely to prove a mechanical hinderance to birth. After extracting child he puts pieces of ice and injects cold water into the vagina to control increase in size, and, if this fails, tampon of compresses dipped in icewater. Don't open so long as it continues to increase. If, after opening, hemorrhage is excessive, use ice, and in case of failure plug cavity with carpie, and plug vagina.

DYSTOCIA FROM SYPHILITIC INDURATION OF THE CERVIX. By Dr. PULEGNAT. (Jour. de Brux., vol. 47.)

FIVE cases are recorded where large and indurated ulcerations of the cervix were the cause of difficult parturitions. All the labors were premature. In the first it was necessary to incise the os and turn, but the mother died, after a child, evidently dead for some tine, had been extracted. In the remaining four cases the children died in from two to four days after birth, although the mothers lived. In the latter the parts yielded sufficiently, but the labor was protracted from their weak condition.

ON THE INFLUENCE EXERTED BY CHLORAL ON THE PAIN OF PARTURITION. BY E. LAMBERT, Esq., late House Surgeon in the Maternity Hospital, Edinburgh. Read before the Edinburgh Obstetrical Society. (Edinburgh Med. Journal, August, 1870.)

THE author proceeds to say, that in drawing the attention of the Society to this subject, it will possess a peculiar interest to their eyes from the fact that it is directly connected with the name of one so justly memorable as Sir James Simpson. It will command this interest at least, that it purports to bring before you and before the profession the facts known to myself in connection with the later researches of Sir James Simpson in the direction of "obstetric anæsthesia," and I cannot but hope that it may be in the power of others to supplement these by many other observations.

I deeply regret that the few facts here narrated could not be brought collectively under the cognizance of his master mind, and that I was not permitted to take counsel of his mature experience as thoughts forced themselves upon me during the prosecution of these researches.

When chloral was brought before the profession, Sir James was foremost in prosecuting inquiry into its therapeutic value. I do not know whether he had applied it in private obstetric practice, but his paper on chloral, of 1st January, in the Medical Times, makes reference to the subject. He states that he has seen the parturient womb contract regularly whilst the patient was unconscious. During the last fortnight of the year 1869 he had attended, with my colleague, Dr. Walker, a case in charge of Dr. Somerville, but I have no notes of the results. On the 31st December I requested his attendance; the case is related under No. I.; there was absolute intolerance of the medicine. The next case occurred 2d January, 1870, and the important results given in No. II. were observed. The last case attended by Sir James Simpson in connection with maternity practice dates 4th January, No. III.

Chloral, it was apparent, could not claim to supplant chloroform, since it abolished consciousness to a less extent, placing the patient, as it were, midway between consciousness and unconsciousness, and rendering her incapable of that control which is essential during the close of the second stage; but this admission only placed in a stronger light the admirable properties of the agent when applied to the relief of pain during the first stage of labor, at a period when it is generally conceded that chloroform is hurtful. As the hypnotic of this first stage,

chloral stands as yet unrivalled; we have only to remember that opium, our only refuge, must be administered with the knowledge that we are conspiring, though for a higher end, against the course of labor.

It is with an earnest intention to further the progress of our art that I invite the attention of your Society to the bare statement of the whole facts which have come under my observation. None more than yourselves will feel the interest that attaches to researches in this particular direction; none, I am sure, will be more anxious to employ the keen edge of criticism to the profit of experimental science.

When we are considering the application of chloral to the suppression of pain during labor, the point of primary importance is to determine the influence of the agent on the uterine contractions. In Cases II., V., X., the second stage of labor was well advanced, and anæsthesia was as complete as could be desired. Cases III., IX., are severally good types of the two classes of patients we more especially meet with in practice under circumstances of protracted suffering, as in both these cases during a tedious first stage. When labor has been protracted until we observe marked distress on the part of the patient, the prominent symptoms are either unnatural excitement or great depression; the pains are irregular, often intercurrent, the intervals not distinctly marked; and who has not heard the patient implore a "wee sleep." In the condition of extreme torture observed in Case II., the effect of chloral is strikingly exhibited in the case as recorded.

The power of the medicine in diminishing pain was well instanced in this case, when the uterine contractions, tested by the hand on the abdomen, began fifteen or twenty minutes before the patient exhibited any consciousness of pain, which consciousness was again lost before the contraction had expended itself. Intercurrent pains disappeared entirely, and the uterus contracted with a perfectly regular periodicity in periods of longer duration than formerly. Intensity and duration cannot but be a test of efficiency, and my conviction was that the contractions were more efficient. Pain was not superseded, because my experience was not sufficient to allow the exhibition of fuller doses; but in a like case, with much marked reflex excitability, I should like to try conjointly with chloral a very moderate exhibition of chloroform. I should prefer this to increasing the dose of chloral.

The class of patients in whom depression is observed is well exemplified in Case IX. The effect was so marked that the phenomena of labor might have been thought to be suspended.