with gauze while waiting for the shoulders. After delivery a torn surface was found extending from the clitoris to the meatus with blood welling up freely and allowing little opportunity to see except for an instant after pressure was removed. The bleeding showing no tendency to diminish under pressure, ligation was first tried, but with almost no benefit. I then proceeded to suture; as the tear involved the upper border of the meatus, and was deep, a catheter was introduceu into the urethra and left in position to obviate possibility of closing it; two catgut sutures controlled the bleeding at once. The mother was about the average in size; the child weighed 94 pounds, the head being large and unyielding. Little attention is paid in obstetric literature to this accident, but its gravity is attested by the fact that fatal cases have resulted rom failure to recognize and properly treat it. I would emphasize the ease Iwith which the bleeding may be controlled by suture.

As etiological factors in the production of tears of the vagina we have been taught to consider primiparity, the age of the primipara, malpositions, instrumental or other intervention and unusual size of the infan.. Yet they may occur at the most unexpected times, as illustrated by the next case.

Case II. January 28, 1898, I attended a Chinese woman, primipara, aged 19, of medium build. First stage, twelve hours; although the vagina was narrow, it did not excite any concern as bag of waters was present, only rupturing at mouth of vagina, and the labor was not precipitous. In the second stage I retarded progress for some time, hoping to prevent external tear, and received the commendation of an ignorant neighbor (my only assistant) because of une excellent care I was giving the patient. My pride

fell, however, when, on the birth of the child an alarming hemorrhage occurred. The placenta quickly followed and as the uterus contracted well, I knew there must be a tear and attempted to control bleeding by tamponing with gauze while waiting for assistance. The tampon, which was renewed several times, was not well placed and much blood was lost. On the arrival of Drs. E. A. Praeger and F. D. Bullard, the patient was placed across the bed and with speculum and tenacula, we with difficulty, on account of the continued hemorrhage, made out a transverse laceration of the upper vagina, involving the posterior lip of the cervix, and extending laterally and downward on both sides; the vaginal mucous membrane seemed then to have been pusned forward by the head and torn loose from most of the posterior vaginal wall. The patient was by this time almost pulseless and Dr. Praeger wisely advised to tampon rather than to attempt suture. A strip of iodoform gauze was passed into the uterus, which remained well contracted; the vaginal mucous membrane was raised into place and the vagina firmly packed with iodoform gauze, effectually controlling the bleeding. This was removed thirty-six hours later. There was no local inflammation; wounds had healed by the ninth day. As evidence that the scars offered no obstruction, will state that a child was born to her one and one-half years later, before she had time to call a physician.

Case III. September 30, 1900, I was called to Mrs. M., primipara, aged 21. Pains all day, becoming more severe alter 6 p.m. Membranes ruptured at 12 m., after which pains every five to seven minutes, but not very strong. October 1, 6 a.m., os nearly dilated, but head not fixed. Usual efforts by medication, baths and postural treatment were made to increase efficiency

of pains which continued at intervals of three to five minutes, but without progress. The heart sounds of the child failing, the patient was placed on table at 2 p.m., anesthetized by Dr. F. D. Bullard, and although cervix was not completely dilated I delivered by forceps, with considerable difficulty, a child weighing nine pounds. There was profuse bleeding and I found on the right side a laceration of the cervix extending into the vagina, on the left a laceration of the cervix only. Five sutures were at once introduced on the right and two on the left side. Aseptic ergot and strychnia gr. 1-20 were given hypodermatically. As the uterus had not contracted strongly during labor, fearing relaxation, and wishing to conserve all the blood possible, as much had been lost, I resorted to the device recommended for atony by Arendt in 1898 of drawing down the uterus with vulsellum forceps in anterior and posterior lips. He says several pulls will produce uterine contractions and prevent further bleeding, but Schwertassek (Centralbl. fued Gynaek. No. 7, 1900,) observed renewed hemorrhage on relaxing tension and recommended that the traction be continued a long time. I therefore left the forceps on the uterus and, as there was some leakage between edges of wound of vagina, a strip of gauze was passed into the uterus and the vagina tamponed, thus compressing the veins in the cellular spaces of the pelvis and preventing the formation of a hematoma. The fundus watched and light was traction on the cervix continued for four or five hours; there was no further bleeding. Gauze was removed in thirty-six hours. Recovery uneventful. Four months later, on examination the cervix did not show that it had been lacerated and there was only a fine linear scar on the side of the vagina.

The number of expediments resorted to in the last case may indicate a lack of confidence in any of the methods. I think the patient might have done just as well without the use of the vulsellum forceps, but having observed the effect of traction on the uterine vessels in vaginal hysterectomy I felt an added security in having the forceps there. Compression of the aorta should have been made to reduce the hemorrhage while the suturing was being done, but was neglected.

Treatment depends upon the site of the tear and is by suture or tampon, each method having its advantages and disadvantages. The suture is ideal where it can be made to include in its grasp the extent of the bleeding surface, a condition which obtains in laceration of the cervix or the lower half of the vaginal wall. In the superior part of the vagina, however, the tear extends into the broad ligaments and opens up the vessels in the cellular tissue, which cannot be closed by superficial sutures of the vaginal wall. Here the tampon is preferable to control bleeding by pressure; however, if the urgency of the case does not forbid, I think better results will be achieved by the introduction of a few sutures even in this instance, drawing the edges of the mucous membrane together, thus minimizing the extent of raw surface and the resulting scars.

The cases are not unique, but show the importance of always being prepared for such emergencies, carrying gauze, speculum and vulsellum forceps that in case of hemorrhage the parts may be inspected, and the necessary treatment, either suture or tampon, applied without jeopardizing tient's life by delay.

245 Bradbury Block.

the pa

This is one of the most ancient of gynecological usages, advised and practiced by Hippocrates some twenty-two hundred years ago, for medicating the interior of the uterus or cleansing it. Subsequently it was used by others amongst the ancients, and later on oy the eminent French surgeon Ambrose Pare in the sixteenth century; within the past forty years it has been quite extensively employed. There is scarcely a therapeutic resort so old or one which has passed through SO many phases of practice-to be forgotten, revived, then rejected and finally reinstated and indorsed. With the ideal reflux irrigator in general use today, preceded when necessary by thorough dilation and under antiseptic precautions, intra-uterine irrigations are considered safe and effective.

If the healthy uterus be injected with fluid, without proper dilatation, the following symptoms will probably be noticed: Uterine pain and colic, abdominal tenderness, feeble, frequent pulse, coldness of the extremities, and other evidences of shock. If, however, the uterus is in a pathologic condition, the dilator is often not called for, because, as a rule, the cervical canal is sufficiently patent to admit the irrigator and untoward or dangerous symptoms are apt to be provoked with less severity, or may be absent altogether, according to the capacity of the canal to afford ready exit to the fluid and other contents of the cavity of the uterus. I may say in passing that the fears formerly entertained of the injection of fluids into the oviducts and on into the peritoneal cavity, has by experiments at different times, demonstrated the rare possibility of this accident. Vidal first operated upon the cadaver and found that with

moderate pressure the fluid did not so enter. Hennings' experiment coincided. Klem could make the fluid pass through the fallopian tubes only on great pressure. Palmer, on "The Inflammatory Affections of the Uterus," in "System of Gynecology," by Mann, tells of having made similar experiments by constricting with a stout cord the cervix around a tube fitted to a strong air-tight syringe. No fluid could be forced through the oviducts unless they were dilated. These experiments were in the dead subject where there is no instinctive contraction of the sphincter at the utero-salpingian orifices; how much greater will be those met in the living? The question may be asked: Do intrauterine injections ever so penetrate in the living subject? In answer I would say that since the uterus when injected is usually diseased in some way or contains morbid materials and as under these conditions the orifices of the organ are frequently dilated, it follows that in a certain rare proportion of cases, penetration of fluids to within the abdominal cavity does occur. Postmortem examinations and Lawson Tait's operation prove the existence of patulous and dilated tubes in many instances. Barnes and others report cases where on autopsy, solutions of iron salts were found at the fimbria. But notwithstanding these admissions and provings, evidently the symptoms cannot be traced to such causes, except possibly in rare instances. In view of these facts, various precautions can be observed here which tend to prevent the ill effects of intra-uterine injections. The following are the more important:

(1.) Dilatation of the Cervical Canal. Whether this is the result of the disease or is accomplished artifi

For mani

cially by a dilator, it matters not, so that the injected fluid flows out of the uterus, retention and distention thereby being prevented. fest reasons, it is more dangerous to inject the uterus when that organ is greatly flexed. A ready exit of the current is also secured by the use of a double or reflux canula. There are a number of these, as Notts, Byrnes, Skenes and others. The one used by the writer since 1880, and which is in general use, is all that could be desired in such an instrument, as it readily permits of a free reflux current, and with it distention is impossible. The canula is fitted to an airtight syringe or a reservoir at a sufficient elevation to give the injecting fluid a gentle force. The fluid should be sterilized water at a temperature of 100 degrees F., and with some reliable antiseptic, carbolic acid, boric acid, bichloride of mercury, or permanganate of potash, etc. For most cases of bichloride (1:200-8000) is the best of all, but the drug is dangerous if continued too long in a given case. It must be admitted that certain risks attend intra-uterine injections, even under the circumstances of a large uterus, a patulous canal, and a free exit for the fluid. But the risks are not great and compared with the dangers of septic absorption, or the urgency for the removal and disinfection of septic matter, fresh invoices of which by a conunuous or intermittent imbibition into the vascular system are being kept up, these risks are very small. Fortunately, the uterus is in a condition less susceptible to these risks of shocks, retention of the fluid and distention of the cavity, the passage of the same into the peritoneal cavity, etc., when the urgency for the employment of antiseptic injection is greatest. Nevertheless, the utmost precaution ought to be instituted in every single case.

(2.) Shock is diminished by using

fluids at a temperature of 100 degrees F.

(3.) Distension and shock are diminished by using the least possible force..

(4.) The possibility of injecting air is prevented by using the fountain syringe and a moderate pressure.

I may say, as a valuable hint, that intra-uterine medication of any kind by injection is contra-indicated when the uterus or the perimetric tissues are especially tender.

It was when a student that my preceptor often cautioned me not to introduce a probe into the cavity of the womb, excepting when it was evidently practical, and plainly demanded, and then with the utmost caution, as it was regarded by him as not a slight matter by any means to invade this cavity, even with a small probe and in dexterous hands and rigid precautions.

The warning thus given me when an inexperienced student has not been forgotten, although more than a quarter of a century has passed since that time. In this connection, I will say that the instrument in universal use at that time was quite unlike the delicate silver probe found in almost every gynecologist's kit of instruments today, as the two I here exhibit will show.

I also have with me a sharp and a dull curette, also a reflux irrigator, which I wish to show in order to the better impressing upon our minds the accelerated danger of using the sharp curette in ordinary cases and the comparative safety attending the use of the dull one. As to the irrigator, I am sure there can be no just criticism.

I am free to admit that the sharp curette has its merits, but is too frequently followed by very dire, even, in some instances, fatal results to the patient; while the dull an te used with almost entire safety, so far