methods, pointing out that the more difficult cases, those with prostatic complication, were the subjects of suprapubic section. Consequently the mortality compared unfavorably with the simpler cases in which the other methods were employed.

Dr. Ross had recently visited Mr. Freyer in London, and had seen some of his work. Mr. Freyer had become so skillful in litholapaxy that he now practically never cut for stone.

E. W. Cushing, M. D.:

Although the treatment of post-partum hemorrhage by stimulation of the contraction of the uterus, by packing its cavity or by suturing rents in the cervix is well established, there are occasions when it is well to remember that arrest of hemorrhage, temporary at least, may be obtained by a simple and safe procedure to which Fritsch (Deutsch Med. Woch.) has recently called attention.

The packing of the uterine cavity is not precisely a simple matter. Even if an obstetrician is in attendance and is quite prepared to do it and has his material in readiness, there is always some danger of carrying infection into the uterine cavity, while as for suture of the cervix, it is not quite easy for everyone to find the tear and to place the sutures deep enough to stop the hemorrhage and not so deep as to run any risk of injuring the ureter or puncturing considerable vessels.

In any case time is precious and while preparations are making, the patient may lose a great deal of blood. Sometimes also the hemorrhage comes when no obstetrician is in attendance or after he has left the house, and the nurse or midwife finds herself in a position of great difficulty and responsibility, in presence of a grave crisis.

In cases of atony of the uterus, according to the following procedure, which is not altogether new, after expulsion of the placenta the body of the uterus is sought with both hands. through the abdominal wall, and when found is lifted up, compressed and turned forward against the symphysis, which furnishes a solid support against which pressure can be exerted, while at the same time the moderate tension on the broad ligaments and the vessels contained therein tends to check the hemorrhage.

Of course in an obese parturient with comparatively strong abdominal walls this procedure might be difficult, but in women who have had many children, and in whom the abdomen is greatly relaxed, being the type in which atonic hemorrhage is most common, it is perfectly easy to lift and compress the uterus in this way. Then, if the flowing is checked, the womb may be kept in this position as long as is necessary by packing a mass of towels, etc., into the great hollow behind it, holding all in place with a firm bandage, which may remain in place for ten or twelve hours.

When after expulsion of the placenta, although the uterus is firmly contracted, hemorrhage persists, and presumably comes from a laceration of the cervix, it is possible to check it by pressing the uterus down into the pelvic cavity by the right hand on the abdomen, while at the same time the closed vulva is pressed upwards with the left hand to such an extent that the cervix is compressed and the bleeding arrested, at least temporarily. In this way precious time may be gained while preparations are making for suture of the cervix, or while the obstetrician having left the house is recalled. If the bleeding is merely venous it may be entirely stopped by this simple

maneuver.

While neither of these methods belong to the highest order of obstetrical practice, or would probably be used in a firstclass hospital, yet, considering all the vicissitudes of childbirth, and the frequency with which it must occur when no proper preparation has been made for eventualities, or even when no physician is present, it is well to bear in mind that by means so simple and so safe one of the most dreaded accidents of delivery may be controlled, and by timely assistance the life of the parturient may be saved.

Arthur Macan, M. D.:

The diagnosis of accidental hemorrhage is particularly obscure when external bleeding is combined with internal, and practically depends on the disproportion between the severity of the symptoms and the amount of visible loss. Still every case of accidental hemorrhage is at first, at all events, one of internal hemorrhage. A certain amount of hemorrhage be

tween the placenta and the uterine wall is by no means uncommon, and many slight cases escape diagnosis altogether. Once the diagnosis has been made, the indications for treatment are to arrest the hemorrhage, without emptying the uterus, if possible, or if this be not possible, to empty the uterus in the way least likely to cause laceration of the soft parts and consequent shock and post-partum hemorrhage. The old method of plugging the vagina and applying the pressure by an abdominal binder and perineal bandage, is the most efficient way of treating all except the most severe cases, is perhaps best even for them. When the uterus has to be emptied Cæsarean section is to be preferred to accouchement forcé; at all events, the hemorrhage can be absolutely arrested by compressing the neck of the womb directly the abdomen had been opened; but in accouchement forcé the bleeding goes on or is even increased for an indefinite time.

A. Donald, M. D.:

I will briefly review my forty cases of chronic endometritis and metritis which occurred in virgins, and which are independent of such causes as cancer, tubercle, fibroid tumor, membranous dysmenorrhea, or infective diseases. In thirty of them the characteristic points were a small cervix, an acute flexion, and enlargement of the body of the uterus. In eight cases the cervix was normal, but the body of the uterus was heavy, and there was retroversion or exaggerated anteversion. In the last two cases there was erosion and hypertrophy of the cervix, but a normal uterus.

The symptoms in order of frequency were: (1) Pain or dragging sensation in one or both iliac regions, or pain in the lower part of the abdomen generally; (2) dysmenorrhea; (3) leucorrhoea; (4) menorrhagia and metrorrhagia; (5) remote symptoms, such as headache, bladder troubles, difficulty in walking, sickness, and nervous symptoms as a whole.

As regards pathology both the uterine mucous membrane and the mesometrium were hypertrophied. Examined portions of the mucosa removed by the curette demonstrated that in addition to the general hypertrophy, the interglandular connective tissue after a preliminary stage of swelling or cedema

presented the appearance of granulation tissue advancing towards the formation of fibrous tissue. In none of the specimens was there any inflammatory change.

In considering the cause of the abnormalities of the cervix and uterus found in the larger number of the cases it may be supposed either that there are two independent primary factors, the infantile cervix and the hypertrophied uterine mucosa, or that the hypertrophy results from the insufficient development of the cervix and stenosis of the internal or external os. In either case hypertrophy of the mesometrium follows hypertrophy of the mucosa, and the increased weight of the uterus, together with the small size of the cervix leads to the acute flexion. These cases may be mistaken either for cases of pure neurosis or for simple lack of development of the uterus as a whole. The permanence of the symptoms and their association with one another are rare in neurosis, while a vaginal examination shows that the uterus is of more than normal size.

My treatment is to curette the uterus thoroughly under an anææsthetic, wash it out with sterilized water, and pack for twenty-four hours with sterilized gauze. The results have been good in the 26 cases which have been followed up for some time; 14 are practically well, 10 very much improved, and only 2 have received no benefit. The full effect of the treatment is not experienced at once, and patients have continued to improve for six months after the curettage. The last symptom to disappear is usually the dysmenorrhea.

The alternatives to this treatment are dilation or incision of the cervix. The effect of dilatation is temporary only, while the cicatricial tissue resulting from the incisions may be distinctly harmful. Although marked retroflexion or retroversion may be present ventrifixation is not indicated. The simpler operation is effective and therefore preferable, and in one of these cases ventrifixation had been previously carried out without relieving the symptoms.

K. C. McIlwraith, M. D.:

I have been asked to present a re-statement of the attitude of the profession toward placenta prævia.

The first question that arises is, should we always proceed

to delivery as soon as hemorrhage comes on, whether the child be viable or not?

There are many diverse opinons on this subject, but all are agreed that there should be no temporizing unless the patient can be placed under constant trained supervision within easy reach of the physician. There must also be considered:

(1) The extent of the first hemorrhage, and its effect on the mother and fetus. If the fetus dies there can be no object in further delay. If the mother nearly dies, further delay is not justifiable, except for resuscitation as mentioned under treat

ment.

(2) The certainty or uncertainty of the diagnosis. There must be some uncertainty about this until the placenta can be felt through the os. At the hospitals I have had many cases come in with a provisional diagnosis of placenta prævia in which the hemorrhage was later found to be due to some other

cause.

(3) Whether the hemorrhage was unavoidable or brought on by causes which could be avoided in the future. Accidents are more likely to cause hemorrhage when the placenta is prævia than when it is normally situated. There is no doubt the unviable children have been saved by waiting, and when the conditions, as detailed above, are satisfactory it should be tried. The patient should be kept in bed and given opiates if necessary.

The next question is, what to do?

By far the most popular, and in my judgment the best treatment is to do a Braxton Hicks' version; bring down one leg, and then leave the delivery to nature, making only sufficient traction on the leg to check hemorrhage in the interval of the pains, and giving such aid as may be required to deliver the after coming head. In partial cases the membranes, and in complete cases the placenta must be perforated with a sharp instrument, as the endeavor to push the finger through detaches the placenta. Detaching the placenta is one method. of treatment, but not the one I am advocating. Rapid delivery in the interests of the child results but too often in laceration or rupture of the uterus, post-partum hemorrhage, and death of the mother. Bipolar version can be done as soon as the