PART I.-ORIGINAL COMMUNICATIONS. 1. J. Halliday Croom, M.D., etc.—Vaginal Hæmatoma—with a Plate, 3. Alexander James, M.D., etc.-Pulmonary Phthisis in Connexion with 4. George A. Berry.-Subjective Symptoms in Eye Diseases, . PAGE 1001 6. Francis Wm. Grant, M.D., etc.-Case of Total Excision of Tongue, 7. J. L. Milton.—The Unity or Duality of Syphilis Historically considered,. 1044 8. W. Scott Lang, M.B., M. R. C. S.-Report of Cases in Mr Bell's Wards, 1. A Manual of Dermatology. By Prof. A. R. ROBINSON, 2. Von ZIEMSSEN's Handbook of General Therapeutics, Vol. III., 3. A Handbook of Therapeutics. By Prof. SYDNEY RINger, M.D., . 4. The Prescriber's Pharmacopoeia. Edited by Prof. NESTOR TIRARD, M.D., 5. The Pocket Pharmacopoeia for 1885. By ARMAND SEMPLE, B. A., etc., . 6. The Essentials of Materia Medica and Therapeutics. By A. B. GARROD, MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH.-SESSION LXV.-MEETING Monthly Report on the Progress of Therapeutics, by WM. CRAIG, M.D., etc.- Periscope of Medicine, Clinical and Pathological, by G. A. GIBSON, M.D., and WILLIAM RUSSELL, M.D.-Occasional Periscope of Der- matology, by W. ALLAN JAMIESON, M.D.-Periscope of Syphilology, Royal College of Physicians, Edinburgh.-Honour to Dr Keiller.—Pure ET PEPSIN CO. (OPPENHEIMER'S.) This elegant preparation is a combination of Euonymin (from which, by an improved process, all the medicinal virtues are extracted and rendered soluble) with pure Pepsina Porci in a fluid and concentrated state. The specific stimulating and cholagogue action of Euonymin on the biliary organs, in conjunction with pure pepsine, has proved Liq. Euonymin et Pepsin Co. to be of great advantage in cases of irritative dyspepsia, with atony of gastric or intestinal muscular layers, and especially in relieving pain accompanying gastric carcinoma, pyrosis, and in dyspepsia with water-brash. 66 DOSE: ONE DRACHM IN WATER. From the British Medical Journal," Feb. 14th, 1885. "An exceedingly valuable preparation, combining, in a very useful and palatable form, a valuable hepatic and digestive agent. It meets a want felt by prescribers in the treatment of indigestion and flatulence due to deficient secretion of bile, as well as atony of the stomach and insufficient secretion of gastric juice. In practice we found it very convenient and valuable." F. J. B. Quinlan, M.D., L.R.C.S.I., F.K.Q.C.P., M.R.I.A., etc., etc., Professor of Materia Medica and Therapeutics, Catholic University Medical College; and Examiner in Materia Medica and Therapeutics, Royal University, writes in the "Medical Press," July 15th, 1885. "Every practical physician is familiar with the efficacy of Euonymin as a hepatic stimulant, and Pepsin has passed into the list of therapeutical requisites. Messrs Oppenheimer Bros. & Co., of London, furnish an excellent Liquor Euonymin and Pepsine, which appears to combine very well the properties of both remedies. I have tried it (in doses of a teaspoonful at every meal) in several cases of atonic dyspepsia with torpidity of the liver, and with the best results. Tried by the egg albumen process, a drachm of the liquor at 130° Fahr. effectually peptonises gr. 72, 3 of egg albumen previously triturated through the standard gauze. This is a result of the most satisfactory kind, and one which none but the very best pig Pepsins will equal." Prepared only by OPPENHEIMER BROS. & CO., Manufacturing Chemists, 1 and 3 SUN STREET, FINSBURY SQUARE, LONDON, E.C. Price 10s. 6d. per pound, packed (for Dispensing only) in 8 oz., 16 oz., 32 oz., and 64 oz. Bottles. 18 Part First. ORIGINAL COMMUNICATIONS. I. ON THE ETIOLOGY OF VAGINAL HEMATOMA By J. HALLIDAY CROOM, M.D., F.R.C.P.E., F.R.S.E., Physician to the Royal Maternity Hospital; Physician for Diseases of Women, Royal Infirmary; Lecturer on Midwifery and Diseases of Women, Edinburgh. (Read before the Edinburgh Obstetrical Society, 13th March 1886.) SANGUINEOUS tumours, thrombi and hæmatoma of the vulva and vagina, whether occurring before, during, or after labour, are comparatively rare accidents. Under such a heading are included all collections of blood forming in the submucous or connective tissue, and they may be found in the cervix, any part of the vagina, labia, or perimetric connective tissue. The condition receives more or less attention in every text-book, and the varieties, with their progress, terminations, and treatment, have been exhaustively discussed, in lengthened memoirs, by Deneux, Laborie, Cazeaux, Hervieux, Hugenberger, and Barnes, and have received shorter notice from many others. Into the general question of the nature and management of these hæmorrhages in general it is no part of my present paper to enter. I wish, therefore, to eliminate, first, the blood extravasations which are limited to the cervix, and which in a minor form are familiar to most of us. In an aggravated and serious form they are at times associated with elongation and hypertrophy. This much I wish to point out, that they are the result of direct pressure and crushing. Second, Those which form in the labia vulvæ, and which are the result of unusual pressure applied to already distended and varicose vessels. My remarks apply entirely to that form of hæmatoma which is vaginal, usually confined to the posterior wall, and is developed during and after labour. Three such cases have come under my observation, and I now give a brief record of each. CASE I. occurred in the hands of one of my dispensary pupils. Mrs M., a multipara in labour with her sixth child. When I saw her the membranes had ruptured for twelve hours, and the head had made no progress though the pains had been strong. On examination I found the head at the brim and movable; os fully dilated. The cause of delay was obvious. The woman's lax abdominal EDINBURGH MED. JOURN., VOL. XXXI.—NO. XI. 6 L walls had allowed the uterus to become anteverted,—so much so, that the fundus uteri was on a level lower than the cervix, and consequently the uterine action was quite unavailing so long as the direction of the force was thus misdirected. I ordered the patient to have a tight abdominal bandage applied, and to have a full dose of ergot. Two hours afterwards the child was born. Next day I was asked by my pupil to see the woman, who complained of great bearing down pains, and something protruding at her vulva. On examination I found the perinæum bulging, and a dark swelling protruding from the vagina. I found the whole vagina filled by a large pyriform mass, base downwards, stretching from the posterior fornix down to the perinæum. She suffered much pain during the night, with strong expulsive efforts; and when she was seen in the morning, a rupture had taken place at the lower end of the vagina, through which had escaped free venous blood and clots. There continued considerable oozing from the aperture for a fortnight, during which time careful antiseptic washing was employed; and at the end of three weeks the tumour had entirely disappeared. CASE II. occurred in the extern department of the Maternity Hospital. The patient was a multipara in labour with her fourth child. As the patient had been in labour for ten hours, as the membranes had been ruptured for six, and as no progress was made, I was called to see the case and deliver with forceps. I found the pains very violent and strong; the head presenting, but not engaged in the brim. The uterus was markedly anteverted, the patient being a big, heavy woman, with a very pendulous belly. The uterine body was thrown well forwards, and somewhat flexed. The delay was evidently caused by the misdirection of the uterine force. I placed the woman on her back, and had a binder applied. On introducing my hand, some fifteen or twenty minutes later, into the vagina, I felt a distinct bulging in the fundus vaginæ in the posterior fornix. The nature of this I did not at the time recognise. As the head was movable at the brim, and did not engage even after the position of the uterus was rectified, I performed podalic version. I found a little difficulty in extracting the head from the vagina. With the last pains the placenta and membranes were expelled en masse. As violent expulsive efforts continued, and as she complained of great pain, and, although there was no hæmorrhage beyond normal, she looked somewhat collapsed, I made a vaginal examination, and found a large tumour bulging the posterior vaginal wall. It extended in a conical shape, the base being at the vulva and the apex at the cervix. Next morning when I saw the patient I found she had passed a restless night. There was pelvic pain, bearing down expulsive efforts, and retention of urine. On examination the vagina was so occluded that I could not reach the cervix. The conical nature of the tumour, its intimate connexion with the mucous membrane, its firmness and tenderness, as well as the fact that it reached quite down to and bulged the perinæum, combined with a rectal exploration, decided me in coming to the conclusion that it was a hematoma of the vagina. Rest, quiet, and opium were enjoined. The next day she was free from pain. There was no rupture of any part of the tumour. In four or five weeks the patient was well, and no trace of the tumour remained. CASE III.-Through the kindness of Dr Alex. Sinclair, I saw with him a patient whom he had delivered two or three days previously with forceps. She was a multipara with her fifth child. Dr Sinclair had used forceps because the head was delayed high up, owing to some degree of anteversion of the uterus. The patient had borne her previous children normally. Dr Sinclair told me that when applying his forceps he felt a swelling in the posterior fornix, and on that account experienced some difficulty in applying the instrument. The swelling on the third day was so large as to fill up the whole vagina, and so closed the canal as to make it impossible to reach the cervix. The perinæum was bulging, and at the junction of the perineal skin with the vaginal mucous membrane there was a rupture which had occurred the previous day, when Dr Sinclair was examining the tumour. The aperture was sufficiently large to admit two fingers, and on doing so the finger came in contact with a mesh-work of cellular tissue and clots. The nature of the tumour was clearly that of a hæmatoma. I need not stop to describe its further course beyond saying, that the cavity was washed out daily with an antiseptic lotion, the patient had no bad symptoms, and in a few weeks was quite well. The rarity of such cases may be gathered from the following statistics, viz.,-Hugenberger, St Petersburg Hospital, met 11 in 14,000 labours. Deneux saw 3 in forty years. Paul Dubois 1 in 14,000 labours. In Vienna Hospital 18 occurred in 33,241 deliveries. The records show that these extravasations are associated with very considerable danger. Deneux, out of his 60 cases, had a mortality of 11. Probably it is owing to this fact, Deneux being the earliest writer on the subject, that the opinion has gained firm ground that this condition is an extremely dangerous one. Now, this is scarcely the fact, for out of 50 cases collected by Winckel, death occurred only six times; and the three cases which I had just mentioned all recovered perfectly, and one had a normal labour subsequently. No doubt a good deal depends on their extent and situation, but so long as they are confined either to the vulva or vagina, remain of moderate dimensions, and do not begin in or extend to the perimetric tissue, they seem to be less serious than was at one time supposed. My present object is to point out what I believe to be the etiology of this form of vaginal hæmatoma, or, at all events, one of the causes. In whatever respects the cases I have recorded may differ, they had the following points |