in common:-1st, The women were multiparæ; 2nd, The labour was delayed; 3rd, The cause of delay was misdirection of the uterine power from anteversio uteri or pendulous belly; 4th, At the occurrence of the hæmatoma the head was still at the brim.

First, then, there is the common feature of pendulous belly. This, of course, when not associated with narrow brim, as it sometimes is in primipara, means anteversion of the gravid uterus from relaxation of the abdominal walls.

This is a question of degree so slight that the contraction of the uterus may be sufficient to remedy the displacements, or to such a marked degree that the fundus uteri comes to lie on a level lower than the cervix. Fig. 1 shows the varying degrees of pendulous belly, from slight inclination of the fundus forwards to that where the fundus lies on a level lower than the cervix.

Nay, more, cases have even been related where, owing to a split in the recti muscles, the gravid uterus has prolapsed through the aperture and reached almost to the knees, covered only by skin and fascia. In even moderate cases there is a certain amount of flexion as well, the under part of anterior wall of the uterus being bent over the anterior wall of the pelvis, the symphysis pubis acting as a fixed point (Fig. 2). In this way tension is made to a very marked degree on the vaginal walls. This tension is produced by two factors-1st, The tilting forward of the uterus over the symphysis-this, of course, being in direct proportion to the amount of anteversion; 2nd, By the uterine pains. They will, by drawing on the posterior vaginal wall, increase the tension already caused by the altered position of the uterus. (This condition is shown in Fig. 2.) It will be apparent, and it is a fact borne out by clinical observation, that the symphysis pubis acting as a fixed point, the greatest tension and stretching will be on the posterior vaginal wall. In an interesting and suggestive paper read to this Society some years ago by Dr Hart on Rupture of the Vagina, he drew attention to two facts bearing on the present subject-1st, That vaginal rupture is generally high up on the posterior vaginal wall; and 2nd, When it does occur, it is generally transverse. The posterior vaginal wall, especially at its upper part, is, during pregnancy, very thin. This thinning is increased in a normal labour by the uterine action dragging up the cervix and vaginal walls; but in the cases I have just referred to, there is the very great additional stretching induced by the abnormal position of the uterus, and the longcontinued ineffectual contraction of the uterine walls. The venous supply to the vaginal wall consists of a large plexus of veins, some submucous and some just outside the muscular coat, emptying themselves into the internal iliac. These veins, in common with the other veins in the pelvis, are valveless. Fig. 3, after Savage, gives some idea of the number and close distribution of these veins. In pregnancy these veins, to a greater or less extent, become varicose, owing, no doubt,

to the heavy uterus preventing the entrance of the venous blood to the vena cava. So uniformly is this varicosity present, that, under the name of Jacquemier's test, it has come to be recognised among the corroborative signs of pregnancy. Often the venous tissues become so distended with varicose enlargement that they become quite perceptible to the finger in the vagina, and can be felt projecting as well-marked cyst-like swellings. Further, it must be borne in mind that, in proportion to the amount of varicosity, so will the wall of the vessel be thin. Hervieux, Laborie, and others are not inclined to believe that varix enters much into the production of these vascular swellings. Perret has collected a series of sanguineous tumours of the vagina, cervix, and vulva, and points out that they occur more frequently by five times in primiparæ than multiparæ, and that they become proportionately rarer according to the number of the pregnancy. Now, in this record Perret mixed up all the varieties. One can easily understand how, under the enormous distending pressure on the cervix and vagina caused by the advancing head, the mucous membrane, carried down by the head, glides over the deeper tissues with a sort of tearing movement. The connecting submucous vessels are torn, blood is extravasated, and small ecchymoses or thrombi are formed. This will to a greater or less extent occur in every labour. But we must not be diverted from the point at issue. The cases I have recorded were all multiparæ, and hæmorrhage took place while the head was still at the brim, and while no pressure was being made in the vagina. The mechanism of the production seems to me to be this,-The thin varicose veins on the posterior vaginal wall all undergo stretching along with that structure by the uterine efforts; but, in the cases referred to, the tension is enormously increased by the anteverted position of the uterus; and further, this tension is long maintained by the ineffectual attempts of the uterus to right itself. What occurs is this during the labour one or more of these vessels give way under the strain, and rupture, but owing to the tension no hæmorrhage takes place. When, however, the case is recognised, and the uterine obliquity overcome, either by position or pressure, or both, the undue tension of the posterior vagina relaxed, the compression of the vessels removed, the hæmorrhage slowly and gradually takes place into the connective tissue. In this way it comes about that the rupture of the vessels takes place during the labour, but that the hæmorrhage actually occurs only after the displacement of the gravid uterus has been rectified. Into the prognosis, course, symptoms, and risks of these varieties of tumours it would be altogether absurd in me to enter; they are well described in every text-book. My object is simply to draw attention to a hitherto undescribed cause of their production, and if I may draw a practical lesson, I would add this as one of the risks. of labour complicated with a pendulous belly, and an additional reason for recognising and rectifying this form of dystocia early.

II.-ILLUSTRATIONS OF UNCOMMON MORBID CONDITIONS OF THE EAR, NOSE, AND LARYNX.

By P. M'BRIDE, M.D., F.R.C.P. Ed., F.R.S.E., Surgeon to the Ear and Throat Department of the Edinburgh Royal Infirmary, and to the Edinburgh Ear and Throat Dispensary; Lecturer on Diseases of the Ear and Throat, Surgeons' Hall.

(Read before the Edinburgh Medico-Chirurgical Society, 3rd February 1886.)

IN this paper I propose to bring under the notice of Members of this Society some cases which seem to me of more than ordinary clinical interest-illustrating as they do morbid conditions and symptoms which are less commonly met with, or which are liable to erroneous interpretation.

(1.) The Prognosis of Chronic Non-suppurative Middle Ear

Affections.

It is foreign to my purpose to attempt here an exhaustive discussion of this theme, to which, indeed, I have elsewhere referred at length. The fact I now wish to emphasize by illustrations is that the surgeon should not be too ready to regard as hopeless cases in which the tuning-fork is heard by bone conduction worse in the deaf or deafer ear, and in which tinnitus is a more or less constantly present symptom. This is demonstrated by the results in the two following cases, the histories of which are necessarily somewhat briefly recorded, owing to the fact that they occurred in private practice:

Mr, æt. 50, consulted me first on the 3rd October 1885. He had then suffered from singing in the ears for about 18 months, and slight deafness for a year.

Unfortunately, at this patient's first visit, my own watch was undergoing repairs, but that which I was wearing was heard on the right side at 12, and on the left side at 33 inches. This watch had a very loud tick, and could be easily heard at a distance of 15 feet by a healthy ear. The vibrating tuning-fork, when applied to the middle line of the forehead, was heard better in the left ear. Moreover, while it was perceived longer opposite the meatus than from the mastoid on the right side (ie., the ear which was more deaf), it was perceived better from the mastoid than opposite the meatus by the left or better ear. In other words, bone conduction was more interfered with on the side corresponding to the ear which was most impaired.

Both drum membranes were slightly thickened, but otherwise normal; air, however, entered the left tympanum more readily than the right by Valsalva's experiment. The patient had had attacks of giddiness, one rather severe, about a year ago. There 1 Transactions of the International Congress, London, 1881.