Eardley Holland

Cranial Stress in the Fœtus during Labour and on the effects of Excessive Stress on the Intracranial Contents; with an analysis of eighty-one cases of Torn Tentorium Cerebelli and Subdural Cerebral Hamorrhage.1

T H E frequent discovery of tears of the dura mater septa, associated with subdural cerebral hzmorrhage, in fe tuses dying during the course of labour, was one of the most striking features of this investigation.2 Out of 167 fresh fcetuses the tcntorium cerebelli was found torn in 81 (48 per cent.), associated with tearing of the falx cerebri in five cases and with subdural cerebral hxmorrhage in all but six. Most were the result of breech or forceps delivery, or of delivery through a contracted pelvis, but a few resulted from apparently normal labour. (These cases, with their more important details, are arranged in the table a t the end.) I am convinced that a proper understanding of the events which lead to these injuries, and of the manner in which they arise, will enable many cases of them to be avoided and f e t a l mortality to be correspondingly reduced. I propose, therefore, to discuss at

Methods of performing Cæsarean Section

The technique of the classical operation was perfected nearly forty years ago; it was in 1882 that the tentative efforts of certain obstetric surgeons culminated in the publication of Sanger’s important paper on the technique of suturing the uterine incision. Prior to this the uterine incision was not sutured u n l e s to control unusual haemorrhage, for the surgeons of those days were fearful of leaving suture material in the peritoneal cavity. Sanger’s method, with unimportant modifications, is that used by the vast majority of modern obstetric surgeons. The classical operation has well stood the test o f time, and deservedly, for it is extremely simple, and, with the general march forward of surgical technique its mortality has been reduced to such an extent that it has become a very safe operation. In consequence no opcration has in modern times had its list of indications so widely, and as .some consider so recklessly, extended as Cmarean section.

Malignant Melanoma of the Vulva.

MALIGNANT melanomata of the vulva are rare. The publication of a case, therefore, and a review of the cases that have hitherto been published, seems justified, especially as the subject has sor far not found its way into English literature, though occasional papers have been published in foreign journals. I have chosen to use the term “malignant melanoma” in preference t o ‘ I melanotic sarcoma,” the name which is usually given to these tumours. They are not all sarcomata, though probably the majority of them are. The present paper will embrace all malignant melanotic tumours or mclanomata of the vulva, whether they be sarcomata o r carcinomata. It may be said at once that the real nature of many of these tumours is still a debatable point amongst pathologists. In a recent paper, Blair Bell has discussed the subject of “pure sarcoma” of the vulva, and has reviewed the published cases. A review then of the melanotic variety of these tumours would seem t o complete the picture and fill in a gap in an interesting and important subject. My own case is the following :--The patient, an octipara, aged 73 , was admitted to the Hospital f o r Women, Soho Square, on August 10, 1907, under the care of Dr. R. T. Smith, to whom I am indebted fo r permission to publish the case. F o r 11 months she had noticed an irritation and itching of the vulva, which had drawn her attention to a tumour “like :t small black cherry.” Her doctor tied a ligature round the base of the tumour, allowing it t o slough off, subsequently cauterizing with silver nitrate. A month later thc same symptoms returned and she again noticed a similar tnmour in the same position as the former one, so her doctor sent her to the Hospital. On examination, an irregular ovoid tumour the size Qf a bantam’s egg, and of a black colonr, was seen occupying that part of the vulva immediately above the clitoris. It arose by a broad I shall refer to this again later.

REPORTS OF LYING‐IN HOSPITALS.

DURING recent years the annual publication of a clinical report has become one of the features of the various lying-in hospitals, and below we revicwthe reports of the Rotunda TIospital and of the &f aternity department of St. Mary’s Hospital, Manchester. These reports, especially when in such completeness of detail as these two, form a valuable coniribution to obstetrical literature. The description and tabulation of a large number of cases are not only of value from a statistical point of view, but form a medium for interchange of thought and comparison of methods of practice. Prom the succebses of our colleagues we may learn t o retain much that is good, and from their failures we may be taught to reject methods which have not proved of service in their hands. Useful as these reports undoubtedly are, their usefulness could be much increased if they mere drawn up, as far as possible, on a uniform plan as regards the tabulation of cases, and methods of treatment. I n the estimation of morbidity, for example, three different standards are used--the British Medical Association, the Rntunda, and the Queen Charlotte‘s Hospital standards. (An admirable comparison of these standards is given by Dr. C. Nepean Longridge, in the Report of Queen Charlotte’s Hospital for 1907.) With a little give and take on all sides, the authorities of the various lying-in hospitals could ~ e l l come to some agreement in this matter, and decide on a definite system f o r the drawing up of their future reports. Thry would then confer a real benefit on the science of obstetrics.

A Case of Intra‐uterine Death of the Fœtus Occurring in Six Consecutive Pregnancies: with Observations upon the Importance of the Examination of the Fœtal Tissues for Spirochæta Pallida.*

A.B., aged 24, was first seen by Dr. Williamson on November Brd , 1903. She came to the Royal Waterloo Hospital because she had given birth to two still-born children, and, believing herself to be pregnant again, wished to know if anything could be done to prevent a similar mishap. Menstruation commenced at 17, and occurred regularly every twentyeight days until the time of her marriage. She w a ~ always a healthy girl, and was one of a family of five; her brothers and sisters are all married, and all have living children. She married at the age of 23, and two months later became pregnant. after 26 weeks’ gestation she was delivered of a still-born child. Six months later she again became pregnant, and again gave birth to a dead child at the end of the 28th week. Dr. Williamson saw her five months after this event. On examination he found she was three months pregnant, but could discover no abnormal condition in the pelvis, and no signs of any general disease. The question of syphilitic infection was carefully inquired into, but with an absolutely negative result. Neither she nor her husband had even followed any injurious occupation. The cause of the death of the fe tus therefore remained a mystery. She was treated with small doses of chlorate of potash, and was lost eight of for nearly two years.