A METHOD OF SECURING FIXATION AND
HARDENING OF THE CENTRAL NERVOUS
SYSTEM BEFORE THE AUTOPSY.*

By B. ONUF (ONUFROWICZ), M.D.,
"PATHOLOGIST TO THE CRAIG COLONY, SONYEA, N. Y.

WHETHER the method herein described is new' I do not know. It was new to me and it is certainly not generally known, otherwise the complaint of the inability to preserve the central nervous system within a few hours after death, consequently the impossibility of studying the finer structural changes in a given case, would not be heard so often.

The method is comparable in its simplicity to the egg of Columbus. The procedure consists in injecting as soon as possible after death a strong solution (12 per cent.) of formalin, first by lumbar puncture, then through the foramen magnum. The former hardens the spinal cord, the latter the brain. By use of a T branching tube, both injections can be combined in one act.

The details of the procedure may be varied according to necessity and further experience.

My first attempt, which proved surprisingly successful, was made with an aspiration needle and the Dieulafoy syringe.

R

Since then I have learned to use a Davidson ball syringe with equal success. It is known that the pump of the Dieulafoy syringe can be used in two ways, according to the manner in which it is connected, i.e. either for exhausting the air or for compressing it. In this procedure it is used for compressing the air.

The subjoined illustration shows the manner in which the apparatus is put together. It is convenient for the purpose to use a bottle with three mouths. This bottle is filled with the injection fluid. Mouth C has a rubber stop through the bore of which passes a glass tube down to the bottom of the vessel. At its upper end this glass tube is connected with the rubber tube ZZZ, preferably non-collapsible, to which is attached the aspiration needle. The latter attachment is by metal contact only, as is the case with many hypodermic needles which fit the barrel of the syringe by contact only instead of by a thread. Such an arrangement has the advantage of being easily detachable.

Mouth B is closed with a common cork or rubber stopper. It can be used for refilling the bottle when the fluid is almost exhausted without disturbing the other arrangements.

Mouth A has a rubber or cork stopper through the bore of which passes a T-shaped tube with which, by means of a thick-walled rubber tube RRR *From the Pathological Laboratory of the Craig Colony for Epileptics, Sonyea, N. Y.

(preferably non-collapsible), the Dieulafoy syringe is connected. Stop-cocks of this T-shaped tube has to be kept open; stop-cock T of the same tube has to be kept closed. It hardly needs mentioning that the tube passing through the bore of the stopper of mouth A must not go down deep enough to reach the fluid. In other words, the bottle must not be filled so high as to have this tube immerged in the fluid.

The Dieulafoy aspiration syringe has two outlets, X and Y. If the rubber tube RRR is connected with outlet X, the action of the pump will exhaust the air in the bottle. If the rubber tube RRR is connected with the outlet Y of the pump, the action of the latter will, on the contrary, compress the air in the bottle.

The manner of required connection (namely, for compression) is indicated by arrows on the syringe. Moreover, a few trials will very soon show whether the pump is arranged for compression or for ex

haustion.

After the apparatus has been put together in working order, one proceeds as follows:

The aspiration needle is detached from tube ZZZ and is introduced into the dural sac in the same manner and locality as in lumbar puncture. In doing so it is advisable to put the corpse into a

sitting or semi-inclined position so as to let the cerebrospinal fluid accumulate in the lowest portion of the dural sac.

A trocaris preferable to a needle because the latter is apt to become obstructed by fat. There may or may not be an escape of fluid from the needle if the puncture is successful. The real test of the success lies in the result of the pumping, i. e. whether, when the pumping is started, the level of the fluid in the bottle is lowered.

After the needle, or trocar, has been introduced with apparent success, the pump is put it action, causing a compression of the air in the bottle ABC, pressing the fluid into the glass tube passing through C, and thence into the rubber tube ZZ. The pumping is continued until the fluid spurts out in a continuous stream from tube ZZ. At this moment, tube ZZ is quickly attached to the aspiration needle and the pumping is the continued. If the experiment was successful, the level of the fluid will now become lowered in the bottle. In case of doubt a mark designating the upper level of the fluid will soon show us whether this level is becoming lower or not. If it does not sink, this means either that the needle, of trocar, has not reached the spinal canal, or that the needle is obstructed by fat and other material. In such case tube ZZZ has to be detached and a wire is passed through the needle. If this is unsuccessful, the needle must be withdrawn and introduced a second time.

I may here add that my experiment succeeded only after I had introduced the needle for the third time. The question now arises how long to continue pumping. My experience is that, after a time the fluid sinks very slowly and the pumping be comes very difficult. Moreover, air is heard sizzling out around the corks or around the tubes passing through the corks, and from time to time the corks are forced out of the mouths. This is about the time to cease, and this forcing out of the coris serves as a safety valve, preventing, in all proba bility, the pressure of the injection fluid on the curd from becoming so high as to injure the tissues.

The idea is first to fill the entire dural sac with fluid and after that the whole spinal canal, into which the fluid will naturally ooze when the dura' has become entirely filled.

One next proceeds to harden the brain. The needle, or the trocar, is introduced into the fourth ventricle, at least that is the aim. The skull is palpated to locate approximately the foramen magnum, then the needle is tentatively introduced in the neighborhood of the foramen magnum and in a direction presumably parallel to the floor of the fourth ventricle. If it strikes bone, it will be rather easy to say whether such is the occipital bone or the spinous process of one of the upper cervical vertebræ. On the whole, it is better at first to strike too high, i.e. against the occipital bone. In such case the needle is taken out again and introduced a little lower down. One can thus gradually feel his way until he strikes just inward of the dorsal margin of the foramen magnum. The needle is then pushed deeply enough to enter the fourth ventricle, not deep enough, of course, to injure the cerebellum or oblongata. Whether the needle really needs to enter the fourth ventricle I do not know. Indeed it seems hardly necessary since the foramen Magendie gives sufficient means of communication between the ventricle and the surface of the cerebrum and cerebellum, so that, if only the subdural or subarachnoid space is entered, the fluid should have a good chance of being distributed over the surface of the cerebrum and cerebellum as well as to the ventricles.

The particulars will have to be learned by experience. Injury to the adjacent parts, cerebellum and oblongata, should of course be avoided. In my case neither of these structures showed any evidence of injury; but choosing between two evils, injury of the cerebellum would, on the whole, seem less harmful, special cases excepted, than injury of the oblongata. By keeping well in the median line, injury to both these parts can probably be prevented. If the needle should enter into the brain substance, this would soon be shown by the failure of pressing the fluid in, after the needle has been reconnected with the pumping apparatus and the pumping commenced. In case of success, the level of the fluid in the bottle will soon become visibly lower. As to the quantity of fluid to be used, I may say that, in my first attempt, about one-half pint was introduced into the brain and about four ounces into the vertebral canal.

Whether it is necessary to use a Dieulafoy aspiration, or rather compression, syringe for the injection, I cannot tell. As I have mentioned already, the same results may be obtained with the much cheaper Davidson syringe or with a similar ball syringe, in which case the bottle described can be done away with. Let me also repeat here, that by the use of a T branching tube, one end of which is connected with the pumping apparatus, the second end with the aspiration needle, passing into the lumbar sac, and the third end, with the needle passing into the forameg mannum, the two injectors, i.e. that into the ducal sac of the spinal cord, and that through the foramen magnum, can be combined in one procedure, thus saving time and equalizing the pressure of the fluid.

I shall now relate the results of the injection in our first case, which was made about one hour after death. First, however, let me mention that the body was then placed in the ice-box in usual position, i.e. lying on the back. This is, of course, the most common position, but there is a particular reason for mentioning it, as will be seen later.

The autopsy was made forty-three hours after death, the body being left meanwhile in the ice-box. The peculiarity was then noticed that the fat of the abdominal wall was of an abnormally firm, waxlike consistency and of a dark, dirty

brown-gray color, while that of the thoracic wall had the usual appearance and consistency. On opening the abdomen, the fat of the mesentery in the lower portion of the abdomen was found to have the same peculiarity as that of the abdominal wall. I suspected that this was due to the effect of the formalin.

Further examination showed that a great portion of the liver also had a peculiar appearance, and here there was no doubt that such was due to the effect of the formalin, since the tissue in some parts looked whitish and was so hard that no other explanation was possible. I then felt certain that the peculiar fat referred to was due to the same cause.

First I was at a loss to account for this fact, but it now seems clear enough. It is natural to assume that, after the vertebral canal became filled with the injection fluid, it began to penetrate through the foramina intervertebralia into the surrounding tisIt should be added, however, that the lungs, heart, spleen, pancreas, and kidneys showed no formalin effects, which is of value to know, as it shows that the spinal cord and brain may be preliminarily hardened without diminishing the value of an ordinary autopsy, to be made later on.

sues.

As to the effect of the injection on the spinal cord and brain, it surpassed my most sanguine expectations. The spinal cord was completely hardened in its entire length and thickness, as shown on a transverse section made through the middle dorsal region and as shown by its hard consistency through the entire length.

The brain also was, to all appearance, more or less hardened throughout. It showed the same elastic hardness which a brain shows after injection of a 10-per-cent. solution of formalin into the aorta (with tying off of the thoracic aorta), as practised by Drs. Adolf Meyer and Dunlap at the Pathological Institute of the New York York State Hospitals. Twenty-four hours after removal of the brain the Meynert section was performed, i.e. the pallium. (hemispheres) was separated from the rest of the brain. It was then shown that the formalin had penetrated everywhere. The hemispheres were found hardened in their whole thickness. The basal ganglia were also hardened, although in varying degree the caudate nucleus less than the thalamus; but all parts showed the effects of the formalin. An absolute hardening of all parts could, of course, not be expected; but the important fact was noticed that no part showed any post-mortem decomposition, i.e. softening and putrefaction. Without the formalin such changes could have been expected with certainty, in view of the fact that the autopsy was performed forty-three hours after death, even although the body was in the ice-box all this time.

However, the most valid proof and most delicate test of the preserving and fixing value of the method was given in its influence on the neuroglia. That this tissue suffers very quickly through postmortem disintegration is known to everybody. familiar with it, and if in a given brain the neuroglia stains well, this is always a proof of early preservation and fixation of the brain. In the first case in which the method of preliminary formalin injection was made one hour after death, and in which the autopsy was performed forty-three hours after death, pieces from four different regions, namely, cerebral cortex, cerebellar cortex, medulla oblongata and caudate nucleus, were removed twenty-four hours after the autopsy and subjected to the procedures required for the Mallory Phosphotungstic-hematoxylin neuroglia stain. The stain succeeded very well in all four regions, but of particular value was its success in the caudate nucleus which, as men

tioned above, was softer than the other parts of the brain, i.e. not so well acted upon by the formalin. How well it succeeded is seen by the adjoining figure showing the neuroglia fibers and neuroglia nuclei of a part of the caudate nucleus. The penetrating value of the method is thus very aptly shown.

The great value of the method needs hardly to be emphasized. Every neuro-pathologist knows how important it is to fix and harden the central nervous system no later than six hours at the most after death. Here, we have means of preserving it immediately after death without inflicting any mutilation on the body and without changing the appearance of the intra-thoracic and

Figure showing a portion of the caudate nucleus stained with Mallory's phosphotungstic-hematoxylin neuroglia stain. Taken with Leits' ocular 4 and immersion 1-12 in.

intra-abdominal organs (with the exceptions mentioned) through the formalin.

The method has this advantage over the otherwise excellent method of formalin injection into the aorta as practised by Drs. Meyer and Dunlap, and elaborated in such an ingenuous manner by these gentlemen-it can be applied immediately after death in cases in which we are doubtful whether an autopsy will be permitted or not.

It has the further advantage over that method, of hardening not only the brain, but also the spinal cord; and the result is not inferior to that of their method.

An additional advantage is the small quantity of formalin required, one quart at the most being needed as against the 1 to 3 gallons necessitated in Meyer's and Dunlap's method; and this advantage is not to be undervalued in view of the relatively high price of this drug.

WHEN I was requested to open the discussion on "Occipitoposterior positions," I thought that the last word had been said on this subject that is, so far as the reader is concerned. The question of the management of occipitoposterior presentations has resolved itself into one of relative simplicity, not that any particular schematic therapeusis will be offered; for schemes in obstetrics, as well as in other specialties of medicines, often go wrong, but the experience offered by meeting many of these cases has allowed me to present fixed, though hardly dogmatic, views on the subject before us, for it is the belief that a finality has been reached with this question, as well as with many other obstetric questions. To be forewarned as to this complication is to be forearmed. It is far more frequently met than is usually thought and taught. But it occurs most frequently as a primary condition and at so early a stage is *Discussion opened before the Obstetric Section, New York Academy of Medicine, April 28, 1904.

certainly not recognized or is not sought for; for it does not enter the mind of the attendant that it is possible to have a malposition of a normal presentation. Of my own personal statistics, I quote from my case book that in the last one hundred consultations in midwifery I have come in contact with twenty-three cases of persistent occipitoposterior positions. This, of course, does not carry with it much importance as to the absolute frequency of this complication, for as a consultant it is most natural to see nothing but complications. But of more importance is the careful review of the cases under my personal care, i.e. private casesthose examined from the onset of labor and in which there has been an early determination of the position, before the head has been markedly influenced. Here I have noted, in one hundred cases, seventy primarily posterior occiputs, cer tainly a larger percentage than I had any idea of; and we doubt not that if all practitioners took the necessary care for a careful and early examination the same high percentage would be found. For this reason I wish to record the fact that primary malpositions of the occiput are present in a much larger number of cases than we are led to believe. How much higher still the percentage may be before the advent of labor is impossible to tell, except by abdominal palpation, but for reasons elsewhere given I pin my faith on internal examination, relegating abdominal palpation to the position to which it belongs-namely, one of absolute unsafety.

And this leads up to the question of diagnosis. Even without an internal examination, the symp toms presented are so characteristic that a presumptive diagnosis can very often be readily made, and this triad of symptoms ought always be associated with a possible vicious presentation of the occiput, ie. early rupture of the membranes, slow nagging and teasing pains and abnormal slow and futile labors. Such evidence can always be clinched by a vaginal examination, or, if the least doubt exists, the introduction of the full hand into the canal. It is absolutely essential for successful treatment to make an early and a clear diagnosis not only of position. but of presentation; and in this I am sorry to say too little is done, for the average practitioner always rests satisfied so long as the hard head presents, caring little or bothering less what area of the fetal head present. Early recognition and timely interference is more than half the battle won, for by such means we can, in an overwhelming majority of cases, change the case from an almost impossible one to one the greatest simplicity, and thus carry it to a suc cessful issue. But of the greatest import is still: What are you going to do in order to cope successfully with these cases? It must be remembered that a firmly flexed head will almost always rotate spontaneously, and that the first step in the treatment of these cases is to insure a permanent and marked flexion; and this can be most readily done by pressing, throughout several pains, the sincip against the chest of the child by two fingers, or the introduction of the full hand in its grasp, exing the occiput and thus obtaining the same result. The permanency of this sustained flexic is assured by using the postural treatment, i placing the patient in that lateral prone position corresponding to the position of the occiput. These minor manipulations done early and carefully, as above described, will, in the great majority of cases cause the head to rotate with resultant normal and spontaneous expulsion. It is advisable to under take operative measures at a late period; cr to be more concise, operate only when there are

present, symptoms to indicate that interference is warranted, symptoms the interpretation of which mean exhaustion on the part of the mother or child. In obstetrics early and uncalled interference is unwarranted and may lead to disastrous ends, while working in armed expectancy is often followed by remarkable and favorable results for mother and child, if only for the reason that in this complication, rotation occurs in a large majority late, i.e. when the head is low down on the pelvic floor. secret of success lies in two directions: (1) operate only in the face of clear indications on the part of either mother or child; (2) operate at once when there is tendency to posterior rotation.

The

When either of the just mentioned conditions arise how are we to meet them?

Cæsarean section and symphyseotomy are included for the reason that we presuppose that we are dealing with a pelvis that is normal, and consequently these operations are beyond the scope of this paper. Yet it occasionally may happen that either one of the just quoted operations might have to be considered, especially the pubic section, in those rare cases in which the occiput is absolutely impacted and no other means can possibly give us a living child.

In quite a few of these cases, the perforator ought always be the instrument of selection, for it would be the height of folly and directly against the interests of the mother to attempt to deliver by another means than by a craniotomy upon a child whose life has already been sacrificed or at best whose vitality is so low that any form of operative measure would deliver a dying or hopelessly maimed child. A rule which I strictly adhere to, so far as circumstances allow, is to elect the perforator in all those conditions just mentioned, only in the presence of a child of good vitality I should elect either forceps or version, and my selection of these methods is practically sharply defined, i.e. version when the head is above the brim, forceps when the head is fixed at or below this point. What I wish to elucidate in this paper is the absolute value of the modern axis traction forceps. But I would The preface my remarks by a note of warning. modern axis traction is a dangerous instrument for the inexpert, even as it is absolutely safe in the hands of one accustomed to its use. It is a forceps for the expert only; and if by its use bad results accrue it is not the fault of the forceps, but of the operator. Its method of application and its action have been more fully gone into in another paper and

cannot be entered into more fully here. But one important method of delivery will be discussed at length, and that is the method which has given almost uniform success and satisfaction. I have given it the name of "rotary axis traction," for by this manoeuvre we fulfil a compound indication, i.e. axis traction and, at the same time, artificial rotation. These, as you will readily see, are particularly applicable to cases of posterior position of either the vertex or the face. I cannot improve upon my statements made in a former article and shall take the liberty of quoting the following from the same: In many of these cases of occipitoposterior positions I have succeeded, by the use of the Tarnier instrument, in rotating the head anteriorly by simply allowing it, while traction is being made, to be influenced by the factors supplied by nature (the resistance offered by the perineal structures and furthered by the turning points afforded by the ischial spines, especially when they are prominent) to provoke such rotation. And herein lies the utility of the instrument. allows the head to pass uninfluenced through the pelvic canal, except for the natural influences which promote rotation; hence the great advantage is the

It

free mobility of the forceps when applied to the head. This rotation begins to occur when the head descends to the pelvic floor, and is instantly evinced by the behavior of the blades-they begin to rotate with the head, the movement increasing with every traction effort, until the forceps has entirely rotated. When, however, such tendency to rotation does not occur, the normal mechanism is probably at fault, and it is then that "rotary axis traction" becomes of supreme value. The forceps may be applied according to the pelvic walls; but an oblique application, i.e. to the sides of the child's head, is better. When in such position, it conforms to one of the oblique diameters of the pelvis, insures a more certain grasp, and very materially aids in the success of this otherwise rather simple manoeuvre. With the right hand, steady traction is made, and at the same time, with the left hand, the handles of the forceps are compelled, or at least influenced, by gentle rotation to turn in the direction of the presenting part; to the left in left occipitoposterior cases, to the right in right posterior ones. This manipulation must be persisted in, slowly rotating all the time while making careful and intermittent traction, timing our measure so that when the head reaches the pelvic outlet, complete rotation shall have occurred and the forceps blade shall be found nearly or entirely inverted. At no time should brute force be used, but the greatest gentleness exercised at all times. I have on a number of occasions tried forcible rotation by the ordinary forceps, and have succeeded, but often at the expense of the maternal structures, with resulting deep tears of the vagina and pelvic floors. "Rotary axis traction" has been tried innumerable times, and it has seldom failed when the forceps was applied to the sides of the pelvis, and never when it was applied to the sides of the fetal skull. The resultant lesions were no deeper or more frequent than in ordinary simple forceps extractions. The prognosis for the child was as good as under ordinary conditions.

*Since writing this article, however, I failed in one case to rotate even though the blades were applied to the sides of the fetal skull.

BRIEF NOTES ON THE MANAGEMENT OF OCCIPITOPOSTERIOR POSITIONS OF THE

VERTEX.

LY JOHN O. POLAK, M.S., M.D.,
BROOKLYN, N. Y.

PROFESSOR OF OBSTETRICS, N. Y. POST-GRADUATE MEDICAL SCHOOL.

THE Occurrence of a posterior position of the vertex is always indicative of faulty mechanism, it matters not whether the fault be a pelvic contraction of the flattened, general, oblique, or kyphotic form, a large head, a small child or a defective pelvic floor, imperfect flexion of greater or lesser degree, always occurs at some stage of the mechanism. Consequently when this malposition does present, it suggests some defection in the factors of labor and a recognition of the cause in the particular case must be appreciated before any treatment can be instituted.

Diagnosis. Before labor and during the early part of the first stage, the diagnosis of occipitoposterior may be readily made by abdominal palpation. The dorsal plane is inaccessible, while the small parts are prominent and found in the middle section of the abdomen. The head is usually not engaged at the beginning of labor, which makes the cephalic prominence marked. The anterior shoulder is found remote from the median line and the heart is heard well around toward the flank or not heard at all. Right occipitoposterior must always be thought of in right dorsal positions, as it occurs nearly or quite as frequently as a right anterior position. A left posterior is less frequent than a right. The

vaginal signs are confirmatory. If the head is engaged, the small or posterior fontanelle may be felt opposite one or the other sacroiliac synchrondrosis with the ball of the occiput posterior. Usually, however, the head is not engaged at the beginning of labor, and further it is frequently improperly flexed, because of the conditions which obtain, in the causation of posterior occiputs. Hence the large fontanelle is at a lower level and is more easily felt. Palpation of the ball of the occiput and the relative location of the ears will make the diagnosis positive. It must be kept in mind that the most frequent cause of fetal dystocia is a posterior position of the vortex and when such is encountered, should there be any doubt in the mind of the operator as to the relations of the head to the pelvis an examination under anæsthesia with the hand in the vagina and two fingers or half the hand introduced into the uterus will remove all uncertainty. The relation that the sagittal suture bears to the diameters of the pelvis is a constant index as to the degree of rotation and must be observed to manage intelligently this abnormality.

Treatment. The majority of posterior cases rotate to the front unaided when the passenger, powers and passages are normal or can be made to assume relative normality. Less than 2 per cent. rotate into the sacrum, notwithstanding that the head must rotate through 135° to be delivered with the occiput under the pubes. This rotation takes place either at the brim, in the cavity of the pelvis or on the pelvic floor.

When the diagnosis is accurately made in the beginning of labor, posterior positions are not as formidable as generally believed. The dangers to the mother are exhaustion, lacerations, and the risks of instrumental interference. To the child-those of a prolonged labor. In considering the management of this abnormality, it is advisable to study the individual case as it presents at the time when it is seen by the accoucher.

Therefore I would classify these conditions as follows:

1. With the head at or above the brim, flexion more or less imperfect, and the membranes unruptured. In the presence of these conditions, postural methods alone deserve our consideration. The woman should be placed on the side toward which the occiput points and directed to maintain this position, which favors anterior rotation and more perfect flexion of the vertex. The genupectoral position which is mentioned in most of our textbooks cannot be maintained by the patient for any length of time and so is only of theoretical value. Every effort should be made to keep the membranes intact until complete dilatation of the cervix is obtained. When dilatation is slow a colpeurynter will facilitate canalization and preserve the membranes.

2. After rupture of the membranes with the head at the superior strait, postural methods may be continued while efforts are being made to dilate the cervix with hydrostatic bags, unless the condition of mother or child demand more radical intervention. After dilatation, a fair trial having been given to posture and the natural forces having failed to rotate the head to the front, manual rotation of the head to the front and engagement of the head by internal and external manipulation, under anæsthesia, may be attempted. This procedure presupposes a dilated or dilatable cervix. The one hand placed on the mother's abdomen pushes the anterior shoulder toward the median line, while the other hand in the uterus pushes the other shoulder in the opposite direction, thus rotating the dorsum anteriorly, as

well as the head, and the tendency to recurrence is minimized. When the malposition of the occiput has been corrected, an attempt to engage the properly flexed and positioned head may be made with the patient in the Walcher position, either by crowding the head into the pelvis manually or by tentative traction with the axis traction forceps. Should this attempt to engage the head fail, podalic version may be elected, except when the size of the child would contraindicate such a procedure. The writer feels that while version is theoretically the proper thing to do in these posterior cases, which have resisted the several efforts of the operator to flex and engage the vertex, experience in estimating the relative size of the child and the pelvis as well as the individual dexterity of the operator will largely determine whether an axis traction delivery or a podalic version shall be elected.

When the head presents as an occipitoposterior in the cavity, anterior rotation may be favored by posture, used in conjunction with manual aid during the pain, by pushing the sinciput upward and backward, thus promoting flexion and anterior rotation. Should the head become arrested and remain stationary for two hours in the second stage, the forceps may be applied, either to the sides of the pelvis and taken off and reapplied as the head assumes its relation to the different pelvic planes or the axis traction forceps may be applied to the sides of the head and be used as rotators as well as tractors, guided by the relation of the saggital suture.

When a posterior vertex is encountered on the pelvic floor, the occiput may be rotated to the front manually or with the reversed forceps, though this possibility only obtains in the case of a small fœtus on a relatively roomy pelvis. Should attempts at rotation of the occiput fail and a posterior position persist, the brow may be pushed upward to exag gerate the flexion while the occiput is slipped over the perineum with more or less tearing of the pelvic floor.

Posterior positions are apt to tire the woman and exhaust the child. The foetus often becomes asphyxiated while in the vagina. The judicious use of forceps will minimize these risks.

In conclusion I would add, make the diagnosis and then apply such treatment as the individual case demands, being governed by the existing conditions at the time at which the patient is seen by the attendant.

287 CLINTON AVENUE.

Exanthematous Eruptions Following Throat Operations From his personal experience and from a careful study of the literature of the subject, Louis Fischer believes that exanthematous eruptions, such as scarlet fever or measles. have nothing to do with the operation itself. The infection evidently takes place before the operation. Th. period of incubation may have been shortened, and that the disease appear sooner owing to the traumatism. The question of prophylaxis by means of local pharyngea antisepsis to destroy pathogenic bacteria in these regions is one that deserves attention. It is important to ascess tain, if possible, whether or no the patient has been 2posed to any infectious disease for a number of days prie to the operation. The thermometer is of valuable as sistance. If the temperature is above normal it s better to postpone operative procedure until norma conditions are established. Fischer believes the infect: 2 takes place before the operation, and that the operatic itself lowers the resistance of the body, and shortens the period of incubation. This will account for all of 'is cases and those reported by many clinical observers, beng called surgical scarlet fever, when in reality they are tre cases of scarlet fever, infected prior to the operation The Laryngoscope.