nancy, takes its character of persistence from the hypertrophy of the heart. It is not to the same cause that we must attribute the greater frequency and severity of pneumonia in pregnant women, and as a consequence, the greater frequency amongst those so suffering, of abortions and premature labour. This condition also predisposes to epistaxis, hæmoptysis, various forms of metrorrhagia, and lastly, to cerebral hemorrhage.

Lastly, the author observes that this normal hypertrophy of the heart does not cease abruptly with gestation, but survives for a time, in relation perhaps to that afflux of blood to the breasts now become necessary for the lacteal

secretion.

[The Reporter has long had his attention arrested by clinical facts to the relation between pregnancy, labour, and pneumonia and bronchitis, but thinks it admits of doubt whether the condition of the heart noticed by M. Larcher offers a complete solution of this relation. With reference to the disposition to floodings, it is interesting to remark that Dr. Robert Ferguson, in his comments upon Gooch's works lately published by the New Sydenham Society, expresses his opinion that the peculiar form of hæmorrhage occurring with contracted uterus may be due to cardiac disease. Lastly, this observation of normal hypertrophy of the heart suggests further anatomical researches into the development of the cardiac nerves during pregnancy, more especially since Dr. Robert Lee has sought confirmation of his views as to the enlargement of the uterine nerves from dissection of the heart of mammals.-R. B.]

III. LABOUR.

1. Report of a Case of Cæsarean Section, with Observations. By EDWARD W. MURPHY, M.D. (Dublin Quarterly Journal of Med. Science, Feb. 1859.) 2. Removal of the Placenta in the Early Months of Pregnancy by Evulsion. By O. C. GIBBS, M.D. (American Medical Monthly, Dec. 1858.)

3. Statistical Researches on the Action of Ergot in Parturition. By M. DEVILLE. (Arch. Gén. de Méd., March, 1859.)

4. A Contribution to the Knowledge of Rupture of the Uterus and Vagina. By Dr. LEHMANN. (Monatschr. f. Geburtsk., Dec. 1858.)

1. Dr. Murphy relates an interesting case of Cæsarean section, and follows it by a valuable discussion on the operation. The case is briefly as follows: On the 11th of July, 1858, he saw, with Dr. Frazer, a woman, aged thirty, who had given birth to seven children at the full time; the last, two years before. The advance of mollities ossium seems to have dated from this labour. When in labour in July, 1858, it was found impossible to introduce two fingers between the pubic rami; by pressing back, however, against the coccyx, Dr. Murphy was able to get two fingers within the brim of the pelvis. In order to do so it was necessary to bend them forwards and upwards, to avoid the strongly projecting promontory. The pubic bones were doubled back so much that the space in the brim seemed hardly two inches in the antero-posterior measurement; on the left side it was contracted to half an inch, and on the right was open to about two and a half inches. Passing the finger round the brim, the space seemed scarcely larger than a florin, through which protruded the os uteri and membranes; the head could just be reached. Some time was given to see what the uterus would do to bring the head within reach of instruments. In consultation with Dr. West, the Cæsarean section was determined upon. The section of the uterus caused considerable hæmorrhage, which was soon controlled by contraction. The patient sank about fifty hours after the operation. Lymph was found on the peritoneum, both lining the abdominal parietes and the intestines. Near the wound the small intestines were of a dark red colour, and injected. The uterus presented a dark red surface

exteriorly; the divided edges were everted and widely separated, without any attempt at union. The pelvis was brittle throughout; all the articulations were loose, and the pubic and ischiatic portions of the coxal bones moved on each other. Both iliac bones were much distorted and very carious, the left being perforated in several places, and as thin as tissue paper; the right ilium was also very thin and diaphanous. The horizontal rami of the pubis were parallel, the pectineal eminence on the left side almost touching the promontory of the sacrum; the space by measurement was half an inch, but the bones were quite easily pressed together. The descending rami were also closed in, the left being carious and eaten through. The acetabula were also eaten through, and the head of the femur was in a carious state.

2. Dr. O. C. Gibbs discusses the propriety of forcibly removing the placenta from the uterus in cases where, hæmorrhage attending, it still remains adherent after abortions. He advocates the practice, recommending the use of the fingers, if sufficient; but otherwise, instrumental aid. He prefers an instrument described and figured by Dr. Carey in the American Medical Monthly,' vol. vii. He relates two cases. In one, that of a woman who had miscarried at three and a half months, the placenta could not be reached by the finger, and manual efforts failed. Very alarming hæmorrhage occurred. Carey's instrument, which has a claw-shaped extremity, somewhat curved, the concave surface being rough, the convex smooth, was introduced, and made to sweep the entire cavity of the uterus, carefully keeping the polished surface of the convexity of the claw towards its walls. Then dragging the placenta down by the claw, and using a finger to fill the office of a second blade to the forceps, it was removed. The hemorrhage immediately ceased, and the patient did well. In the second case, the patient was supposed to have reached six weeks of pregnancy. She had flooded for three days. It was concluded that the ovum could not be saved; it was removed by Carey's instrument with the same success as the first case.

3. M. Deville, in tracing the effects of ergot upon fœtal life, sets out by affirming that it is almost always easy to determine the causes which have destroyed an infant in utero, such as premature delivery, vicious presentations, &c. When, he proceeds, none of these causes exist, and a mature, healthy child is born dead, presenting all the appearances of asphyxia, it may be declared that ergot has been given. Analyzing various documents collected during the years 1845 to 1848, in Paris, M. Deville arrives at this result: that out of 515 still born children, 72, or about one-seventh, perished from ergot. Researches continued by M. Deville since 1848, show that the number of stillborn children tends to increase every day, and that this increase is owing to the administration of ergot or to induced abortions.

4. Dr. Lehmann contributes a very valuable essay, accompanied by 11 cases, on rupture of the uterus. As to the frequency of this accident, it is reported to have occurred in 8 cases out of 10,387 labours by J. Clarke, in 1 out of 2947 by Mauriceau, in 31 out of 16,654 by Collins, in 3 out of 4180 by Paraud. According to Burns, the proportion is 1 in 940; Churchill, 1 in 650; Fritzel, 1 in 621; Keewer, 1 in 430; Bluff, 1 in 466; Ingleby, 1 in 300 and 1 in 4000; McClintock and Hardy, 1 in 737; Ramsbotham, 1 in 4429. In Dr. Lehmann's own experience in the Amsterdam Lying-in Hospital, which includes nearly 7000 labours in seventeen years, rupture occurred three times only. He has, however, seen 8 other cases to which he was called in consultation. As to the etiology, Dr. Lehmann says that rupture happens far more frequently from the violence of contractions without, than with, a pre-existing pathological alteration of the uterine tissue, as in the case of an obstruction too great to

overcome. He has on several occasions convinced himself that the powerful contractions exerted to overcome a mechanical obstruction, are followed by a partial rent in the uterus or vagina only when the tissue, through violent pressure against the promontory of a rachitic pelvis, the crista pubis, or the sharp ileo-pectineal line, has undergone a kind of bruising, softening, or gangrene. Dr. Lehmann then relates his cases, which we will here condense :

CASE I.-On the 24th of September, 1844, he was called by a midwife to a multipara, who felt her first pains at the end of her sixth month. Her previous labours had been lingering. During pregnancy she had suffered much from abdominal cramps. The waters escaped about noon, and the head presented. At 5 P.M. the patient was suddenly seized with violent pain, extending from the back to the abdomen, during an uterine contraction. From this time contraction ceased, and the presenting head disappeared. At 8.30 P.M. Dr. Lehmann found the abdomen much distended, and very painful on pressure, especially in the epigastric region. The abdominal walls were unusually thin; the fœtus seemed quite external to the uterus. The os uteri was flaccid, but partly closed again. The pelvis seemed normal. Considerable hæmorrhage had set in, and the patient's state was that of collapse. Delivery by turning was effected with great facility. The seat of rupture was not observed. The uterus contracted only moderately, it was soft, and a little blood appeared externally. The patient sank in a few hours. At the autopsy, thirty-six hours after death, the uterus was well contracted in the pelvis. Its anterior aspect seemed healthy; the posterior showed a rent, beginning at the fundus and running in an oblique direction for more than three inches down to the neck. The tissue near the rent was, as well as through the entire posterior wall, soft and anæmic, here and there oedematous; the edges had a livid, black colour, and were partly sphacelated. Behind the uterus, in the pelvic cavity, a large quantity of coagulated and fluid blood was poured out. The pelvis was quite normal.

CASE II-A cachectic multipara, aged thirty-six, was a fourth time pregnant, having previously been normally delivered; had been complaining for some months of rheumatic pains in the abdomen and legs. On the 22nd of December, 1845, at the normal term of gestation, pains set in. On the 23rd the os was partly open, head presenting. Irregular pains, and slow progress. The os was fully expanded, and the head had descended into the pelvic cavity, when the patient suddenly uttered a loud shriek, and exclaimed that her body was torn within her; the pains hereupon ceased, and collapse set in. When seen by Dr. Lehmann the abdomen was excessively distended, and painful to pressure. The head was still in brim, and some blood came from the vagina. On trying to apply the forceps the head receded. The hand introduced to turn; a rent across the anterior and left side of the cervix was felt. The child was extracted in two minutes. The uterus contracted immediately, and remained as a hard ball above the pubes. The child was still-born. The patient was removed to hospital, and partially rallied; but next day symptoms of anæmia and collapse returned, and carried her off three days later. The abdomen contained much blood. The uterus was well contracted; there was a rent running in an oblique cross direction, so that the anterior wall of the vagina where it is united to the uterus was nearly quite torn away. The texture of the uterus near the rent was pulpy and discoloured, and the uterus in several places was soft and pasty. The pelvis was generally too small; conjugate diameter was 3.50". The ileo-pectineal ridge was very sharp and strongly developed.

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CASE III.-On the 12th of May, 1846, Dr. Lehmann was hurriedly called to see a pluripara, aged forty. She had been dead half an hour when Dr. Lehmann arrived. He learned that the woman had borne children quickly

after one another; and that during the last months of her seventh pregnancy she had continually complained of pains in the abdomen, with fever. Labourpains had come on the night before, but progress was tedious. In the morning the os was partly open, and the head presented. The enormous distension of the abdomen raised the belief of twins or excess of the liquor amnii. About midday, pains being light and irregular, the patient suddenly uttered a shriek, and became corpse-like, vomited a black bloody matter, and died in a few minutes. The abdomen was greatly distended, and the parts of the child could be easily felt through the thin walls. The pelvis seemed normal. Autopsy not permitted.

CASE IV. On the 19th of July, 1847, Dr. Lehmann was called to a woman, aged thirty-two, cachectic, and pregnant for the fourth time. She was already dead. The first pains had appeared the night before; they were weak, irregular, and painful. In the night ergot was given on account of this torpor uteri, but no more active labour ensued. When the os was fully expanded, and the head depressed in the pelvis, the forceps was applied. During the tractions the patient had suddenly risen up and fallen back dead, whereupon the forceps was withdrawn. On the right posterior side, where vagina and uterus unite, there was a large oblique rent, through which the hand passed to the promontory, so that nearly the entire posterior wall of the vagina was torn away from the uterus. A large quantity of blood followed as the hand was withdrawn. The pelvis seemed contracted in the first degree; the conjugate diameter being 4′′. The abdomen was much distended, and as if divided in two unequal parts. The child being possibly alive, the forceps was again tried, but the head slipped away on traction. It was extracted, still-born, by version. Autopsy not allowed.

CASE V. On the 9th of July, 1852, a woman, aged twenty-six, who had been rachitic in childhood, only beginning to walk at seven, was taken into the hospital, and delivered of her first child by cephalotripsy. She returned on the 22nd of August, 1853, again pregnant, to have premature labour brought on. She was very small in stature, and deformed. Pelvis kidney-shaped; conjugate diameter 2.75". The labour was fixed upon at about thirty-four weeks of gestation on the 1st of September. For this end a wax bougie was inserted, and repeated on the 3rd; next day pains appeared; the os opened somewhat; head presenting. At 11 P.M., 5th, the waters escaped in great quantity; on the 6th, labour being tedious, a borax mixture was given; on the 7th, labour advanced, but slowly; strong pains set in; the head was slowly driven quite into the pelvic brim; signs of exhaustion were increasing. Whilst waiting for the forceps, the patient complained, after a great exacerbation of the pains, of headache, syncope, oppression, and began to vomit copiously. Collapses followed. The child was quickly delivered by forceps; when the head passed much blood came, which was attributed to the separation of the placenta. A few minutes later the placenta was removed, whereupon the uterus contracted slowly, remaining larger than usual. The eight-months' child was dead; the skull was much compressed. On the next day, there having been no reaction, the abdomen was more painful and much distended, tympanitic; peritonitis followed, and ended fatally on the eighth day after delivery. A large quantity of purulent exudation was found in the abdomen. The uterus was well contracted; its peritoneal covering being clothed with an exudation-layer. On the fore part of the lower segment and cervix was a cross rent three inches long, the edges of which were uneven and discoloured; the whole posterior wall of the bladder was also torn and gangrened, forming with the rent in the cervical portion of the uterus a common cavity. The tissue of the uterus, and also of the bladder in the vicinity of the rupture, was very pulpy. Much fluid and congested blood in the abdominal cavity.

The inner surface of the uterus was of a greyish-black colour (endometritis gangrenosa), the musculature of the fundus was normal, without fatty metamorphosis. The conjugate diameter of the pelvis (which is preserved) was 2.50". The brim was kidney-shaped.

CASE VI-A mother of five children, pale and cachectic, complained much of pains in the abdomen during her sixth pregnancy. She had ague. On the 18th of April, 1855, term of gestation ended, pains set in; labour progressed very slowly during the two succeeding days; the os was open about an inch, and the breech presented; the pains ceased, and exhaustion appearing, Dr. Lehmann was sent for on the 21st. The abdomen was unusually distended; uterus lax, but exceedingly painful to touch. The child had not been felt to move for some days; auscultation revealed nothing. The child was felt quite moveable at brim; right shoulder presenting; hand introduced; a large quantity of coagulated blood was found in the uterus, and on the right hinder side, at the fundus, a large rent in an oblique direction, through which the lower extremities of the child had escaped into the abdominal cavity. The child was delivered still-born and putrid. After the placenta was removed, during which a large quantity of blood flowed, the uterus contracted moderately, and remained soft and large; collapse followed, and in two hours death. Autopsy not permitted.

CASE VII-A healthy multipara, of ordinary stature, aged thirty-seven, was, on February 3rd, 1857, at the end of her fifth pregnancy. According to her statement her first two children were born dead from funis presentation. Her third child was born alive. The fourth labour was conducted by Dr. Lehmann in the hospital; it lasted four days, and resulted in a dead child. A narrowing of the pelvic brim was recognised as the cause of this. In the fifth pregnancy the abdomen was of very large circumference and greatly overhanging. The foetal heart was heard on the left side. The os uteri was open 2"; head at brim, and moveable. The waters broke on the 4th, and the os expanded fully all but a thick border. Towards evening the pains had quite ceased, and exhaustion progressed; but the abdomen was free from pain, and the fœtal heart was still heard. It was then determined to deliver by turning. This was effected with some labour. The child was dead, weighed eight and a half pounds, and showed a depression on the left parietal bone caused by pressure against the promontory. After removal of placenta, the uterus contracted, but remained of considerable size. Collapse followed; and death early the next day. In the abdominal cavity was a considerable quantity of fluid blood. The musculature of the uterus was soft, flaccid. At the posterior side above the left Fallopian tube was a large rent, stretching obliquely from the fundus to near the neck. The walls of the uterus were very thin, and here and there infiltrated with serum. The uterine tissue at the seat of rupture appeared fatty. The pelvis was kidney-shaped at the brim, and showed also a considerable scoliotic curving of the sacrum. The conjugate diameter was 3". The rent had taken place at the part where the head had pressed it against the montory. Probably, says Lehmann, an inflammatory softening had ensued from the continuous pressure against this spot during the latter period of gestation. The slight power evinced by the uterus during labour seemed due to the diseased condition, which was verified by dissection.

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CASE VIII.-On March 5th, 1858, Dr. Lehmann saw a woman, aged thirtysix, pregnant for the ninth time. The waters had escaped two days, and the patient, who had been quite well during this pregnancy, experienced slight pain in the loins and abdomen. A hand was presented. Time was lost in fetching Dr. Lehmann; the shoulder was driven down; attempts to turn were now rendered vain by the strong contractions. Dr. Lehmann found the patient exhausted; abdomen much distended, and painful to touch. Pains had now