ments, usually the shorter, may be comminutively fractured-the penetration being more forcible and deeper than in the preceding cases. This variety is observed in stelliform fracture of the radius, in fracture of the neck of the femur when the great trochanter is fractured at the same time, and in fracture of the lower end of the femur, when there are at the same time intra- and supra-condylian fracture. To these cases a proper clinical import has not been given, and fractures are described just as formerly. But how are we to reduce fractures when their fragments are so solidly penetrated and ingrained as to be scarcely separable, even after death; or when one of the fragments has become shortened by crushing or by comminution? It is evident that surgery can do nothing here, and that the limb must remain enlarged and shortened, and that the action of the joint must be impaired.

5. Therapeutical conclusions.—It is not the author's object to deter from attempts at reduction of fractures. These, he admits, must be made, and in case of failure repeated. But when complete adaptation cannot be thus obtained, and the failure is explicable on one of the grounds mentioned, attempts should not be multiplied, or complicated and expensive appararatus resorted to. In the author's opinion, a careful and attentive surgeon may obtain with the most simple appliances all possible results. The consecutive deformities or imperfections may be inevitable; and it is an illusion to suppose that in all cases they may be completely prevented.

Physician to the Royal Maternity Charity, Assistant Obstetric Physician to the London Hospital, &c.

I. PHYSIOLOGY OF THE UNIMPREGNATED FEMALE.

Appearances of the Yearly Ripening of Ova in Woman. By Dr. MATTEI. (Gaz. des Hôpitaux, No. 22, 1859.)

Dr. Mattei regards the theory of the monthly maturation of ova concurrently with menstruation as erroneous, and believes that for each ovary only one annual ripening takes place. The months of January, February, March, and April are especially favourable for this maturation. The appearances of this condition come on at times very gently, at others very painfully. The general appearances are alterations of the voice, sleeplessness, at times neuralgias, prostration, vomiting, frequently palpitation, cough, hoarseness, without material change in the breasts. As local symptoms there are, sensation of weight or pain in the abdomen, from the sacrum to the thighs, and especially pains in that side of the pelvis on which the lymphatic glands are swollen and tender; there is also heat and excitement of the external genitals. The menstruation is disturbed; it is seldom rendered more profuse, most frequently more scanty, coming on earlier, and attended with nausea. At times leucorrhoea, diarrhoea, dysuria, sympathetic symptoms in the breasts; the excitation of the ovarian region causes pains, nausea, even hysterical cramps; hematocele, peritonitis, and phlegmon may occur. According to the individual, these symptoms may last for four, twelve, or twenty-eight days, and disappear altogether, or pass into symptoms of pregnancy or false conception. The interval between the ripening of the ova in the two ovaries is variable. The minimum observed by the author was four days, the maximum, five months. Dr. Mattei further says that this yearly ripening mostly ceases at the same epoch as the germination of plants and the rut of animals.

II. PATHOLOGY OF THE UNIMPREGNATED FEMALE..

On the Extirpation of Interstitial Fibroid Tumours of the Uterus. By B. LANGENBECK. (Deutsche Klinik, 1. 1859.

Langenbeck refers to the little success attending the medicinal treatment of uterine fibroids; and distinguishing them into sub-mucous, sub-peritoneal, and interstitial, says that the subperitoneal are not favourable for removal by operation, on account of the danger of peritonitis. Încluding three cases of removal by the author, there are twelve cases in which the operation

has been performed; in seven, cure ensued. The following is a condensation of Langenbeck's

cases:

1. T—, aged thirty-five, mother of two children, had suffered much the last two years from metrorrhagia. After three days' pains a tumour of the size of a child's head had descended into the vagina, and at last beyond this. It was taken for the head. The pains weakened, and the patient collapsed. Langenbeck being called, made an incision through the entire tumour exposed beyond the vulva, and there appeared under the layers of the os uteri a yellowish-white fibrous mass, which could be separated easily, partly with the fingers, partly with the scissors. Hemorrhage slight. The dead child was immediately extracted. The patient died in the following night.

2. E, aged thirty-seven, but suffered from profuse metrorrhagia. In November, 1856, Langenbeck found her very anæmic. The os uteri was high up, open, with a swelling the size of a hen's egg in the posterior wall. The anterior wall was thinned, the posterior one thickened. After attempts had been made during eight days to expand the os, extirpation of the firmly-fibrous tumour was carried out. The bleeding was inconsiderable. Two months later normal menstruation returned. Recovery was permanent.

3. S, aged thirty-five; after two normal labours and one abortion, metrorrhagia set in, and produced a high degree of anæmia and weakness. Langenbeck found a tumour the size of the fist in the fundus uteri; the hinder lip of the os uteri was doubled in size; this enlargement extended into the posterior cervical wall. The anterior lip was thinned, the orifice open; and through this the finger felt a swelling the size of a goose's egg, projecting an inch and a half into the rectum. On March 24th, 1858, extirpation was undertaken. The operation was difficult and of long duration, because the tumour was nowhere distinctly bounded, and was very resisting. The hæmorrhage was not considerable. Free suppuration from the uterus ensued; and in August, 1858, the cure was established.

III. PHYSIOLOGY OF PREGNANCY.

1. On the Causes of the Spiral Direction of the Umbilical Vessels, and the Convolutions of the Cord in the Human Fatus. By JOHN SIMPSON. (Edin. Med. Jour., July, 1857.) 2. On the Transmigration of the Ovum as a Cause of Tubal Gestation. By Professor KUSSMAUL. (Verhandl. d. Naturl. Med. Ver. zu Heidelberg, Band iv. p. 102, 1858; and Schmidt's Jahrb. No. 5, 1859.)

Mr. John Simpson gives a very interesting physiological account of the forces producing the spiral direction of the umbilical vessels. Our limits impose upon us the necessity of devoting the greater portion of our space to extracts from the more inaccessible foreign journals, and constantly compel us to pass over or to notice with brevity the contributions of our brethren at home. So in this instance we must forbear to trace the train of facts and arguments advanced by the author. The spiral or twist of the umbilical cord is known to be most frequently from left to right. Velpeau considered this to be caused by rotations imparted to the foetus in the liquor amnii by the movements of its limbs. Schroeder van der Kolk supposes that the greater pressure of the blood in the arteries than in the vein causes a recoil, which reacting on the pubes of the floating embryo, causes it to turn on one side or the other according as they are placed on the left or right side of the umbilical vein in the annulus umbilicalis. The author adduces evidence to show that the direction of the twist is dependent on the structure and distribution of the arterial system of the foetus, and the action of the heart upon the fluid within its tubes. Until after the eighth or tenth week there is no twist in the cord. At and after this period it will be found that the aorta is parallel with the spinal column in its left side in the dorsal region; then tending, in the lower part of its course towards the mesial line, to divide into the right and left iliac vessels on the bodies of the lumbar vertebræ, thus presenting a curve whose concavi y looks forward and to the right. From this crossing of the aorta from the left side of the spine to near the middle line of the body, it is manifest that the right iliac division has in a considerable degree the appearance and direction of the main trunk, whilst the left presents more the aspect of a branch. In a diagram from 'Quain's Anatomy,' the author shows that the angles which the right and left divisions of the aorta form with the abdominal aorta are respectively twenty-one and thirty-five degrees, showing that the right follows a course fourteen degrees nearer the direction of the aorta than the left does, and consequently, that it receives a more direct and stronger current of blood. The author refers to eleven preparations in the Anatomical Museums of Edinburgh which prove this point. Now, the cord being fixed at one end by its attachment to the placenta, cannot yield by twisting to the pulsating force conveyed through the hypogastric arteries; but the foetus floating freely in a fluid of its own specific gravity, readily gives way to the

recoil acting on its pelvis; and from the position of the vessels at the umbilicus, the vein will represent the pivot on which it will move, whilst the right artery, having the greatest power of recoil, will determine the direction of the rotatory movement, that is, from right to left. Mr. Simpson next applies his theory to the elucidation of the mode of production of convolution of the cord round the neck of the child. This is found almost always in one direction -namely, passing from the umbilicus over the right shoulder of the child, across the nape, then forward by the left side of the neck, and so on, according to the number of convolutions. This is also due to the unceasing pulsation of the foetal heart continuing the rotation of the fœtus, so that its head passes into a loop of a long funis. If the funis be unusually long, the foetus, at an early period of gestation, may pass completely through the loops, and thus form true knots upon the funis.

2. Professor Kussmaul describes a preparation of tubal gestation in the eighth or tenth week, in which the left Fallopian tube is developed into a fruit-sac at the point of its entry into the uterus, whilst the left ovary contains no corpus luteum, there being, however, two corpora lutea in the right ovary. The tubes are perfectly permeable down to the point where the fruit-sac is situated in the left tube, where a thick bunch of chorial villi stops the way. This being removed, the left tube is also free. Kussmaul concludes that the ovum developed in the left tube had passed down the right tube, and across the cavity of the uterus; and cites the following instances as similar to this one: 1. The cases of transmigration of the ova from the ovary of one side into the uterine horn of the opposite side in animals with uterus bicornis (Bischoff). 2. The case of transmigration of the human ovum from the ovary of one side into the rudimentarily-developed uterine horn of the opposite side (Scanzoni). 3. The case observed by Drejer and Eschricht at Copenhagen. 4. The observations of the development of the placenta on the one side of the uterus, whilst the corpora lutea were found on the opposite side. 5. The case of Oldham and Wharton Jones, in which the ovum apparently passed directly from the ovary into the tube of the other side, which had become adherent to it, developing itself in the uterine walls, and in which death followed the bursting of the sac. The violent uterine colics and general spasmodic attacks which women in these cases suffer during menstruation, deserve attention. In the present case, according to Kussmaul's view, the transmigration of the ovum took place through the uterine cramp and antiperistaltic motion of the uterine end of the tube.

IV. LABOUR.

1. Contribution to the Knowledge of Gestation outside the Uterus. By PROFESSOR HECKER. (Monatschr. f. Geburtsk., Feb. 1859.)

2. Case of Extra-uterine Pregnancy complicated with general Anasarca and Ossification of the Uterus. By R. W. HARDEE, M.D. (North Amer. Med. Chir. Rev., May, 1859.) 3. Case of Tubal Pregnancy, with Rupture and Death. By G. G. STEELE, M.D. (North Amer. Med. Chir. Rev., May, 1859.)

4. A Case of Placenta Prævia Succenturiala. By Dr. KUENEKE. (Monatsch. f. Geburtsk., May, 1859.)

5. Laceration of the Right Sacro-iliac Synchondrosis during Labour. By SCANZONI. (Allgem. Wiener Med. Zeitz., No. 8, 1859; and Schmidt's Jahrb., No. 7, 1859.)

6. On Uterine Catheterisation, with Catgut for the Induction of Premature Labour. By C. BRAUN. (Monatsschr. f. Geburtsk., May, 1859.)

7. A Case of Spontaneous Rupture of the Uterus. By KAPLER. (Monatschr. f. Geburtsk., April, 1859.)

1. Professor Hecker makes a valuable contribution to the knowledge of extra-uterine gestation. He relates in the first place a case which he considers to have been one of ovarian gestation—a well-made woman, aged twenty-eight, who had borne a first child three years before. From that time she had menstruated regularly until recently, when conception was suspected. Now often on rising from bed she experienced a peculiar syncopal feeling which impelled her to lie down again. Then retention of urine appeared, and on vaginal examination, the os uteri was found pressed against the pubes, and the post-uterine region was filled by a firm elastic swelling resembling in size the uterus in the third month of pregnancy. This was taken for the retroverted uterus. Great efforts were made to effect reposition; during these collapse took place, and death in half-an-hour.

The autopsy revealed from four to five pounds of blood in the abdominal cavity; the uterus not gravid, much inclined forward, enlarged, its inner surface plainly lined with a decidua; behind it was a cyst, which without regard to its relations was cut out, leaving the uterus in situ. The cyst was of the size of the head of a child two years old; its walls were thin, and it bore a great resemblance to a dropsical ovarium. In one spot it was rent open; it

contained a well-formed male foetus, whose development corresponded to a pregnancy of eighteen or twenty weeks. Nothing could be detected in the corresponding Fallopian tubes, but at the lower part of the cyst was a swelling that was clearly recognised as the ovary. The idea of an after-union of the cyst with the ovary by adhesions was excluded by the most searching examination; they were evidently continuous and one. (There can be little doubt that the pregnant ovarian cyst was ruptured by the force used in attempting to reduce the supposed retroverted uterus.)

Professor Hecker then prosecutes an elaborate statistical inquiry into the various points connected with extra-uterine pregnancy. His analysis shows that frequently either a long pause in fertility precedes tubal gestation, or there has been previous sterility. That this sterility and the tubal gestation are co-effects of the same cause is proved by dissections. The lapse of time from the first appearance of symptoms of illness to death was in twothirds of the cases (48) within twenty-four hours, and in more than half of these in twelve hours. Of sixty-four dissections, in 37 cases the gestation was found in the left tube, and in 27 in the right.

Of 31 cases, at the time of rupture of the tube, the foetus was five weeks old in 1 case, six weeks in 5 cases, six to seven in 4 cases, six to eight weeks in 5 cases, beyond three months in 9 cases, beyond four months in 6 cases. Reckoning from the cessation of menstruation, the gestation had lasted from four to six weeks in 6 cases, six to eight weeks in 5 cases, three months in 2 cases, four months in 1case, five months in 1 case. Thus in far the greater number of cases the fatal catastrophe happens within the first eight weeks.

The Professor believes a common cause of tubal gestation to be inflammatory adhesions impeding the free course and connexion of the tubes with the ovaries. He supports this opinion by eight dissections, in which adhesions, the result of partial peritonitis, were formed, by the fact of the frequent sterility antecedent to tubal gestation, by the well-known sterility of prostitutes, which follows upon colic-the colica scortorum.

Attendant changes of the uterus are frequent. Thus of 40 cases there was marked enlargement of the uterus in 24. The development of a decidua is mentioned in 25 instances.

I. A case of tubal gestation is then cited, which we reproduce. A woman aged thirty-three had borne five children, and in the course of her sixth pregnancy, suddenly died under symptoms of internal rupture. In her abdomen was found a foetus of four to five months, which had escaped from a rent in the right tube. The uterus was five inches and a half long, three broad, provided with decidua and gelatinous plug. The right Fallopian tube which had carried the fœtus was not, as is usual, united to the uterus between the fundus and body, but between the body and cervix; and there was this remarkable circumstance, that the corpus luteum was found not in the right, but in the left ovary.

II. Interstitial Gestation.-The total number of known cases of development of the ovum within the uterine portion of the Fallopian tube is 26. In all the course was fatal, but the probability of a more protracted duration is greater than in ordinary tubal gestation. The time of survival after setting in of fatal symptoms is twenty-six hours in 16 cases. In the majority of cases here also the gestation was on the left side. The duration of gestation was generally less than three months. Two cases in which the duration exceeded this time are cited. In the majority of cases it appears that the cavity formed in the walls of the uterus for the ovum is shut off by a distinct septum from that of the uterus proper.

III. Abdominal Gestation.-Professor Hecker has collected 132 instances in which the ovum had attached itself to some spot in the abdomen. In 90 out of 105 cases the patients were pluriparous. Of the 132 cases, 76 ended in recovery, and 56 in death. Thus the prognosis of abdominal gestation is more favourable than might be supposed. The foetus may preserve its life for a long period. In Schmitt's case, the abdominal gestation lasted three years, and the child was, on the death of the mother, through the Cæsarean section, taken out asphyxiated but living; in the case of Grossi, the movements of the child were felt for twenty-three months.

A remarkable physiological phenomenon is the frequent appearance of labour-pains when the abdominal gestation has lasted nine months. That these pains have their seat in the uterus is probable from the development this organ mostly, but not always assumes; but it is more probable that these pains arise in the abnormal sac which holds the foetus. Frequently it is found that the walls of this sac are partly composed of organic muscular fibres. Recovery took place after the expulsion of the foetus in 28 cases, through stony conversion in 17 cases, after expulsion of the foetus through the anterior abdominal wall in 15 cases, after abdominal sections in 11 cases, after vaginal incisions in three cases, and in two cases by modes not well determined.

The termination of abdominal gestation by discharge of the fœtus through the rectum is frequent and mostly a very tedious process. The elimination of the foetus through the abdominal wall is generally a still slower process; for in 15 cases there are 7 in which the women

went through one or more intra-uterine pregnancies before being disburdened of their extrauterine child. But when the process is begun, its course is shorter, and admits of being assisted by art, as by dilating the perforated opening and extraction of the fœtus.

The following is a summary of the 56 fatal cases: death followed hectic in 18, peritonitis in 12, rupture and hæmorrhage in 7, fæcal vomiting in 2, dropsy in 1 case. It followed operative measures in 12 cases-namely, Cæsarean section 5 times, puncture of the sac and cauterization 4 times, section through vagina in 2 cases. In 5 cases the mode is undetermined.

Professor Hecker then relates the two following cases which came under his own observation:

1st. A woman who had borne one child at the age of eighteen, began to complain eighteen years later of nausea, want of appetite, and a sense of weight and fulness in the abdomen; menstruation, however, being regular. Two months later than this, December, 1856, her illness became aggravated, and the abdomen enlarged,,being painful on moving. Examined on the 17th of January following, she was excessively emaciated and in a hectic condition; the abdomen was so painful, that scarcely could the slightest touch be borne. It was ascertained that a hard body, of irregular form, was present in the right side, feeling like a fœtus; the uterus appeared to contain nothing, and a smooth elastic body was felt behind it, which could be pushed upwards. The diagnosis of extra-uterine gestation was confirmed on the 9th of June, before which time, movements of the foetus were perceived by the patient and by others; on laying the hands on the abdomen, the different limbs of the child could be made out. The movements had now ceased, and it being concluded that the child was dead, the Cæsarean section was set aside. About Christmas, 1857, pains in the abdomen returned with hectic. In the night of the 8th of March, 1858, suddenly a strong effort at defæcation occurred, followed by discharge of half-a-pailful of watery yellow fluid, without admixture with fæces. This discharge, in all probability, of liquor amnii, caused a considerable collapse of the before distended abdomen. Great prostration attended; and an abscess opened below the navel on the 26th of March, through which came two cranial bones, and afterwards the rest of the head and the whole child in a putrid state. The woman died in two hours later. No inspection permitted.

2nd. A woman, aged thirty-eight, who had borne, three children, was admitted into the Lying-in Hospital of the Berlin Charité on the 21st of March, 1857. She had believed herself pregnant since October, 1856, and complained of much pain in the abdomen. The abdomen was enlarged as in a seven months' pregnancy, very tender to the touch, and so evenly distended that nothing distinctly could be traced, but movements of the child were sensible both to the eye and to the touch. The fœtal heart could not be heard, but a very loud vascular rush was heard to the left of the navel. There was colostrum in the breast. Internal examination was so painful that it had to be carried out under chloroform. The os uteri was close behind the pubes, open, and the fingers struck upon a fatty mass feeling like placenta, which gave a carcass-like smell. The posterior vaginal roof was deeply depressed into the pelvis by a round immovable body like a child's head; this, when examined by the rectum, appeared to spring from the sacrum. On the 25th of March the foetal movements ceased, on the 26th peritonitis suddenly set in, and death followed on the 27th. Immediately afterwards, a dead female child, thirteen inches long, was removed by abdominal incision. The autopsy was performed by Virchow. It revealed recent and universal peritonitis; the extra-uterine sac reached to the transverse colon, was united to the anterior abdominal wall, but elsewhere free. The uterus was much enlarged.

2. Dr. Hardee relates an interesting case of tubal gestation. He was called to a negro woman who had general anasarca. On examining the abdomen, he felt a large tumour resting upon the left side; the uterus presented the sensation of a hard bony mass; no os tincæ could be felt. It was reported that the tumour had been growing for fifteen years. The dropsy increased rapidly, so that repeated tapping became necessary before her death. On laying open the abdomen, the uterus and a foetal head, larger than at term, were brought to view. The head resting just before the heart, and on the left side of the body; it was firmly attached to the uterus and intestines. After moving the head, a decayed mass was seen, but what it was could not be determined. All the bones of the foetal head were present, with the exception of the superior and inferior maxillaries. The uterus was about ten inches long, about four inches wide, and four thick, forming one hard bony mass, weighing six or eight pounds.

3. Dr. Steele's case of tubal pregnancy is highly interesting both in a diagnostic and pathological point of view. He was called to a servant woman, aged about twenty-six, who had married a second time-having had a child some years before-two months back. Two