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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 foetus seemed quite external to the uterus. The os uteri was flaccid, but partly closed again. The pelvis seemed normal. Considerable hæmor

rhage 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 cedematous; 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; the conjugate diameter was 3.50". The ileo-pectineal ridge was very sharp and strongly developed.

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 foetal 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 promontory. 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.

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

ceased. This symptom had occurred suddenly, and had been followed by collapse. Turning was now effected with unusual facility. Child still-born. The placenta removed, the uterus contracted and remained as a hard body. Little blood escaped. Without rally, the patient died on the following morning. Autopsy not allowed. The rent was not felt during life. The diagnosis rested on the symptoms.

CASE IX. In May, 1854, Dr. Lehmann was called to a multipara, aged thirty-eight, on account of a shoulder presentation. An obstetrist called in had failed in turning on account of the strength of the contractions. The patient was collapsed, abdomen much swelled and exceedingly painful; the uterus loosely drawn around the child. The pains had entirely ceased, and the foetal heart could not be heard. The presenting shoulder was easily pushed back, and the version and extraction effected. Child dead. The placenta with a great quantity of blood followed spontaneously. The uterus contracted well, but collapse increased, and death speedily followed. Autopsy refused. Diagnosis rested on symptoms.

CASE X.-In November, 1856, Dr. Lehmann was called to a primipara, aged twenty-six, on account of retention of the placenta. The breech had presented and had been expelled by the uterus; the head had been delivered by the forceps. Child dead. The patient was much exhausted, and the uterus contracted. Blood flowed continuously. In passing the hand for the placenta, Dr. Lehmann found a large cross-rent in the lower segment of the uterus where the vagina is connected behind, through which the entire hand passed into the abdominal cavity. The pelvis was contracted at brim, the conjugate diameter being scarcely 4". The visceral convolutions projecting through the rent were replaced, and as efforts to open the os uteri could only endanger the widening of the rent, the separation of the placenta was left to nature. This was effected on the fifth day. Endometritis followed, and malignant puerperal fever carried off the patient on the tenth day after labour.

CASE XI.-On the 2nd May, 1858, a woman aged thirty-five was in labour in the Lying-in Hospital with her second child. Gestation had been normal. The belly showed an unusually strong pronation of the uterus. The foetal heart was heard in the right side. The os was open 2" with a thick, soft edge, the head presenting but lying much over the symphisis. The labour went on tediously, notwithstanding strong pains. At 10-30 of the 3rd May, the os was fully expanded, but the head had not altered for many hours; a miscoloured, stinking fluid escaped from the vagina; the pains had ceased. The uterus was strongly contracted round the foetus; the abdomen was of irregular form, but free from pain. With the lever the head was first brought into the pelvic brim, and then delivered by the forceps, dead. The uterus contracted well. For the first few days the woman did well. The uterus, however, preserved a large size, but remained painless. The labia pudendi began to swell, and gangrene appeared in the mucous membrane of the vulva. Sloughs fell. On the seventh day a light fever appeared, with shivering resembling ague. This was successfully encountered by quinine. On the tenth day, when the patient seemed doing well, the uterus having sunk into the pelvis, a copious flooding suddenly came on and destroyed the patient. It was concluded that, through a gangrenous softening at a higher part, vessels had been injured, and caused the flooding. The uterus was found at the neck and the upper part of the vagina, especially at the left, and behind, quite gangrenous, and a large round hole with sharp edges quite through. The muscular fibres were fatty. About 1.50" from the neck was a second smaller hole; in this divided vessels were seen which had given rise to the fatal flooding. At the posterior side of the body of the uterus, which had lain against the promontory, was an incomplete rupture of 150" long. The

pelvis was narrowed at the brim; the conjugate diameter measured 3.20". The symphysis pubis was very thin and softened; the ossa pubis through diastasis separated more than an inch. Purulent fluid escaped from the articular cavity. The ossa pubis and the innominata were moveable. [One cannot help observing that several of these women were in labour too long, and that delivery by perforation or turning at an earlier period would have saved the lives of some. -REPORTER.]

BOOKS RECEIVED FOR REVIEW.

A Manual of Medical Diagnosis. By A. W. Barclay, M.D. Second Edition. London, 1859. pp. 616.

Aerztlicher Bericht des Allgemeinen Krankenhauses in Wien. Vom Civiljahre, 1857. Wien, 1858.

Hemorrhoids and Prolapsus of the Rectum. By Henry Smith, F.R.C.S. London, 1859. pp. 46.

Localised Movements, or Muscular Exercises combined with Mechanical Appliances for the Treatment of Spinal Curvature. By H. H. Bigg. London, 1859. pp. 120.

A Letter to the Earl of Shaftesbury on the Laws which regulate Private Lunatic Asylums. By E. J. Seymour, M.D. London, 1859. pp. 59.

What shall we do with our Lunatics? By Alfred Eccles. London, 1859. pp. 16. Chloroform and other Anæsthetics; their History and Use during Childbirth. By John Chapman, M.D. London, 1859. pp. 51.

The Army in its Medico-Sanitary Relations. Edinburgh, 1859. pp. 84.

Handbuch der Historisch-Geographischen Pathologie. Bearbeitet von Dr. August Hirsch. Erste Abtheilung. Erlangen, 1859.

The Boston Medical and Surgical Journal. Jan. 27, 1859.

Report on the Sanitary Condition of the City of London, 1857-8. By H. Letheby, M.B. London, 1859.

A System of Dental Surgery. By J. Tomes, F.R.S. London, 1859. pp. 599. Three Reports relating to the Hastings Water. Hastings, 1859.

On the Hygienic Management of Infants and Children. By T. Herbert Barker, M.D. London, 1859. pp. 120.

Healthy Skin; a Popular Treatise on the Skin and Hair. By Erasmus Wilson, F.R.S. Sixth Edition. London, 1859. pp. 288.

The North American Medico-Chirurgical Review, March, 1859.

American Medical Monthly, Feb. 1859. Diphtheria; a Lecture delivered at the Norfolk and Norwich Hospital. By W. H. Ranking, M.D. Norwich, 1859. pp. 30.

An Essay on the Action of Medicines on the System. By F. W. Headland, M.D. Third Edition. 1859. pp. 447.

American Journal of Insanity, Jan. 1859. Third Annual Report of the United Lunatic Asylum for the County and Borough of Nottingham, year 1858. Nottingham, 1859.

The Journal of Mental Science. Edited by Dr. Bucknill. April, 1859.

Quarantine as it is, and as it ought to be. By Gavin Milroy, M.D. London, 1859. (Reprint).

The Emotions and the Will. By Alexander Bain, A.M. London, 1859.

Ophthalmic Hospital Reports, Jan. 1859. Eighth Annual Report of the Wilts County Asylum. Devizes, 1859.

The Cyclopædia of Anatomy and Physiology. Edited by Robert B. Todd, M.D., F.R.S. Five Vols. London, 1835-59. Art versus Nature in Disease. By A. Henriquez, B.L.P., M.R.C.S. London, 1859. pp. 281.

On Diphtheria. By Ernest Hart. London, 1859. (Reprint.) Gazette Hebdomadaire, Avril, 1859. The Assurance Magazine, April, 1859. Gazette Médicale d'Orient, Avril, 1859. Reports in Operative Surgery. Series the Third. By Richard G. H. Butcher, Esq. Dublin, 1859. pp. 50.

A Treatise upon Penetrating Wounds of the Chest. By Patrick Fraser, M.D. London, 1859. pp. 140.

On the Cervix Uteri in Pregnancy. By J. M. Duncan, M.D. Edinburgh, 1859. (Reprint.)

On the Influence of the Variations of Electric Tension on the Remote Cause of Epidemic and other Diseases. By William Craig, Consulting Surgeon to the Ayr Fever Hospital. London, 1859. pp. 436.

Clinical Lectures on the Principles and Practice of Medicine. By J. H. Bennett, M.D. Third Edition. Edinburgh, 1859. pp. 1005.

Gooch on some of the more Important Diseases Peculiar to Women, with other Papers. Prefatory Essay by Robert Ferguson, M.D. London, 1859. pp. 235. (The New Sydenham Society.)

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