and before its time, to do that for which it is not prepared. It is but reasonable to anticipate that help will often be useful. And help can be given to facilitate the dilatation of the cervix, and to supplement the contractile energy, if this cannot be aroused. The course I adopt is as follows: Having determined as closely as possible the period of gestation, I fix the day for the operation. On the evening of that day, the patient being in bed, I pass a No. 8 or 9 elastic bougie into the uterus, as far as it will easily slip in; it will generally go in to the extent of four to six inches. The end projecting beyond the os is then twisted up into the vagina; this keeps the bougie in situ. The patient keeps her bed for the night, so as not to disturb the bougie. Next morning, it will almost always be found that some degree of preparatory action has been effected. The cervix will be softer, and perhaps admit the finger; the vagina will be well lubricated with mucus; and some uterine contraction or pains will be present. If this should merge into active labour, the bougie may be withdrawn; otherwise it may be left or replaced. Towards the afternoon, the cervix will be more yielding and expanded. The further course must then be determined by the special indications of the case. If the pelvis be normal, and the labour have been induced on account of constitutional disease, it is generally better not to resort to any active accelerative measures, but to let the labour take its own course. When the cervix will admit of two or three fingers, if active pains are not present, it will, however, be desirable to tap the membranes by making a small scratch with a stilet or a quill. The drawing-off of a little liquor amnii, allowing the uterus to collapse, commonly stimulates it to increased activity, and in a few hours the child may be expelled. It is, of course, necessary to watch, lest the position of the child should become unfavourable, or the cord become prolapsed; circumstances, I repeat, very likely to occur in premature labour. If the labour have been provoked on account of pelvic distortion, greater assistance will be required. The first difficulty to overcome is the resistance of the cervix uteri. The great agent in dilating this structure is the direct pressure upon and within it of the foetus and membranes distended by liquor amnii. But when the brim is contracted, this pressure can rarely be exerted effectually. Hence the tediousness and the danger attending the laissez-faire or expectant treatment. The child may perish from long compression; the mother may be exhausted by protracted pain and shock. To avoid these dangers, it is now necessary to dilate the cervix by means that imitate as nearly as possible the natural agency. Introduce the caoutchouc water-dilator into the cervix, taking care that the narrow middle part of the bag be gripped in the ring of the cervix; then distending it gently and slowly with tepid water, the finger on the cervix takes note of its effect. In half-an-hour or an hour, the middle sized bag will commonly have increased the dilatation so that the cervix will admit three or four fingers. This is the time to rupture the membranes. If the uterus act with sufficient power, and the pelvic contraction be not so great as to impede the passage of the child's head, watch, and let nature do her work. But if the head is delayed at the brim, the physician must intervene. He has two alternatives. He may first try the forceps. If the distortion is moderate, the conjugate diameter measuring say 3-50", the head may come through. But if it do not come easily, and especially if the conjugate is reduced to 3.00" or below, turning is the true accelerative means. If I may trust my experience, I should, without hesitation, say the prospect of a child being born alive under the conditions postulated is much better than under any other mode of delivery, and even better than is the prospect under turning in ordinary circumstances at the full period of gestation. The explanation is as follows: the child's head is not only smaller, but it is more easily moulded; it is caught at the smaller or bi-temporal diameter, between the projecting promontory and the symphysis pubis; the jutting promontory leaves abundant room on either side in the sacroiliac region of the brim for the cord to lie protected from pressure; and if care be taken that the cervix uteri be adequately expanded, the head comes through so quickly that the danger of asphyxia is not great. The mode of turning demands consideration. The object being to secure a quick delivery, the soft passages must be well prepared. We might turn by the bi-polar method without passing more than two fingers through the os uteri. But I have found that, although it is always well to avail ourselves more or less of the bi-polar principle to facilitate turning, it is desirable in this case to pass the greater part of the hand through the cervix to grasp the further knee. The reason is this: the cervix that will admit the hand will in all probability admit the ready transit of the child. We thus secure adequate dilatation. When the turning is completed, extraction must follow. It should be performed gently, drawing upon the one leg until the breach has passed the outlet; the extraction of the trunk should be slow, and a loop of cord should be drawn down to take off tension. When the arms are liberated, the neck of the child is in danger of being constringed in the circle of the cervix. This is the moment for acceleration. The two legs are held at the ankles by the left hand, whilst the right hand fingers are crutched over the back of the neck. The head is sure to enter the contracted brim in the transverse diameter; it then has to describe the circle round the point of the jutting promontory which I have described (Lectures on Obstetric Operations,' Med. Times and Gazette, 1868) as "the curve of the false promontory." Traction must, therefore, at first, be carefully exerted in the direction of this curve or orbit; that is, well backwards, so as to bring the head round and under the promontory. When it has cleared the strait and is in the pelvis, the occiput commonly comes forward, and traction is changed to the direction of Carus' curve, to carry the head through the outlet. Unless rigorous attention be paid to the above rule for bringing the head through the brim, so much time may be lost as to imperil the success of the operation. Turning, as a mode of delivery in contracted pelvis, is not, I believe, yet established as an orthodox proceeding. Certainly to be successful it requires precision in diagnosis and skill in execution. But these are requisite conditions in all surgical operations. I have now, with tolerably mature experience of the operation in all its applications, no hesitation in expressing my opinion that turning in contracted pelvis, where labor is induced prematurely, is an operation of the highest value as a means of extricating the mother from peril, and of saving the child. It has this great advantage: it enables us to postpone the induction of labour for two or three weeks or more, so as to reach the stage of greater development of the child. If, for example, we preclude ourselves from turning, and the pelvic contraction leave only 300" or less of conjugate diameter, we must bring on labour at the end of seven months, or spontaneous delivery may be defeated, and with this the child is lost: whereas, if we contemplate turning, the gestation may be allowed to go on till the end of eight months; for a living child may easily be drawn through a conjugate of 3·00". A further advantage obtained by this postponement consists in the greater probability of having to deal with a viable child. If we calculate too closely, say from the first week after the last menstruation, and fix the induction of labour 220 days from the time, we may find that the child has really not attained a stage of development corresponding to our calculation. One design of the proceeding is thus frustrated by error of estimation. But, if on the other hand, we feel confidence in putting off the labour until the 250th day, we cover this range of liability to error, and secure a child that is at any rate viable.—St. George's Hospital Reports, Vol. 3, 1868, p. 111. 86.-ON STRICTURE OF THE INTERNAL OS AS A CAUSE OF MISCARRIAGE. By Dr. WILLIAM MARSHALL, Mortlake, Surrey. Mrs. D., aged 30, a delicate woman, five months advanced in pregnancy, was taken with labour pains about six o'clock one evening. I saw her at 8.30. The pains were strong and forcing, very similar in character to those which immediately precede the expulsion of the head in a primipari. I was told that when pregnant last she had miscarried at the fifth month, and that the pains then, for three hours, had been very severe-much worse than she had ever had them in any confinement, and similar to what they were now. On examination, I found the os uteri dilated to the size of half-a-crown, and very soft. On passing my finger further up in order to feel the foetus, I found the canal of the cervix becoming decidedly narrower, when suddenly she cried out that I was cutting her, and jerked herself away. On a second attempt the same thing was repeated; but on a third, being prepared for her moving, I ascertained that a tight resisting constriction existed at the internal os, which would not admit the tip of the finger. As soon as I touched the constricted part, she complained of a severe cutting pain; and on attempting to pass the finger through it, she became hysterical, and on my persisting, perfectly maniacal. On withdrawing my finger she immediately became rational, and complained of the agonizing pain I had caused her. As she was quite positive that in her previous miscarriage she had suffered for three hours as much as she was doing now, I waited for a couple of hours. During this time the pains were very strong, and the suffering greater than I had ever seen in any confinement. In order to make a thorough examination, I put her under chloroform. The external os was very soft, and dilated; but at the internal os there existed a constriction which still readily allowed the finger to pass through, and which seemed now quite dilatable. The breech was presenting, and I had no doubt that when a pain came it would be pushed through, and the whole thing soon be at an end. The pains, however, did not return as long as I kept her under chloroform, so that I was forced to discontinue it. The stricture returned with the first pain, firmly grasping the tip of my finger, which I had retained in the uterus. I now gave her a dose of ergot, and waited until one o'clock, when, finding that little or no progress had been made, I determined to notch the stricture in one or two places, under chloroform, as it was impossible to touch it without causing intense pain, and bringing on a maniacal paroxysm. I went home for a probe-pointed bistoury, and on my return in half-an-hour, found the strictured part, with the breech forced into it, protruded through the external os, which was drawn up around it. After a few pains, the breech passed through the constriction: I pulled down the body, and finding that the head would not come, pushed my finger past it. hooked it over the crown, and pulled the head through the stricture. Without drawing my finger, I detached the placenta, and withdrew it and the finger at the same time. While doing all this, the patient was perfectly maniacal-she shrieked, kicked, struck and bit at those around her. Immediately on withdrawing the finger she became rational, and apologised for what she had done; the agony had been so intense, she said, as to drive her for the time out of her senses. recovered without a bad symptom. She To one interested in uterine pathology, this case is, I think, of considerable interest. Firstly, With regard to the stricture itself, it is remarkable (1) that a stricture should have existed in such a spot; (2) that it should have been so exquisitively painful to the touch; (3) that the pain should have given rise to paroxysms of hysterical mania. May not some forms of puerperal mania depend upon a uterine lesion acting on an hysterical system? Secondly, That the stricture was the cause of the miscarriage in this and the previous pregnancy I have no doubt. I have never seen this mentioned as a cause of premature labour. The uterus up to the fifth or sixth month of pregnancy, grows and expands almost entirely in its upper part. At that time it enlarges downwards from the internal os; but in this case the stricture would not allow it to expand, and by continued irritation, induced labour pains. Thirdly, If this be true, it throws some light upon "What is the cause of labour?"-a point, I believe, still undetermined. If you examine the uterus at the eighth month, you find a considerable portion of the neck still unex panded; if you examine at the end of the ninth month, you find the neck entirely obliterated. What happens then? Does the uterus stop growing? No; it still continues to enlarge downwards, and it can only do so by dilating the os. Had this stricture been situated at the external os, the uterus would have gone on growing until the end of the ninth month, and then, just as in the miscarriage, by irritation of the stricture, labour pains would have set in. It is not necessary, however, to invoke the aid of a stricture at the external os to induce labour pains. The os is the most sensitive part of the whole organ; to dilate or to irritate which is to bring on pains. This the natural growth of the uterus does; then, those contractions of the uterus, sometimes painful and sometimes painless, which occur every hour or two during the latter months of pregnancy, recur with greater frequency; the membranes and the head of the child are pushed down upon the os, exciting it more more and more to induce pains by reflex action, until finally the labour is accomplished. This I have long regarded as the explanation of the cause of labour: the natural expansion of the uterus, acting on the sensitive os, begins to dilate it, and through it reflexly the necessary pains are called forth.-Glasgow Medical Journal, Feb. 1869, p. 156. 87.-CARBOLIC ACID IN THE SICKNESS OF PREGNANCY. By EDWARD GARRAWAY, Esq., Faversham, Kent. Carbolic acid is the only remedy which I have ever found of any avail in pregnant sickness, and of its efficacy here I entertain no doubt whatever. Patients who have had it in one pregnancy, invariably ask for "that tar medicine" in the next. In other forms of sympathetic vomiting, it has proved no less valuable. I quote the two most noteworthy cases I have met with, premising that I am not given to exaggerate. Miss, aged 19, a highly hysterical girl, the subject of pelvic abscess, had vomited every meal immediately after swallowing it for three years. Physic and physicians, of course, had been exhausted upon her. I gave a drop of carbolic acid three times a day. She retained this from the first. After ten doses had been taken-i. e., on the fourth day-a meal was kept down; and from this time she retained alternate meals. In a fortnight, two meals out of three stayed; but the unwonted presence of so much food in the stomach occasioned such distress, that I was induced to partially withdraw the remedy, and allow two out of four meals to be rejected. The carbolic acid, however, was gradually persevered with; and, in the course of a year, the stomach was able to bear and retain four meals a day. Mrs. -- at the eighth month of gestation, engaged me to attend her, and complained that she had been sick throughout her pregnancy. I declined prescribing, assuring her that the vomiting would cease immediately after delivery. However, it persisted as before; and she then informed me that for nine years she never passed a day without vomiting, sometimes several times. This condition resulted from an attack of fever. I waited a fortnight after her accouchement, and then put her upon carbolic acid. She never once vomited again. The remedy was continued a fortnight, then gradually withdrawn. I give drop-doses of the crystal, liquefied by heat, and diffused in half an ounce of thin mucilage, three times a day.-British Med. Journal, March 13, 1869, p. 235. 88.--ON THE DIAGNOSIS OF ACCIDENTAL HEMORRHAGE FROM PLACENTA PREVIA. By Dr. EDWArd Calthorp. The os uteri being unopen, and therefore a physical demonstration of the placenta impossible, any evidence by which we can determine between the two conditions mentioned at the head of this paper must be of value; I speak of the diagnosis of placenta prævia from accidental hemorrhage in the later months of pregnancy. We all know, who have had experience im midwifery, the soft, velvety, hot feel of a gush of uterine hemorrhage, when that takes place the hand being in the vagina. It is from the character of the discharge we are to form our diagnosis in the present case. In a case of placenta prævia-say at the sixth month-the discharge, if any, is blood 66 pur et simple," and on examination the vagina is most likely full of, or at least contains, clots. In a case of accidental hemorrhage, the discharge is liquor sanguinis, and the vagina free from clots; and it is easy to understand how this is. The blood in placenta prævia comes directly from the uterine or placental vessels, or both, into the vagina, and is there discharged as blood, leaving coagulations behind in the vagina; whereas, in accidental hemorrhage, the blood, before being discharged, has to find its way to the os, separating the membranes as it comes down and depositing its fibrine, so that the discharge is liquor sanguinis, and the vagina is free from clots. How often, in a case of accidental hemorrhage arrested and gone to full term, do we not find, on the placenta being expelled, a large mass of fibrine discharged with it (I have more than one in my possession, and have seen numbers). In like manner, after a confinement in which perhaps a small piece of membranes has been left behind in utero; serving as a nucleus, do we not find the discharge" dirty water," as the nurse says, the uterus large, above the pubes, and the patient weak and blanched; the fibrin is deposited, and the liquor sanguinis discharged; and the mass, if allowed to remain in utero, prevents the proper contraction of that organ, and is often the precursor of disease, retroversion, &c., and may account for the moles, "false conceptions," &c., so frequently described. But this is scarcely belonging to my subject. Finding no mention, then, in any authority of this mode of diagnosis (one of many) between these most serious complications, and knowing, by experience, that it is fully to be relied upon, except in cases in which the placenta is very near the os, or the hemorrhage very profuse, must be my excuse for publishing these few rough notes.-Lancet, April 3, 1869, p. 458. 89.-ON A CASE OF POST-PARTUM HEMORRHAGE. The following case may be of some interest as introducing a new mode of arresting uterine hemorrhage. In the year 1860, I was called upon to attend Mrs. G., an hemorrhagic patient (a lady of the middle class), in her first confinement. Parturition was tedious, both from the length of time occupied, in consequence of the insufficiency of the uterine action, and from the occurrence of persistent vomiting; and delivery was accomplished with the aid of the forceps. The placenta was expelled by the natural efforts some twenty minutes after, but the uterus contracted feebly, and shortly afterwards severe hemorrhage took place. I was here ably assisted by my son, Dr. G. F. E. Wilkinson, then a student of medicine, and with his aid ergot and food and stimulants were administered, and cold injections thrown up, but with no success; slight contraction taking place, but the uterus then becoming perfectly flaccid. Hemorrhage continued, and the patient became rapidly depressed. The pulse at the wrist was almost imperceptible, and there appeared every reason to apprehend immediate dissolution. At this trying juncture I observed a large sponge lying in the room; and as both my hands were engaged in endeavouring to control the fearful hemorrhage, I directed that the sponge should be threaded with some strong string, and washed in cold water, when I squeezed it into as small a compass as possible, and introduced it into the uterus. Immediate contraction took place round the sponge, and after gently applying a bandage over the abdomen, and persisting in feeding for some |