III.

REPORT ON THE PROGRESS OF MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN.

A Manual of Obstetrics, Theoretical and Practical. By W. Tyler SMITH, M. D. (London: Churchill, 1858.)

MR. CHURCHILL has added to his admirable series of manuals, one on obstetrics. Dr. Tyler Smith is the author of this manual, and in it he gives an excellent digest of the anatomy and physiology of the reproductive organs, and of the theory and practice of obstetric medicine and surgery. The work will prove a very welcome addition to the library of the general practitioner, and it will no doubt become a great favorite with students. The whole of the subjects entering into a treatise on obstetrics are discussed with great clearness, and notwithstanding the brevity which is necessary to the construction of a manual, the work is not only very readable, but the most important of the debated questions, both in the physiology and pathology of the reproductive organs, as well as in practical obstetrics, are so well set forth that the "Manual" is calculated to prove a valuable guide to those students and practitioners who may desire to become independent observers, and to record for scientific and practical purposes the results of their obstetrical experience. Not the least interesting portion of the work is that in which Dr. Smith sums up his views on the nervi-motor functions of the uterus.

As an illustration of Dr. Smith's style, and as a valuable summary of a debated but very important question in obstetric practice, we quote, in the main, Dr. Smith's remarks on the partial or entire separation and extraction of the placenta in cases of placental presentation.

After treating of the use of the plug, or tampon, puncturing the membranes, and turning the child in these cases, Dr. Smith proceeds :

"I have now to refer to the artificial extraction of the placenta before the birth of the child, which has certainly been one of the most prominent points in obstetric practice during the last ten or twelve years. It is one, the settlement of which is of great interest, as nothing can be more unsafe than halting between two opinions upon such a subject. From an early period it had been remarked by accoucheurs that cases of unavoidable hemorrhage were occasionally met with, in which the placenta was expelled spontaneously before the birth of the child, and that others occurred in which the hemorrhage was arrested by the spontaneous separation of the placenta. The first person who seemed to have pointed out the deduction of a rule of practice from such cases was Mr. Chapman, of Ampthill. The placenta was also removed in some cases of placenta prævia by Mr. Kinder Wood, of Manchester, and subsequently by Mr. Radford. Probably cases have always occurred in which accoucheurs, finding the placenta loose in the vagina, or almost entirely detached, have removed it. Dr. Simpson took up this subject in 1844, and with his usual ability and force, pointed out what he considers the advantages of this operation, the principles upon which it is founded, and the cases in which it is applicable. The tenor of Dr. Simpson's earlier writings was such as to lead to the belief that he wished to supersede, in great measure, the operation of turning, by the separation and extraction of the placenta. This impression has continued to a great extent up to the present time, and it is upon this impression chiefly that its opponents have attacked and denounced the opera

basis of a general method pointed out in the memoir; and that "the principle of this method is to know that the wounds excluded from the air neither inflame nor suppurate."

It is enough for our present purpose to place these facts side by side, without comment; but it must at least be regarded as additional evidence of the truth of the observation, that those who trace the progress of modern surgery to its source will not fail to discern, in the principles which Hunter established, the germs of almost all the improvements which have been since introduced.

The illustrations given by Hunter, in proof of the general law above adverted to, are sufficiently conclusive. No surgeon, he tells us, could have failed to observe the difference between a simple and a compound fracture, in reference to the progress and result of the case. How rarely is a simple fracture followed by suppurative inflammation, and how seldom does a compound fracture unite without suppuration, even when the wound is small and apparently insignificant.

Here, then, we have two similar accidents produced in the same way, by the same amount of mechanical violence; or it may be that the simple fracture is occasioned by a greater amount of mechanical violence than the compound fracture. The only difference is, that an external wound exists in the one case, and not in the other; yet how different the results! And who can suppose that the difference depends upon the additional injury to the soft tissuesskin and cellular tissue-which alone distinguishes the compound from the simple fracture.

How severe, also, are the results following open wounds, though never so small, communicating with joints, so frequently fatal to the limb or the life of the patient. And how seldom does any inflammation follow a subcutaneous opening into a joint, if made with proper precautions and followed by appropriate treatment.

These facts are of the utmost importance in a scientific and practical point of view, and suggest reflections of the gravest nature, in reference to the principles of treatment to be adopted in certain injuries.

In very many surgical operations, it is true that the surgeon has no choice with respect to the mode of procedure, whether by open or subcutaneous wounds; but, in many instances, modern surgery has proved that the old plan of open wound can be advantageously superseded by the subcutaneous method, and operations which but a few years or months since were constantly performed by open wound, are now being done subcutaneously.

Mr. Adams especially endeavors to show that, by observing the law pointed out by Hunter, the surgeon can, in many operations, so adapt his mode of procedure as to prevent or regulate the degree of inflammation which might be expected to follow an operation; in fact, that, in no small or unimportant degree, he is enabled to establish the conditions which influence or direct the reparative process in wounds according to one or other of the various processes of healing.

1st. He can perform many operations in the most delicate and important regions, so that no inflammation may follow; such as the subcutaneous operation for the removal of loose cartilages; the section of articular ligaments for the reduction of dislocations, the cure of distortions, &c. ; the needle operations for cataract, drilling, &c.; the evacuation of the fluid contents of cavities; the freeing of depressed cicatrices, &c. And, with the object of avoiding inflammation, he is also enabled to combine the object of promoting the development of a new connective tissue, where this is necessary to the restoration of function; as in tenotomy and myotomy.

2d. He can avoid excessive inflammation when its oocurrence in some degree cannot be prevented, as in the method of "forced rupture," or forcible extension of partially anchylosed joints; the operation for hernia without opening the sac, &c.

3d. When a limited amount of inflammation is necessary to the reparative process, he can purposely excite it and regulate its intensity, not with absolute certainty, but to a great extent, and generally so as to avoid the dangers of

no hemorrhage between the expulsion of the first placenta and the birth of the second child. It is reasonable to suppose that the same thing occurs in placenta prævia, after the separation and extraction of the placenta, in the intervals which occur between the pains. The tendency to hemorrhage from dilatation of the orifices of the veins during the pains is corrected by the descent of the head or presenting part, and the mechanical compression of the uterine walls.

"Dr. Simpson unequivocally demonstrates that in a great number of cases recorded by various authors, both before and since the publication of his views, the placenta has been detached and the hemorrhage arrested. There can, indeed, be no question upon this point. Those most opposed to Dr. SimpsonDr. Robert Lee, for instance-record cases in which the hemorrhage has ceased after the spontaneous expulsion of the placenta. The cases in which, in his most recent writings, Dr. Simpson would advise separation and extraction, are those in which the evacuation of the liquor amnii is of no avail, and when the state of the patient is such as to call for interference; but where turning or other measures of delivery are impracticable, from rigidity, or non-development of the os and cervix uteri, or a high degree of distortion of the pelvis. He would also employ it in the case of dead, premature, or non-viable children, particularly when the uterus has contracted, or is so imperfectly developed as not to admit of turning. It is questionable if rigidity can be a valid plea for this operation, except in very rare cases. When the os uteri is sufficiently open to allow of the admission of the fingers for the purpose of separating the entire placenta, there will generally be room enough for the admission of the hand. I believe the separation and extraction of the entire placenta to be suitable for those cases in which it is attached all round the os uteri, and in which the exhaustion is so great as to render some more rapid attempt at assistance than the operation of turning imperative. In some of these cases the patients would be killed by turning, if the hemorrhage were going on simultaneously with the operation.

"The extraction of the placenta offers a means of arresting hemorrhage, and after a short rest the patient may be sufficiently rallied to bear turning; for it must be remembered that in many of the cases in which the placenta has been extracted artificially, turning has been necessary to complete the delivery. In all cases where the child is alive and viable, delivery should be effected by turning or the forceps, as soon as possible after the extraction of the placenta, if the state of the patient is such as to bear the operation. Extraction may be sometimes useful in cases where turning is impossible, as in cases of contraction of the uterus, or great pelvic deformity, when the removal of the placenta may arrest hemorrhage and facilitate the operations of turning, craniotomy, or evisceration. It may also be practised in some cases of dead or premature children, when the hemorrhage is going on, and turning is difficult from any cause. When the flooding is not profuse, and when the uterus is roomy and the waters undischarged, the extraction of the placenta before the child offers no advantage whatever. The whole subject has been ably treated by Dr. Chowne, and Dr. Fleetwood Churchill gives a very candid exposition of the advantages and disadvantages of the operation."

Certain statistical arguments have been advanced in favor of the operation. "By the ordinary methods of practice, rather more than half the children are lost; and Dr. Simpson attempts to show that the mortality is scarcely more than this when the placenta was extracted before the child. He gives a table of 141 cases; of these, the child was saved in 33 cases; in 99 cases it was born dead; in 1 the child was anencephalous, and died shortly after its birth; in 28 cases the result, as regards the child, was not stated. But such a state of mortality cannot be hoped for from artificial extraction. In many of the cases of spontaneous expulsion the foetus, membranes, and placenta, are expelled by the same pain. Dr. Simpson, as Dr. Fleetwood Churchill observes, has only recorded one case of the child being born alive when the interval after the removal of the placenta was more than ten minutes. Dr. West collected 17 cases, but in 16 of them the children were lost. If this great proportion of fœtal mor

6thly. The morbid changes referred to in deductions 2 and 3 are competent to explain all the phenomena of strabismus.

7thly. The phenomena of strabismus cannot be accounted for on any other hypothesis.

On the subject of treatment the author remarks: "If the view I have taken of the pathology of strabismus be correct, it must be obvious that no treatment can be of any avail in confirmed squint, except division of the shortened muscle" (page 130). He is "well aware that incipient and slight cases of squint may sometimes be cured without operation, and that instances are not wanting, in which more confirmed distortions have been got rid of by persevering efforts on the part of the patient; but even when such efforts have been attended with success, the accompanying impairment of vision is not removed. Now, dividing the muscle by which the strabismus is produced not only rectifies the malposition of the eye, but improves its vision, and on these grounds I hold the operation to be preferable to all other methods of treatment. (Preface v.)

In the mode of performing this Mr. II. still advocates the sub-conjunctival method, which was first recommended and put into practice in this country by Mr. Brooke in 1845; again strongly urged and its advantages set forth by himself in 1854; and lastly by Mr. Critchett in 1855. In opposition to this lastnamed gentleman, who has asserted that both eyes are equally implicated, and that it is therefore immaterial which is selected for operation, Mr. Holthouse maintains that this is not the rule but the exception, and that in most cases it is material to select the worse eye, and to operate on it only. To determine which is the bad eye, Mr. Holthouse employs what he calls the vision test, the value of which depends on the fact that in about 90 per cent., or more, of all strabismus cases, the sight of the most distorted eye is worse than the other. After giving some judicious rules for the operation, Mr. Holthouse expresses his conviction "that there is no operation in the whole range of surgery, which is so entirely unobjectionable and free from risk; complete failure can only arise from its imperfect performance, while improvement may be predicated in every case, and perfect success in most" (page 140).

The remainder of the work is devoted to paralytic affections of the eye, and certain forms of impaired vision, in which the author endeavors to prove, and we think successfully, that there is a particular form of amblyopia which is due to muscular action, and which, from its being most frequently observed in strabismus, he has termed strabismic vision. "With regard to the nature of the imperfection," observes Mr. Holthouse (page 173)," it must first be clearly understood, that I do not include under the term strabismic vision every kind of imperfect sight which may accompany strabismus; all I maintain is, that there is, in addition to any and every defect of sight which may coexist with the deformity, this special one also superadded."

After an enumeration of the symptoms, for which we must refer our readers to the work itself, he continues: "It differs from myopia in being improved by convex lens-it differs from presbyopia, in requiring the approximation of objects to the eye-from asthenopia, in being persistent and not intermittentfrom limited adjusting power, in the total absence of all power of adjustment -and it differs, lastly, from certain cases of incipient amaurosis, in its being remediable by operation. What now is the nature of the defect? Is it a dioptric or a sentient one?

"The symptoms we have described as characteristic of the affection, show that it partakes of the nature of both these defects. In slight cases it would appear to be chiefly, if not entirely, a dioptric defect; in bad cases the sentient part of the eye also would appear to be implicated; and in all, the defective sight, however it may vary in degree, is brought about by abnormal muscular action" (pages 174, 175).

In support of this position the author refers to several cases given in his work, of which the following is perhaps one of the most striking; it is that of a gentleman, 41 years of age, who for the last 5 years had become affected with strabismus of the left eye; previous to this occurrence "both eyes were highly myopic; but afterwards the near-sightedness of the squinting eye was much

diminished, and its vision improved. It would appear, therefore, that the slight pressure which must be exerted on the strabismic eye, in an antero-posterior direction, whenever it is straightened, is sufficient to render it slightly presbyopic or to lengthen its focus; hence the improvement of vision in the case just referred to" (page 177). The whole of this chapter on muscular amblyopia is thoroughly original and well worth perusing.

Cases illustrative of a New Method of Treating Deep-seated Inflammation of the Globe, or Acute Glaucoma. By Mr. CRITCHETT, Surgeon to the Royal London Ophthalmic Hospital. ("Ophthalmic Hospital Reports," No. 2, 1858.) When diseases invade the deep-seated structure of the eye, it is extremely difficult to give to them a correct and scientific nomenclature; hence it is that such terms as amaurosis and glaucoma are employed to designate a great variety of morbid phenomena. It seems probable that the extensive use of the ophthalmoscope, and the careful microscopic investigations that are carried out in the present day upon extirpated globes will enable us to employ a more rigid and exact set of terms. The inconvenience at present experienced results from the employment of these terms to designate more than one group of symptoms, so that some confusion is apt to result in the minds of ophthalmic surgeons, in conveying to each other the results of their experience. Nevertheless there are certain well-marked groups of symptoms both objective and subjective, so regular in the order of their sequence, that every practical ophthalmic surgeon at once recognizes them; and in proportion to the severity of the disease, to the rapidity with which it develops, to the extreme pain that accompanies it, to its destructive effects as regards sight, and to its intractable character, are the leading features of the disease impressed upon the memory. The disease of which the cases about to be related are types, usually occurs rather past the middle period of life, and in persons of feeble constitution, either originally, or as the result of some debilitating cause. It generally attacks one eye at time, and there is frequently a considerable interval between the invasion of the first and second eye. The symptoms come on very suddenly, and proceed with great rapidity. At the outset of the attack the pain is of a most intense character, extending to the brain, and lasting many hours, sometimes two or three days; there are frequent flashings of light, and the sight is rapidly and seriously impaired, and if the disease pursues its course in its worst form, is permanently destroyed. On examining the eye shortly after the onset of the disease, the appearance is very characteristic and peculiar, the pupil is fixed and widely dilated; the humors are dull and muddy, and cannot be fully lighted up by the ophthalmoscope; the surface of the globe is of a bluish-red color; the deeper layers of vessels appearing chiefly injected. The anterior chamber is reduced in size, and the lens seems thrust forward into the pupil. The globe is tender to the touch and of stony hardness. At a subsequent stage, and when all perception of light is gone, these appearances undergo some important changes and modifications which are not quite uniform in their character. At one or more points the sclerotic frequently thins and bulges, the humors become much discolored and of a greenish hue, and the lens cataractous. The sclerotic looks thin and of a dark color, as if the choroid could be seen through it; and upon the surface are seen some large blue distended vessels, showing that the chief onus of returning the blood is thrown upon these superficial veins.

It is to the earlier stages of this disease that Mr. Critchett is desirous of directing attention. It is difficult to localize the precise seat of the inflammatory action of this stage, but it is probably the retina. The distinguishing feature of such cases, that which causes such intense agony, and so rapidly impairs and destroys the sight, is the distension to which the globe is subjected; the perfect balance that subsists in the normal state between the fluids of the eye and their firm inelastic fibrous case is lost, and the latter is placed in a condition of extreme tension by the former; a tension that is constantly increasing until the sclerotic thins and yields to the pressure from within, or until the impetus of the disease exhausts itself. All the ordinary methods of treatment are utterly useless in this disease; the most active antiphlogistic means, such