the treatment of retention of urine from enlarged prostate, enlargement of the prostate from inflammation, malignant disease of the organ, tubercular disease and cysts, the bar at the neck of the bladder, prostate concretions and calculi, form the subjects of successive chapters. There is much valuable matter under each of these heads, but we would especially instance the remarks upon the effect of enlarged prostate upon micturition, upon malignant and tubercular disease, and upon diagnosis and treatment. The last two subjects, indeed, are in every respect deserving of attention.

The last chapter is devoted to a careful consideration of that important, but not uncommon complication of enlarged prostate, stone in the bladder, and especially of the best modes of successfully applying lithotrity as a means for its removal.

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

tion. In one of his latest publications on the subject, in 'The Lancet,' 1847, vol. i., he has corrected this, and insists upon the limitation of the extraction of the placenta to cases where the other recognized modes of management were insufficient or unsafe, or altogether impossible of application,' or where the old methods of practice were attended by extreme hazard or extreme difficulty.' Dr. Simpson combined with his advocacy of this practice an exposi tion of his views as to the source of the hemorrhage in placenta prævia, which met with great opposition. Dr. Hamilton and others advocated the doctrine that the hemorrhage in placenta prævia 'proceeds from the separated portion of the placenta more than from the ruptured uterine vessels.' Dr. Simpson endorsed this view to the full extent, and I suspected it is this, as much as the rule of practice itself, which has excited the opposition which has been manifested. According to this hypothesis, the blood lost in separa tion of the placenta flows from the placental cells, the supply to these cells being kept up by vessels supplying the undetached portions of the placenta. It is supposed that, as the separation proceeds, the veins from the uterine surface, from which the placenta is detached are closed so as to prevent any retrogressive hemorrhage from the uterus."

Dr. Smith believes this theory to be altogether untenable, for there are no proofs of the escape of the great quantities of blood lost in these cases, from the placental surface; and although there is an unobstructed channel for the flow of blood from the curling arteries, through the placental cells, and the openings found upon the placental surface when this has been separated from the uterus, yet there are valid reasons why we should believe that the sudden and great gushes of blood poured out in placenta prævia do not escape in this way. The uterine arteries are of comparatively small calibre, and the openings upon the placental surface are neither large nor numerous. Supposing one half of the placenta to be detached, it is highly improbable that the profuse loss frequently met with in these cases could come from the uterine arteries entering the undetached portion of the placenta, even if they were all dis charging blood simultaneously. Moreover, there are good reasons for believing that the uterine veins are the real sources of hemorrhage in placenta prævia. The size of the venous openings, the valveless state of the uterine veins, the channels being unimpeded from the right auricle to the open mouths of the sinuses, furnish anatomical arguments in favor of this source for the flow of blood, which are stronger than those derived from the anatomical arrangement of the uterine curling arteries and the placental sinuses, in favor of the opposite view. Then there are the facts connected with post-partum hemorrhages. The only hemorrhages comparable for suddenness and extent to the losses in placenta prævia are those which occur after labor, and subsequent to the expulsion of the placenta, in cases where it has been attached to the fundus uteri. In inversion of the uterus, after completion of delivery and the separation of the placenta, the flooding is known to be enormous. Here, then, can be no question but that the hemorrhage takes place from the open mouths of the uterine veins. For these and other reasons, detailed in the book, Dr. Smith infers that "in the hemorrhage from the placenta prævia the blood escapes in great part from the uterine surface, and not from the material surface of the placenta." Doubtless some blood exudes from the surface of the placenta in cases of partial separation, whether the placenta be attached to the fundus or cervix, but he contends "that this is not the chief source of flooding in placenta prævia."

"While I thus take exception to Dr. Simpson's theory of the nature of hemorrhage in placenta prævia," continues Dr. Smith, "I do not question the correctness of the fact upon which he lays so much stress, namely, the frequent and indeed common arrest of the hemorrhage on the entire detachment of the placenta. Dr. Simpson's theory does not appear to me to be necessary to the explanation of this matter. In my work' On Parturition,' I pointed out that the separation of the placenta furnishes a source of irritation which excites the uterus generally, and the muscular structure at the site of the placenta especially, to contraction, and that in this way hemorrhage was prevented. This is probably the reason why, in twins with separate placenta, there is frequently

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.

46

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

tality should be preserved, it must go far to prevent the adoption of extraction in any but the most unpromising cases.

"Dr. Barnes has entered more fully than any previous author into the subject of placenta prævia and its treatment. He believes that in placenta centralis the action of the pains detaches the placenta in concentric rings from below upwards, until the separation is carried sufficiently high to admit of the passage of the foetal head. This point being reached, he contends that the hemorrhage ceases, although a sufficient amount of placenta may remain attached to allow of the preservation of the child. In placenta lateralis, also, cases are met with in which no interference takes place, but in which the placenta is detached from the os uteri and from the internal surface of the uterus to a certain extent, after which there is no further hemorrhage. Thus there is a zone or line round the lower part of the uterine cavity, above which the placenta is tolerably safe against detachment during delivery, and below which separation with hemorrhage are inevitable. Dr. Barnes founds upon these data the principle of practice for which he contends-namely, the artificial separation of the placenta, when the os is sufficiently open, to such a distance above the os uteri as to admit of the passage of the foetal head, and thus to save the patient from the intermittent separation and hemorrhage produced by the pains. He would affect at once, by passing one or two fingers into the uterus, rupturing the membranes, and sweeping them round the os and cervix, what nature only does slowly and dangerously, believing that the natural contractions of the uterine tissue will prevent any dangerous effusion of blood after this operation, or that, if uterine action be wanting, it may be compensated for by internal and external stimuli, plugging the vagina, the administration of ergot, astringent injections, or the use of electricity. When the detachment of the placenta has been completed to the extent pointed out, Dr. Barnes would, as I understand him, leave the case to nature, unless special reasons for other interference should exist. Dr. Cohen, of Hamburg, has proposed, in cases of partial or lateral placenta prævia, to detach entirely the placenta from that half of the cervix to which the smaller portion of its bulk is attached, when, as he states, the placenta passes over during the pains to the side of its chief attachment, and the hemorrhage ceases. Dr. Cohen mentions that he has, in many instances, performed this operation with invariable success as regards the mother, and that he has rarely lost a child. This method is evidently an ingenious modification of that proposed by Dr. Barnes. As regards the use of astringents, Dr. Barnes recommends the sesquichloride of iron, or a pared lemon, but I would suggest the use of alum and iron as a most powerful astringent. In the application of pressure, an inflated air pessary of sufficient size would be more effective than any other kind of plugging. As a summary of the whole of this important subject, it may be stated that

"In turning we have the great advantage of controlling the duration of labor, and in the performace of the operation the hand and arm of the accoucheur, and subsequently the part of the child brought down, plug the cervix uteri very efficiently. I believe also that except in cases of limited attachment of the placenta at the os uteri, the chances of saving the child is as great as by any other method. The risk to the mother from the operation, unless in extreme cases, is very slight. Turning cannot, however, be practised until the os uteri is dilated to a certain extent, up to which time plugging must be depended upon if we determine to turn. Cases are also sometimes met with in which the exhaustion of the patient is so extreme as to forbid the operation.

"In separation and extraction of the placenta we have the means of arresting the flooding when the mother is too weak to admit of turning. Hemorrhage does not, however, invariably cease on the extraction of the placenta, and by this procedure the life of the child is almost certainly sacrificed. The best cases for its performance are those in which dangerous exhaustion exists, or when the child is already dead.

"In partial detachment of the placenta there is a fair chance of saving both mother and child in favorable cases. But although I give its full value to the principle enunciated by Dr. Barnes, it must in practice be difficult to know, in individual cases, at what point of detachment the hemorrhage is certain to