stances the child was hydrocephalic or dropsical; in 3 the mother was already dead; there were 5 cases of spina bifida; 7 deaths took place from prolapsed funis, and 3 from the arm and head being tightly wedged in together. In 4 instances the mother had suffered from repeated convulsive paroxysms. In other cases the application of the forceps had been repeatedly attempted by preceding practitioners, or the passage was narrowed by the presence of tumors. Dr. Meissner remarks, by the way, that the separation of the epidermis is not always a certain sign of the death and putrefaction of the child, as it may be produced by an acrid condition of the liq. amnii. Extraction. This was performed in 247 cases, and became necessary when, in breech, knee, or foot presentation, the child's life was threatened by cessation of pain, faulty position, or prolapsus of funis. Only 145 of the children were born living; but then 13 had died through pressure on the funis, before the author's arrival; 18 were in a state of putrefaction, 10 were already born except the head, 8 were immature, and in 5 others there was hydrocephalus or other form of dropsy. In 42 instances extraction had to be performed on account of cessation of pain after turning. Perforation.-In his thirty-six years' practice, this operation has only been performed by the author thirty-two times, and he had attended 3299 labors before he had his first case. He has always followed the maxim laid down by the chief German practitioners, of never proceeding to the operation until assured of the child's death; and it has several times happened to him to see living children born in cases which have been left for days together to the powers of nature, and which in previous labors had been delivered by perforation. Premature labor.-So much has the performance of the operation for premature labor limited that of perforation, that while to the year '42 he had had to resort to perforation in twenty-eight instances, he has during the subsequent fourteen years only performed it four times. He has never induced premature labor prior to the thirty-sixth week, and has never found this too late, the bones continuing thus long sufficiently soft and yielding to accommodate themselves to the narrowed pelvis. When the reckoning is uncertain, he performs the operation thirty-six weeks after the last menstrual period. Forced delivery (accouchement forcé).-By this term, the author understands the whole series of operations (as artificial dilatation of the os uteri, bursting the membranes, turning, extraction, or removal of placenta) which may be required for delivery when the further continuance of pregnancy is dangerous to mother and child. It is especially called for in certain cases of eclampsia, placenta prævia, and obstinate vomiting. He enumerates under this head two instances of opening the adherent os uteri by means of the knife, and eight cases of its forcible dilatation. This last procedure was resorted to because, after the labor had continued three or four days, in place of dilatation of the os uteri, general debility and delirium set in. The author has resorted to it fifty-five times during thirty-six years. In thirty-three of these cases both mother and children did well, although, as the dilatation was usually undertaken for placenta prævia, most of the latter were born some weeks too soon. As the majority of cases (31) were examples of placenta prævia, in which hemorrhage had continued long before the patients were seen by the author, it is not surprising that ten of the mothers died; but another statement of the author, that even when he arrived at his patients he plugged the vagina, and awaited pains before proceeding to deliver, is somewhat extraordinary. Casarean operation. Of the six examples of this that have fallen to the author's lot, five were performed on mothers being already dead, the children being saved in none. In the case of operation upon the living subject, both mother and child lived. Placenta removals.-The number of these (447) must seem very large; but it is to be remarked that, perhaps not one-tenth of these cases were examples of abnormal adhesion requiring separation, the placenta being frequently detained from other causes, preventing the success of the ordinary manipulations, as "stricture of the uterus," spasmodic contraction of the uterus from too early interference, &c. General results. Of the mothers, 41 were lost; 25 during, and 16 after de livery. Of the former 25, 11 were already lifeless when seen; and of the 14 others, 1 died from rupture of the omentum with internal hemorrhage, 10 from placenta prævia necessitating forced delivery, 2 from nervous shock after favorable labor, and 1 from hemorrhage. Of the 16 mothers who died after delivery, 1 died from cancer of the stomach, 1 from pneumonia, 3 after repeated attacks of eclampsia, 1 from putrescence of the uterus, 1 from typhus following the birth of a putrid premature child, 4 from puerperal fever following operative procedures, 1 from " paralysis of the lungs," 3 from the consequences of loss of blood, and 8 after several hours' operative attempts by a country practitioner. Of the children 399 were born dead, as already stated, under the various operations. Besides these, 36 died within the first fourteen days after birth; viz. 4 from debility from too early birth, 6 from atelectasis pulmonum, 2 from trismus, 1 from fissure of the cranium after a forceps operation, 1 from chronic hydrocephalus, and 2 from want of breast-milk. After remarking upon the remarkable sequences met with in practice of unusual pathological occurrences, and of the operations required for their relief, the author observes, that, as a general rule, forceps operations are found to be most frequent in cold, changeable weather, which induces rheumatic affections of the uterus, not only rendering the dilatation of the os very painful, but delaying its accomplishment for days. This condition may be often prevented by clothing warmly the lower part of the person; and when it is present it should be treated by Dover's powder. The standing too much over the fire, also, may, by over-heating the abdomen, lead to a plethoric condition of the anterior wall of the uterus, which may not be without its influence in inducing morbid adhesion of the placenta. Such an occurrence is best prevented by abstaining from this practice, and bathing the abdomen with cold water. When adhesion has taken place repeatedly at the same place, in consequence of an indurated condition of a portion of the uterine wall, we should, after the termination of the puerperal condition, endeavor to induce absorption by mild mercurial or iodine frictions, tepid baths, together with hemlock and mallow injections. If these do not succeed, the baths at Krankenheil, near Tolz, in Bavaria, which have been found so useful in fibroid and hypertrophy of the uterus, should be tried. ART. 149.—On the prevention of laceration of the Perinæum. By Dr. MATTei. (Vierteljahrssch. für Prak. Heilk., 1858; and Med.-Chir. Review, Oct., 1858.) Dr. Mattei gives the following views on the means of preventing laceration of the perinæum: It is especially necessary that the head pass the vulva in a favorable direction. This can only happen when it passes with the necessary degree of flexion. Whilst the occiput passes under the pubic arch, the face has not yet quitted the pelvic outlet; first, when the upper part of the neck comes under the pubic arch, can the extension of the head (or the separation of the chin from the breast) begin. If the distension of the perinæum begins too early, the head must pass the vulva with unfavorable diameters; namely, with the great oblique, or great or straight diagonal diameters. Such a passage easily causes laceration. Hence it is the task of the physician to prevent a premature distension by the head. This he effects by placing two fingers between the labia, or, in some cases, between the pubic arch and occiput, so as to bring the head downwards and outwards, at the same time laying the other hand on the hinder part of the perinæum, upon which the face is lying, and pushes this upwards. This manoeuvre is to be executed during the pains, which will thus protrude the head forwards in the requisite arc. A very simple means of expediting the birth of the head consists in compressing firmly the distended perineum with the whole hand. This resembles the squeezing out of the kernel from a cherry. On the passage of the shoulders care must also be taken lest the two shoulders pass together. ART. 150.-History of a Forceps Case. By Dr. ROBERT LEE, Obstetric Physician to St. George's Hospital. (Medical Times and Gazette, Sept. 18, 1858.) CASE. At 10 P. M. on Monday, August 23d, 1858, I was requested to see a lady, æt. 40, who was stated to have been in labor since the Saturday morning. "The head on the perinæum; the pains have gone off; she looks well, but the pulse is 120, and there has been no progress during twelve hours. When the membranes gave way not precisely known." At 11 P. M., pulse rapid; no pain whatever. The head pressing upon the perinæum-the external parts partially dilated. An ear under the symphysis pubis readily felt. There was a peculiar fetor in the discharge from the vagina. Auscultation was employed, but the sound of the foetal heart could not be heard. Had I been absolutely certain that the child was dead, I would not have applied the forceps, although it was a favorable case for delivery with the forceps. The movements of the child had been but little felt by the mother during the day. I applied the blades of the forceps readily, and got the head nearly in the world, when the perinæum appearing to be in great danger, I took off the blades, and by slight pressure with the fingers on the sides of the head in place of the blades, I easily extracted it. A bloody fluid escaped from the mouth and nose. The skin of the abdomen was peeling off. It must have been dead at least two days. The labor had commenced at 4 A. M. on the Saturday morning. It went on all the Saturday, Sunday, and Monday, till Monday night at 11 P. M. It was the first child. Two ounces of chloroform had been given during the Saturday and Sunday. Once the patient was nearly insensible. On inquiry why this had been done, the medical attendant stated that he did not approve of it, but the patient insisted upon having it. She informed me that a lady of her acquaintance was attended by "a chloroform doctor," and that she had, in consequence of this, contrary to the advice of her medical attendant, insisted upon taking it. It appeared almost certain that if he had not yielded to the wishes of his patient, she would have placed herself in other hands. I observed to Dr. after the delivery with the forceps of a child that had been dead two days, that it would be most important in cases of protracted labor, if any means could be discovered by which the life or death of the child could be determined with absolute certainty. The method of treatment in many cases would be regulated by this. Had I been certain in this case that the child was dead, I would not have delivered with the forceps, but by craniotomy. Since the occurrence of this case I have applied the stethoscope over the anterior fontanelle immediately after birth, but the pulsation of the arteries of the brain was not heard. I tried the instrument recently invented by Dr. Alison, but this was equally unsuccessful. The 12th chapter of M. Mauriceau's second book is entitled, "Les signes qui font connoitre que l'enfant est vivant ou mort dans la matrice." He was fully aware of the importance of the subject, and among other expedients recommended by him to ascertain the fact with certainty, was introducing the hand into the uterus to feel whether there was any pulsation in the arteries of the umbilical cord, or in the artery at the wrist. "Et si mettant la main dans la matrice, on trouve l'enfant froid," says M. Mauriceau. "A sense of coldness in the abdomen," is one of the symptoms enumerated by Dr. Merriman as among those which are useful "in proving that the foetus has been dead in utero for several days or even weeks." Among the "signs of a dead child," the eleventh mentioned by Smellie is, "a coldness felt in the abdomen." I felt curious to know whether the temperature of a dead child during labor was different from that of a living child, for during labor the fact could readily be ascertained. I soon found that the temperature of a living child immediately after birth was 98°. In a case of twins, the feet presented. I measured the temperature of the feet and thighs before the nates were expelled, and the heat was 98°. After the expulsion of the breech, the thermometer was introduced into the anus, and the heat was 98°. After the birth of the child I found the temperature of the axilla, mouth, and head the same. I ruptured the second bag of membranes, and when the head was expelled, but not the body, I put the thermometer in the mouth, and it was 100°. The heat of the mother's mouth and vagina was 98°. I have not had an opportunity of ascertaining what the temperature of a dead child is, either before, during, or after delivery. ART. 151.-History of a case of Craniotomy. By Dr. ROBERT LEE, Obstetric Physician to St. George's Hospital. CASE.-On Sunday morning, at half-past one, of the 26th September, 1858, I was called to an obstetric case. The patient was 31 years of age; first child. The practitioner had first seen her at half-past six o'clock on the Saturday morning. Labor, it was stated, had been progressing slowly ever since. "All to-day fecal matter has been passing per vaginam. She appears to be getting exhausted. Pulse 120; tongue furred. It appears to be a case where there is nothing left for us but perforation." The husband, who came with a letter from the medical attendant, was in a state of great alarm, and said, in driving home, “Will it be necessary for you to give my wife chloroform ?" My answer was, Certainly not; I have never seen chloroform do the slightest good in any case of midwifery, and in some the greatest mischief." On reaching the house, I found two medical practitioners in attendance. The circumstance which had excited the greatest anxiety was, "the fecal matter passing per vaginam." They assured me it was not the meconium, but the contents of the mother's bowels which were escaping. I inquired if there was any symptoms of rupture of the vagina, but there had been no vomiting, and the head was in the pelvis, and actually resting upon the perinæum. One of the medical attendants spoke of the forceps, but did not actually propose to use the instrument. I inquired if the forceps had ever been applied by him to the head of a child positively known to be dead, which was the fact here. To this question no reply was given; but it was my impression he had never done this. The I found the patient a good deal exhausted, and the pulse rapid. The pain had entirely ceased. The discharge from the vagina extremely fetid. head was so flaccid, and the bones so much pressed over one another, that there could be no doubt the child had been dead for a considerable period. I examined the posterior wall of the vagina; but there was no rent, and no feculent matter was passing per vaginam. I had not a thermometer with me to determine exactly the temperature of the head; but it did not feel colder than the vagina. No chloroform was given before proceeding to perforate and extract the head, which was speedily done. There was no thermometer in the house; but I applied my hand to the body of the child immediately after its escape, and there was no sensible difference in the temperature between this and a living child. Both practitioners did the same, and we all came to the conclusion that the temperature must have been about the same as that of the mother. The bandage was applied, but the placenta did not come away for about half an hour; and as it adhered was removed by the medical attendant very carefully and successfully; slight hemorrhage followed, but soon ceased. The forceps would have been employed in this case, had the child been certainly known to be alive, or if its death had remained doubtful. It might now, I think, be considered as an aphorism in midwifery-that the forceps is not applicable to dead children, nor in cases where the os uteri is not fully dilated, and the head has not descended into the cavity of the pelvis and can be felt. But I had forgotten, the aphorisms in midwifery have all of late been turned topsy turvy. ART. 152. On the comparative use of Ergot and Forceps in Labor. (Amer. Med. Monthly, July, 1858.) The more enlarged our clinical experience, and the more accurate our observation, the more rarely, in Dr. Barker's opinion, shall we have recourse to ergot before delivery. Delay in labor, moreover, is held to be more dangerous than promptness in the use of the forceps. Ergot is said to be safe only in those cases where the presentation is natural, the pelvis well formed, the os uteri well dilated, the vagina and vulva lax and moist, and, in short, everything prepared for delivery, nothing being wanting but efficient action of the uterus. The conclusion is, that the dangers are many and great, and the advantages few. On the other hand, the dangers resulting from the use of the forceps are set down as overrated, and the dangers of delay as greatly underrated. The plain, practical question for the lying-in-room, Dr. Barker thinks, is—which is safest for mother and child, the use of instruments, or further delay? And to this question the answer is to be found in the accompanying quotation: "Professor Simpson has shown that the maternal mortality attendant upon parturition increases in ratio progressive with the increased duration of the labor. He has made out the following table, showing the proportion of 138 natural deaths in relation to the duration of labor in 15,850 cases of delivery recorded by Dr. Collins : : Proportion of deaths. No. of deliveries. No of deaths. From 25 to 36 hours "So also the infantile mortality attendant upon parturition increases in ratio progressive with the increased duration of the labor, as is shown in the following table of the proportions of stillbirths, in reference to the duration of labor in 15,850 cases of delivery: Duration of labor. No. of No. of deliveries. stillborn. Proportion. 7050 347 1 in 23 6362 346 1 in 18 1672 "Within 2 hours From 3 to 6 hours From 7 to 12 hours From 13 to 24 hours From 25 to 36 hours Above 36 hours . "It will be thus seen that the dangers of delay, both to mother and child, become a question of the gravest importance. Among our systematic authors, Burns has more strongly, and I think more truly, pointed out these dangers than any other of our English writers. He says the continued pressure of the head on the soft parts is productive of further diminution of the capacity of the pelvis, for inflammation is excited, and at the time the return of the blood by the veins is obstructed, and of serum by the lymphatics. This impairs the power of the soft parts, and renders the inflammation of the low kind, so that even when delivery is accomplished sloughing succeeds, whereby very dreadful or loathsome effects are produced, if these, indeed, be not prevented by the death of the patient, in consequence of a similar low inflammation being communicated to the peritoneum. This swelling of the parts contained within the pelvis may take place although the head be not impacted, but the head cannot long be impacted without producing that. "Here, then, is one effect of a most formidable and alarming nature, which we apprehend in the case under consideration. But this is not the whole of |