the evil; for the upper part of the vagina, or the cervix uteri, may be lacerated in consequence of this debilitated state, or any part of the uterus may be ruptured by strong and spasmodic action; or uterine or peritoneal inflammation may be excited previous to delivery, proving fatal in a few hours after labor is terminated; or hemorrhage may occur, to a fatal degree, from want of energy in the uterus after delivery; or general inanition and exhaustion are produced; the pulse becomes frequent, and at last feeble; the mouth parched; the skin hot; the mind confused, and the strength sunk; or the powers of life may be worn out, so that the patient shall die without any decided inflammation or disease referable to a common nosological system. In the 'Clinical Midwifery' of Dr. Robert Lee, who is no advocate for the frequent use of the forceps, and, indeed, who never uses them except when the head is at the lowest strait, occurs the following statement, which seems to me very significant: In thirty-eight cases of this report the labor continued from forty to seventy hours. In the cases of spontaneous rupture of the uterus and convulsions only was the delivery effected before the labor had lasted upwards of thirty hours. In a very large proportion of the cases the difficulty arose from distortion, or a contracted state of the pelvis. Rupture of the uterus took place in three before perforation; and the inflammation and sloughing of the uterus, vagina, and bladder, which proved fatal in eight hours, were chiefly or solely produced by the longcontinued violent pressure on the soft parts, by the head of the child before it was opened and extracted. In those who recovered with vesico-vaginal fistula, or contraction of the vagina from cicatrices, the unfortunate occurrence arose from craniotomy being too long delayed.' In eighty-seven of Dr. Lee's cases, where craniotomy was performed, local lesions on the part of the mother are noted as having occurred in several instances. Out of the eighty-seven cases, eight, or about one in every ten, suffered from vaginal inflammation and sloughing; four, or nearly one in every twenty, were left with vaginal fistula. In a paper on the subject of Urethro-vaginal and Vesico-vaginal Fistulas,' published. in the North American Med.-Chir. Review' for July and November, 1857, by Dr. N. Boseman, of Montgomery, Alabama, he states, that in nineteen cases of these fistulas the shortest duration of labor in any one of these cases was thirty-six hours, and the longest eight days; the average being about four days. In nine of these cases instruments were employed to aid in the delivery; in six no artificial means were resorted to.' He adds: Judging from the nature of the fistulous openings in the cases where instruments had been used, and where they had not, I am forced to the conclusion that nearly if not all of them were the result of sloughing.' In further confirmation of the views advanced as to the danger of delay in labor, I add a note from Dr. Sims, who has undoubtedly had a larger experience in the lesions resulting from parturition than any man living:— My dear Doctor-Out of about one hundred and twenty cases of vesicovaginal fistula, I have had time to look over the histories of only seventy. Of these, forty-one were delivered by instruments, the rest being left to the unaided efforts of nature. 44 4 These fistulas are sometimes produced by laceration, but most commonly by a slough, which is generally in proportion to the duration and degree of impaction, whether instruments are used or not. Instruments are often blamed for injuries which are produced, not by their use, but by the want of their timely application; in other words, by the prolonged pressure resorted to. The cases left entirely to the unaided efforts of nature, other things being equal, suffered the greatest loss of structure; those in which instruments were used sustained, as a rule, less loss in proportion as they were resorted to early or late, thus showing that the mischief was the result of prolonged pressure.'" 666 ART. 153. A new method of treating Prolapsus of the Funis. (Transactions of the New York Academy of Medicine, vol. ii. part 2, 1858.) In a course of lectures on obstetrics, delivered by Dr. Thomas in the University Medical College of New York, about two years ago, he investigated this subject, and came to the following conclusions: first, that the causes of the persistence of this accident (whatever may at first have produced it) reduced themselves to two, the slippery nature of the displaced part and the inclined plane offered it by the uterus, by which to roll out of its cavity;* and secondly, that the only rational mode of treatment would be inverting this plane, and thus turning to our advantage not only it, but the lubricity of the cord, which ordinarily constitutes the main barrier to our success. This he found could be readily accomplished by placing the woman on her knees, with the head down upon the bed, in the posture assumed by eastern nations in worship, and now often resorted to in surgical operations upon the uterus and vagina. Let it be remembered that the axis of the uterus is a line running from the umbilicus, or a little above it, to the coccyx, and it will be seen (here are two diagrams which make the point very evident) that by placing the woman in this position it will be entirely inverted. Dr. Thomas then relates three cases in which he carried out this practice easily, and saved the life of the child, and after this he proceeds to lay down certain rules, which are 1. That if the cord be detected in the unruptured bag, the woman be at once placed in position before escape of the waters, and that no efforts at return of the prolapsed part be made by the hand. The position alone will, I believe, cause its return to the uterus; and if it does not, we may do so manually as soon as the waters escape. 2. That if the pelvis be so fully occupied by the presenting part as to preclude return of the cord by the hand, a gum elastic catheter and tape to be used as a porte-cordon. 3. That no manipulations be commenced until the woman be placed in position. 4. That in returning the cord the whole hand be introduced into the uterus; the fingers alone will fail. ART. 154.-Port-wine enemata as a substitute for transfusion of blood in postpartum hemorrhage. By Dr. LLEWELLYN WILLIAMS, of St. Leonards-on-Sea. (British Med. Journal, September 4, 1858.) CASE.-On September 22d, 1856, I was called into the country a distance of four miles, to attend Mrs. C- æt 42, then about to be confined of her tenth child. All her previous accouchements had been favorable. When about six months advanced in pregnancy, she received a violent shock by the sudden death of her youngest child, since which time her general health had become much impaired. She had a peculiar pasty anæmic appearance, and complained much of general weakness. On my arrival I discovered the os uteri fully dilated; the membranes ruptured spontaneously; and after three or four powerful pains, a fine female child was born. Placing my hand on the fundus uteri, I felt it slowly contracting under my grasp. My patient exclaimed, "I am flooding away," and fainted. I immediately had recourse to such restoratives as were at hand, and presently she began to revive. On making an examination, I found the placenta lying detached in the vagina, and removed it without difficulty, together with a large quantity of coagula. I had administered a dose of volatile tincture of ergot. The uterus continuing to contract feebly, and more than the usual amount of discharge being present, I applied some cold cloths to the vulva and hypogastric region; this having little apparent effect in arresting the discharge, though steady pressure was continuously applied with the hand on the abdomen, I had recourse to the plan recommended by Gooch, of throwing a quantity of cold water suddenly on the abdomen. My efforts still being foiled, and the hemorrhage continuing, the powers of life manifesting evident symptoms of flagging, I introduced my left hand into the uterus, after the manner also recommended by Gooch, endeavoring to compress the bleeding vessels with the knuckles of * When the woman is placed on the side, the axis of the uterus is not so favorable to prolapse as when on the back; still it aids very much in causing the accident. this hand, whilst with the other I pressed upon the uterine tumor from without. This combination of external and internal pressure was equally as unavailing as any of the other plans already tried. At last, by compressing the abdominal aorta, as recommended by Baudelocque the younger (Mémoires de l'Académie des Sciences," January, 1835), I was enabled effectually to restrain any further hemorrhage. The condition of my patient had now become sufficiently alarming, she having been for upwards of half an hour quite pulseless at the wrist, the extremities cold, continual jactitation being present, the sphincters relaxed, and the whole surface bedewed with a cold clammy perspiration. It now became a question what remedy could be had recourse to, which should rescue the patient from this alarming state, it being utterly impossible to administer any stimulant by the mouth. My distance from home, together with considerable objection to the operation itself, which is not here needful to dwell upon, made me abandon the idea of transfusion of blood; but, as a means which I believe will prove equally as powerful as transfusion in arresting the vital spirit, I had recourse to enemata of port wine, believing that this remedy possesses a threefold advantage. The stimulating and life-sustaining effects of the wine are made manifest in the system generally; the application of cold to the rectum excites the reflex action of the nerves supplying the uterus; and the astringent property of port wine may act beneficially by causing the open extremities of the vessels themselves to contract. I commenced by administering about four ounces of port wine, together with twenty drops of tincture of opium. It was interesting to note the rapidity with which the stimulating effects of the wine became manifest on the system. Two minutes after the administration of the first enema, there was a slight pulsation distinguishable in the radial artery, which perceptibly increased in strength for the space of five minutes, after which the pulse again began to flag, and I had recourse to the administration of a second enema twenty minutes after the first. A more marked improvement was now manifest in the patient. She regained her consciousness; the pulse continued feebly perceptible at the wrist. In half an hour I had again recourse to the enema, with the most gratifying result; and, after ten hours' most anxious watching, I had the happiness of leaving my patient out of danger. The quantity of wine consumed was rather more than an ordinary bottle. ART. 155.-On the treatment of Uterine Hemorrhage. By the late Dr. LABATT, late Master of the Rotunda Lying-in Hospital, Dublin. (Dublin Quarterly Journal of Medicine, May, 1858.) The following remarks, which have much practical value, occur in a paper edited by Mr. Hamilton Labatt, the son of the writer: "First," says Dr. Labatt, referring to a case which he has just related, "I kept the patient out of bed, as advised by Dr. Denman, till the child was on the point of being born, being of opinion, with Dr. Denman, that the erect position is favorable to uterine contraction. Secondly, I allowed the child to be entirely expelled by the action of the uterus, and even opposed some resistance to its progress through the passages, and immediately after administered a cordial anodyne draught, which I have for many years been in the habit of doing in such cases, and often with great advantage, always combining the opiate with a cordial. Thirdly, I firmly held the uterine tumor in my grasp for several hours, and then applied a pad and roller. It was the invariable practice of all the old practitioners in this city to give a glass of burnt brandy with nutmeg, immediately after delivery, and I think such a cordial will often be found beneficial, by promoting uterine contraction, and thereby favoring the separation and expulsion of the placenta, and I cannot say that I have ever known it to produce injurious consequences." And in another place: "Although I do not at present mean to treat of the general management of uterine hemorrhage, I think it well to offer a few remarks on the use of opium, which has of late been largely used by some practitioners. I have read accounts of cases of flooding, in which seven or eight hundred drops of tincture of opium were given within six or eight hours, and, as alleged, with the best effects. The opinion which I had long held respecting the nature of the proximate cause of uterine hemorrhage in childbed, and the effects I had often witnessed of large doses of opium on uterine action, led me to suppose that it was not likely, in such large doses, to prove beneficial in the complaint in question. However, the extraordinary success attributed to the practice by some respectable practitioners led me to give it a fair trial, and the result has been a conviction on my mind that opium ought not to be given too freely in floodings attended with great weakness. I have generally observed that, when administered in very large doses, it increases the weakness, disorders the stomach, and tends to suspend the healthy uterine contraction, and prolong rather than check the discharge. It is good practice to give a moderate dose of black drop, or Battley's sedative liquor combined with burned brandy, volatile aromatic spirit, or Hoffmann's liquor, immediately after the birth of the child, when we have reason to apprehend flooding, and the same may be repeated if necessary. "It is generally supposed that if, after the expulsion of the placenta, the uterus be felt well contracted, small, round, and firm over the pubis, there is no reason to apprehend hemorrhage; this may be true to a certain extent; nevertheless, if due care be not taken to maintain this state of salutary contraction by the means already advised, the uterus may relax, and hemorrhage ensue; therefore, the cautious attendant will patiently continue his preventive measures till all immediate danger of hemorrhage shall have subsided, and then apply his pad and roller. "I would here beg to offer a suggestion, for the guidance of the young practitioner in his attendance during the anxious and critical period of childbirth. I would strongly urge him to remain with his patient as much as he possibly can, from the commencement of labor to its termination; his presence will be acceptable to the friends of the patient, and comfortable and cheering to herself, and she will have the benefit of seasonable advice and assistance on any of those emergencies which every now and then unexpectedly occur in the progress of labor. But this is not all; the presence of the confidential medical attendant, and his humane and kind deportment, will inspire the sufferer with confidence and hope, and thus, by the well-known influence of mental impres sions on the action of the uterus, will tend to lead the case to a speedy and happy issue. I do not pretend to say that such is the invariable result, for I have known cases to go on slowly where the practitioner remained for hours on the spot, and where, during his short absence, pains suddenly increased, and accomplished the delivery before his return; but I have seen more than sufficient to justify me in asserting, that if accoucheurs would remain more at the bedside of the patient than is the practice of the present day, and soinetimes pretend to assist, with the intention, as Dr. Denman remarks, of giving confidence to the patient, or composing her mind, the duration of labor and sufferings of the patient would often be abridged; and I dare to say that the success of Dr. Hamilton, who assures us that no patient under his charge for the last thirty-five years has been above twenty-four hours in labor, and excepting in cases of disproportion, none so long,' was more owing to this circumstance than to any direct manual aid he may have afforded." ART. 156.-On Puerperal Convulsions. Dr. R. U. WEST, of Alford. (Assoc. Med. Journ., May 26, 1854.) In this paper Dr. R. U. West holds that all cases of genuine convulsions depend more or less on irritation of some kind; that cerebral congestion is to a greater or less extent induced in all; that that is the condition which is so uniformly relieved by bleeding; and that, for the sake of applying "the principle of removing the cause of the convulsions, of substituting new modes of irritation different from that which has produced the convulsions," to repeat the language of Denman, it is suggested that the most useful practical classification of convulsions would be: CLASS 1. Irritation uterine. Convulsions during labor, and generally ceasing on the termination of the process. Treatment: bloodletting to remove induced congestion; but chiefly, speedy delivery. CLASS II. Irritation extra-uterine, and interfering indirectly with the estab lishment of the labor through the diverted nervous influence. Convulsions preceding labor, which appears to be imminent, and ceasing or becoming materially milder on the accession of true labor. Treatment: bloodletting as in class I, and for the same reason; but chiefly the induction of the labor process, which will probably prove to be the natural counter-irritant, while at the same time attention must be paid to the removal or alleviation of ascertained or probable causes of extra-uterine irritation. Other counter-irritants, such as sinapisms, may also be used. A MIXED CLASS, between these two. Irritation probably uterine, and consisting of some cause, such as excessive rigidity of the os uteri, calculated to prevent the parturient process from going on normally. Convulsions before and during labor. Treatment: bloodletting as before, and for the same reasons; but chiefly the removal of the cause which appears directly to hinder the process from going on. CLASS III. Irritation sometimes mental, sometimes of a physical extra-uterine nature. Convulsions coming on after the labor, the parturient process having possibly, by its natural counter-irritant effect, prevented the play of the pernicious influences now set at liberty. Treatment: bloodletting as before, and for the same reasons; and, as far as possible, the removal or alleviation of probable sources of irritation; while, as in class II, different forms of artificial counterirritation may also be tried. A MIXED CLASS, between the last two. Irritation probably uterine, and continued either from the induced excited state of the nervous system, or perhaps, in the worst cases, from some lesion within the brain. Treatment: perseverance in the plans usually successful in convulsions; but chiefly counter-irritation of various kinds-sinapisms, blisters, &c., supposing bleeding to have been already practised. ART. 157.—Iodide of Potassium as an Anti-lactescent. By M. ROUSSET. (Journ. de Méd. de Bordeaux, May, 1858; and Gaz. Hebd. de Méd. et Chir., Sept. 17, 1858.) In cases where it is desirable to suppress the secretion of milk-inflamed breast or nipple, the birth of a dead child, and so on-M. Rousset has for some time been in the habit of using iodide of potassium in tolerably full doses. The anti-lactescent action, he tells us, is soon apparent. He appears to have had seven cases in which he has tried this treatment; but these are not reproduced in the 'Gazette Hebdomadaire.' ART. 158.-Normal Lactation in the human race. By Dr. Wm. HENRY CUMMING. (American Quarterly Journal of Medical Science, July, 1858.) In vigorous women the secretion of milk is copious; and this large amount is indicated in the unimpregnated state by the great development of the mammary glands. In no animal with which we are acquainted is there a larger promise in this respect. The amount ordinarily furnished by a good nurse is from one and a half to two quarts daily, or from four to five pounds; but cases often occur in which two children receive abundant supplies from one mother, involving a secretion of eight pounds at least. An infant three months old will take from forty-eight to sixty-four fluid ounces daily, in six or eight half-pint doses. During the first year, therefore, he will take from 1000 to 1300 lbs. What is the composition of this milk? Without entering into long and tedious details, it may be simply said that, by the latest and apparently the most exact analysis, its composition is |