THE REPORT 
ON THE 
PROGRESS OF OBSTETRICS 
AND OF 
GYNAECOLOGY: 
READ BEFORE THE 
MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, 
AT ITS 
TWENTY-FOURTH ANNUAL SESSION, 
HELD AT 
CARLISLE, PA., 
JUNE, 1873. 
BY 
WILLIAM GOODELL, M.D., 
PHYSICIAN IN CHARGE OF THE PRESTON RETREAT, CLINICAL LECTURER 
ON THE DISEASES OF WOMEN AND CHILDREN IN THE UNIVERSITY 
OF PENNSYLVANIA, PRESIDENT OF THE OBSTETRICAL 
SOCIETY OF PHILADELPHIA, ETC. 
[Extracted from the Proceedings of the Society for 1873.] 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1873. THE REPORT 
ON THE 
PROGRESS OF OBSTETRICS AND OF GYNECOLOGY. 
Gentlemen:- 
In accordance with the letter of the resolution, by which your 
President conferred upon me the honor of giving the annual address 
on Obstetrics and the Diseases of Women, I shall review the pro- 
gress made during the past year in these branches of medicine. 
Trusting, however, to a broader interpretation of the spirit of this 
resolution, I shall venture to infringe upon its strict phraseology, by 
subjoining to most of the subjects a bibliography which will often 
range beyond that limit of time assigned to me, but which, I humbly 
hope, will, on that account, better aid others in working for the com- 
mon good of the profession. 
In Obstetrics proper, the past year shows a very fair amount of 
progress. 
The Abortive Action of Quinia.-The thrice-vexed question of the 
action of quinia upon the uterus has a large share of 
attention. That this agent does sensibly excite uterine contractions 
can hardly be doubted; the evidence on this point is overwhelming. 
Yet it is uncertain whether the few reported cases of abortion under 
its use have been owing to this action, or to the paludal poison for 
which it was prescribed. The testimony here is so conflicting, that 
the Societe de Medecine, of Gand, in Belgium, has proposed the 
subject as a prize essay for 1874. After carefully weighing the evi- 
dence of his own experience and that of others, your reporter has 
arrived at the following conclusions: (a) Thatquinia, by producing 
intermittent contractions of the womb, has, in large doses, occa- 
sionally brought on an abortion in the very early months of gesta- 4 
tion. (6) That it should not on that account, however, be withheld 
from pregnant ague-patients; for, other things being equal, an 
abortion is more likely to be induced by the visceral congestions 
and muscular succussions attending an attack of ague than by the 
oxytocic property of the antiperiodic. (c) That the uterine action 
of this drug is too slow and too uncertain to be relied upon in the 
emergencies of ante- or post-partum hemorrhages. But that, in 
decided doses, it will often prove of service in menorrhagic or me- 
trorrhagic attacks, (<Z) That, like ergot, it acts most efficiently 
after labor has begun ; a dose of ten grains being usually followed, 
in inertia, by a prompt return of the pains, (e) That, apart from 
its tonic and antiseptic properties, quinia excellence the remedy 
for puerperal disorders. By lowering the high temperature generated 
both by accelerated molecular metamorphosis and by rapid chemical 
combinations, it retards the oxidation of the tissues, hinders the 
formation of fibrinous concretions, and, therefore, prevents cardiac 
plugging. By contracting the walls of the womb, it tends to keep 
the protective coagula of the uterine sinuses from becoming loose 
and soluble, and to inhibit putrid and purulent absorption. Both 
by constringing the <joats of the capillary system of bloodvessels, 
and by paralyzing the amoeboid movement of the -white blood-cor- 
puscles, it presents, in puerperal fevers, an obstacle to fibrinous 
exudation and to the migration of the leucocytes into serous 
cavities. 
Bibliography.-Gazette Obstetricale, February 5, 1873, p. 150 ; 
Archives of Scientific and Practical Medicine, January, 1873, p. 53, 
and June, p. 384 ; Boston Medical and Surgical Journal, February, 
1873, p. 160 ; London Medical Record, February 26, 1873, p. 121 ; 
National Medical Journal, October, 1871, p. 281; W. Tyler Smith's 
Lectures on Obstetrics, 2d Am. Ed., p. 202; London Practitioner, 
June, 1871, p. 373; p. 170; Medical and Surgical Re- 
porter, February 5, and April 9, 1870, pp. 309, 345; Cincinnati 
Lancet and Observer, 1861, p. 114; Georgia Blister and Critic, 1854, 
p. 309; Savannah Journal of Medicine, vol. 1, p. 19; vol. 3, p. 
161; Journal de Medecine, Chirurgie et Pharmacie, vol. 34, p. 163 ; 
Archives Generates, 1842, vol. 14, p. 466; Obstetrics, by Wm. FL 
Byford, ed. 1870, p. 133 ; Gazette des Hopitaux, 1873, p. 31, from 
Bulletin General, 1873, p. 236; Philadelphia Medical Times, Feb. 
1, 1873, p. 276; Northwestern Medical and Surgical Journal, May, 
1873, p. 425 ; Medical and Surgical Reporter, November 9, 1872; 
Gazette de Joulin, April 1, 1873, p. 189; Obstetrical Journal of 
Great Britain, May, 1873, p. 113; Medical News and Library, May, 
1873, p. 74; L'Union Medicale, Nos. 71 and 83,1871 ; No. 70,1872, 5 
also No. 62, 1873, p. 800, in which is shown the abortive action of 
quinia on pregnant dogs. 
Vaccination during Pregnancy.-Upon another disputed point in 
obstetrics a far more definite conclusion has been reached. During 
the terrible epidemic of smallpox which has lately swept over this 
land, and which is even now apparently making the circuit of the 
civilized world, the question, whether a pregnant woman should be 
vaccinated, was one of great importance. To popular prejudice and 
to the weight of a dictum of the late Dr. Charles D. Meigs (Ob- 
stetrics, 1859, p. 597), it is feared that many lives were sacrificed. 
Thanks to judicious observation, this important question has been 
definitely settled. 
Through the statistical and timely paper of Dr. E. W. Jameson 
(Philadelphia Medical Times, June 1, 1872, p. 327) the absolute 
innocuousness of vaccination or of revaccination in every period of 
utero-gestation is conclusively shown. 
Dr. Jameson reports over 100 cases of pregnant women who 
were revaccinated in the obstetrical wards of the Philadelphia 
Hospital. As far as he could learn, no bad results occurred. In 48 
cases, which came under his own observation, no unusual symptoms 
manifested themselves, although " some of the women suffered con- 
siderably with their arms." More than half of these cases were 
advanced beyond the fifth month of pregnancy. There were several 
miscarriages, but they all happened in those in whom the vaccina- 
tion had proved unsuccessful. 
This admirable paper forestalled one on the same subject which 
your reporter was at that time preparing from an experience gained 
in the wards of the Preston Retreat. We are glad to say that our 
conclusions tally exactly with the author's. During the late terri- 
ble epidemic we either vaccinated or revaccinated over 150 pregnant 
women who were in the last months of their pregnancy. Every 
woman upon her admission was at once vaccinated, and conse- 
quently the local or constitutional symptoms were often at their 
height on the very day of labor or on the days immediately suc- 
ceeding it. Yet not the slightest appreciable ill effect was produced 
on the patient. In no single instance did any septic or inflam- 
matory action set in. During the whole continuance of this epi- 
demic, no case of variola, modified or unmodified, occurred in the 
Preston Retreat, nor was there among the inmates a single death 
from any other disease. 
The infants also were all vaccinated within the first week after 
birth. One noteworthy feature was, that in most of them repeated 6 
operations wholly failed; another, that in those that " took" the 
period of incubation and of maturation was shorter than natural. 
To these phenomena we are disposed to attach no other significance 
than that of the well-known resistance of very young infants to 
contagious diseases, which would tend either to prevent or to modify 
the vaccine impression. The idea was at first entertained that the 
recent vaccination of the mother had protected the child. But 
this was disproved by the fact that in two instances the child was 
subsequently attacked at home by smallpox, and died; and that 
cases have occurred in which a protected woman has given birth to 
a variolous child (Boston Medical and Surgical Journal, June, 1873, 
p. 584, and Chicago Medical Journal, May, 1873). 
Strong ground in favor of vaccinating the pregnant woman is 
taken by well-known writers, but the space assigned to this paper 
forbids more than a mere reference to R. Barnes, T. H. Tanner, A. 
Keiller, Struthers of Leith, F. P. Atkinson, and to George Yarrow, 
who vaccinated twenty women from the third to the ninth month 
of pregnancy. 
Bibliography.-British Medical Journal, March 4th, 1871, p. 218 ; 
Signs and Diseases of Pregnancy, by T. Hawkes Tanner, Am. ed., 
1868, p. 362; Transactions of the Obstetrical Society of Edinburgh, 
1872, vol. ii. p, 306 ; Edinburgh Medical Journal, Nov. 1871, p. 423; 
Lancet, February 3d, 1872, p. 145; Boston Medical and Surgical 
Journal, February 13th, 1873, p. 162 ; Half-Yearly Abstract, July, 
1871, p. 225. 
The Prediction of Sex by Auscultation.-From the researches of 
Frankenhauser, Hutton, Munro, Steinbach, Cumming, Devilliers, 
and others, it is evident that the pulse-rate of the female foetal 
heart is, on the average, so much higher than that of the male, 
that the prediction of the sex of the unborn infant by auscultation 
is quite possible. In the male the pulsations average 131 to the 
minute; in the female, 144. The number of heart-beats in the 
former ranges from 124 to 147 to the minute; in the latter, from 
135 to 154. When the average pulsation,is about 140 to the minute, 
the diagnosis of the sex is doubtful. M. Joulin states that by the 
researches of M. Devilliers, this difference in the pulse-rate is proved 
to be owing not to sex, but to the volume of the child. In a large 
child the pulsations are slower than in a small one. But as a large 
child is usually of the male sex, only in so far as this rule holds 
good will a diagnosis of sex by auscultation hold good. Be the 
cause what it may, Cummings out of 59 cases correctly predicted 
the sex in 40. Of 57 cases examined by Steinbach he was wrong 7 
in 10, and unable to predict in 2. Of 50 cases, Frankenhauser was 
right in all. Hutton correctly predicted the sex in 7 consecutive 
cases. 
Apart from the eclat inuring to the physician, no practical results 
have thus far been gained by this addition to our knowledge. But 
we predict that in cases of contracted pelves it will be utilized in 
deciding the question of the induction of premature labor. No 
single cause of dystocia is so common as that arising from a large 
head, and more especially that from the greater size of the male 
infant's head. The difference between the circumference of the 
head of the boy and that of the head of a girl averages, it is true, 
only three-eighths of an inch-a difference which may be represented, 
according to Dr. A. R. Simpson, by the thickness of a single fold 
of a table napkin wrapped around the head. Yet so nicely ad- 
justed is the size of the foetal head to the calibre of the pelvic 
canal, that this slight difference is enough to make the birth of the 
male child more than twice as fatal to the mother as the birth of 
the female child; and to cause the large average of 160 male still- 
births to 100 female (Medical Record, June, 1873, p. 302). 
Bibliography.-New York Medical Journal, July, 1872, p. 70; 
British Medical Journal, September 21st, 1872, p. 332; Edinburgh 
Medical Journal, December, 1870, p. 492 ; Transactions of the Edin- 
burgh Obstetrical Society, vol. ii. 1872, p. 64. 
Forceps.-With regard to the forceps there has been some dis- 
cussion whether the blades should be applied to the sides of the 
child's head, irrespectively of the position, or in the transverse 
diameter of the pelvis, viz., with relation to the curve of the ob- 
stetric canal. The American and the French schools of medicine 
teach the former method of application; the German and the 
English the latter. Those who are interested in this question are 
referred to an ingenious paper by Dr. C. C. P. Clark (American 
Journal of Obstetrics, May, 1871, p. 138), in which he warmly ad- 
vocates the application of the blades with relation to the pelvic 
axis, and also to an extended discussion before the Obstetrical 
Society of Philadelphia (Ibid., Aug. 1872, p. 341), in which both 
sides of the question are sustained. 
To your reporter the gist of the matter seems to hinge very much 
upon the kind of forceps used, and the degree of skill on the part 
of the operator. While the application to the sides of the child's 
head is undoubtedly the more scientific, for it marks the child the 
least, it offers the greater mechanical advantage of bringing down 
the head edgewise, and it compresses the least vital portions of the 8 
brain, yet it requires more experience and greater address than 
the other method. Again, whenever the interval between the blades 
-as in Hodge's forceps-is so narrow as to permit the exertion of 
much compression, the aim should be to grasp the head in its bi- 
parietal diameter. On the other hand, when the width between the 
blades precludes any great compressing power-as in Simpson's 
forceps-not only is the necessity for applying them to the sides of 
the head not so great, but their very shape interferes with such an 
adjustment in the oblique positions of the head. 
The range and power of so valuable an instrument as the forceps 
should be carefully defined; for what member of this association 
has not noticed the growing necessity for skilled assistance in labor? 
Our forefathers got along pretty well without the forceps. One 
nonogenarian we know, who practised for fifty years in a country 
town without owning a pair, and without ever seeing an application. 
He and his contemporaries relied on what a witty Frenchman termed 
" plenty of patience and more lard." There seems, however, to be 
but little doubt that every successive generation is marked by a 
perceptible increase in the number of instrumental deliveries. This 
fact has been attributed both to a more extended knowledge and 
to the construction of better instruments; but, while admitting the 
influence of these causes, we believe that a greater one underlies 
them. In our opinion Dr. J. G. Richardson has offered the best 
solution-on the ground that every addition to our stock of knowl- 
edge is antagonistic to that great law of nature, the survival of the 
fittest and the extinction of the unfit. In the animal kingdom sym- 
metry is preserved and strength hoarded up by the survival of the 
strongest. In man this same law would, in a measure, hold good 
did not art and science tend to restrain its operation. 
So original are the views of this gentleman, and so intelligently 
expressed, that we cannot do better than to quote them in extenso. 
In an introductory lecture to the course on pathological anatomy 
at the University of Pennsylvania {Philadelphia Medical Times, 
Oct. 2, 1871, p. 3), he uses the following suggestive language:- 
" Consider for a moment how medical science has helped to change 
the original process of childbirth, which, you know, among animals 
or savage women, is easy and relatively painless. Without physi- 
cians, a mother, savage or brute, whose pelvis varied much in the 
direction of unusual narrowness, would either bear still-born in- 
fants, and so fail to perpetuate her deformity, or (what would yet 
more efficiently accomplish nature's purpose of extinguishing the 
unfit variety) would herself perish in the pangs of travail. In civi- 
lized countries, however, by the aid of the forceps, premature labor 9 
and Caesarean section, progeny of such unsuitable mothers has for 
generations been saved alive, and sent forth into the world to marry 
and to procreate sons and daughters, who in their turn transmit 
this pain-producing idiosyncrasy, until at the present day multi- 
tudes of American and European families are infected with a 
hereditary tendency to narrowing of the pelvic straits, and the 
consequent fearful aggravation of parturient suffering." 
Cephalotripsy.-Owing to very recent ingenuity the operation of 
cephalotripsy offers so many advantages that it bids fair, in badly 
contracted pelves, to take the place of every other method of de- 
livery. By that of craniotomy, hours are spent in breaking up 
and in removing bit by bit the vault of the cranium, before the 
operator can reach the hard base where the chief obstruction lies. 
It is related of Dr. Hamilton, that after perforating a head one 
evening, he began at half-past nine o'clock on the next morning to 
break up the arch of the cranium. " At half-past two in the after- 
noon the woman was delivered, but the doctor was literally obliged, 
from exhaustion, to be carried home in a sedan-chair." . Thanks to 
the cephalotribe, the sheer manual labor of the operator is greatly 
lessened, and such a history as the above is not likely to be re- 
peated. 
In craniotomy, not only must every fragment of bone be twisted off, 
but the abrupt removal of each is very likely to wound the mother's 
tissues, or the hand which attempts to guard them. Again: in the 
final extraction by either the crotchet, cranioclast or the craniotomy 
forceps, not only is the mother's pelvis made the compressing agent, 
but, unless the presentation is changed to that of the chin, the head- 
globe is dragged down, not by its centre, but by one edge of its 
bony shell: to use a homely illustration, it is like pulling open a 
tight bureau-drawer by one of its knobs instead of by both. Finally, 
the whole process of delivery by this method is a very long and 
tedious one. Adverting to this operation, the late lamented Dr. 
Hugh L. Hodge uses the following strong language: "The head, 
more or less diminished in size, was forcibly dragged through the 
contracted pelvic passages. Hence all further compression was 
effected, not by the instruments employed, but by the walls of the 
pelvis; the lamentable consequences of compression thus made are 
well known. Wounds, lacerations, contusions of uterus, vagina, 
and bladder and other tissues, followed by bloody infiltrations, in- 
flammation, abscesses, gangrene, etc., too often with a fatal result, 
constitute the real dangers of craniotomy; hence the important 
principle of directly and efficiently compressing the cranium is one 10 
of the great improvements of modern obstetric science. We ought, 
therefore, to be grateful to M. Baudelocque neveu, for first carrying 
out this principle by means of his ' brise-tete,' or cephalotribe, as 
described by him in 1832." 
On the other hand, by one and the same movement of the blades, 
repeated on poles of different axes of the perforated head-globe, 
the cephalotribe squeezes out the brain, harmlessly crushes the 
vault, and so cants the hard base of the skull as to make it pre- 
sent edgewise. Very few bone-spicula need to be removed, for 
they are covered by the scalp Thus, the dangers to the mother's 
tissues are greatly lessened, and the time required for the operation 
is wonderfully shortened. Being also a very efficient tractor-in 
fact, a compressing extractor-this instrument draws down equally 
both sides of the crushed shell, greatly diminishes the pressure 
upon the mother's tissues, and saves the soft parts from the risks 
attending the use of those instruments which do not slip off, but 
break away from their hold. Among the numerous models of the 
cephalotribe, we deem that of Braxton Hicks's to be the best. An 
experience with it in several bad cases of deformity leads us to re- 
commend it warmly. But no higher praise of it can be given than 
the fact that, in the hands of R. Barnes, and of its inventor, it has 
been the means of successfully delivering two women, each with a 
pelvis wdiose conjugate diameter was not over an inch and a half. 
To the members of this Association, of whom so many were the 
pupils of the late Dr. Hugh L. Hodge, it may not be uninteresting 
to knew the high estimate he put upon the value of the cephalo- 
tribe. His last finished literary work was a letter to the Obstetri- 
cal Society of Philadelphia, from which we have given the above 
extract, urging a recognition of the claims of this instrument 
{American Journal of Obstetrics, May, 1873, p. 110). The last 
days of this great and good man were in fact spent in the prepara- 
tion of an elaborate paper on this subject. When conscious of the 
hopelessness of his recovery, he, a few hours before his death, ex- 
acted from his son a promise to complete this paper and to present 
it to the above-named society. 
Bibliography.-Edinburgh Medical Journal, Dec. 1870, p. 491; 
British Medical Journal, Oct. 1870, pp. 358 and 425 ; Dublin Quar- 
terly Journal, Nov. 1870, p. 330 ; London Obstetrical Transactions, 
vol. viii., p. 276 ; and vol. xi., p. 191 ; Transactions of the Edin- 
burgh Obstetrical Society, vol. i., pp. 1, 36, 66, and 115; vol. ii., 
pp. 155 and 406; Medical Times and Gazette, March 1, 1873, p. 
237. 11 
Caesarean Section in the United States.-An admirable statisti- 
cal paper was read by Dr. Robert P. Harris before the Obstetrical 
Society of Philadelphia, on the Caesarean operation in this country 
{American Journal of Obstetrics, Nov. 1871, p. 409 ; Feb. 1872, p. 
622). It followed, as a complement, another paper of great merit 
on the " Deformities of the Pelvis, their Origin and their Typical 
Character" {Ibid., Nov. 1871, p. 440). By painstaking research, 
and by an extensive correspondence, he collected the histories of 
60 cases of Caesarean section performed by our own countrymen. 
Of these 28 were fatal to the mother, and 33 to the child; while, of 
106 cases occurring in Great Britain, 88 proved fatal to the mother, 
and 46 to the child. Of 15 women operated upon, in this country, 
during the first day of labor, 10 recovered, and 14 children were 
delivered alive. 
From a careful analysis of these cases, the conclusion to which 
the author arrives is that "promptness of decision and action are 
all important, if success is to be secured as a result of gastro- 
hysterotomy. As soon as the deformity of the pelvis, or the nature 
and extent of the obstacle to delivery, can be ascertained, it should 
be determined whether craniotomy, cranioclasm, or the Caesarean 
operation should be resorted to ; and if the last, it ought to be per- 
formed as early in the labor as possible, and for these reasons, 
viz.:- 
" 1st. Prolonged muscular action not only reduces the strength 
of the patient, but favors hemorrhage from the uterine incision, and 
from the utero-placental sinuses,by the induction of muscular inertia, 
and consequently by the failure of prompt'contraction after the re- 
moval of the foetus. 
" 2d. General exhaustion favors the production of a fatal result 
from shock, peritonitis, and septicaemia. 
" 3d. The results of those operations which have been properly 
performed in the United States show that where no attempt at 
forcible delivery has been made, and the section has been com- 
pleted within twenty-four hours from the commencement of labor, 
gastro-hysterotomy is by no means as dangerous an operation as 
the general statistics would indicate. 
" 4th. Experience teaches that where muscular exhaustion of the 
uterus has not been permitted to occur, the organ will usually con- 
tract firmly and permanently, thereby shortening the uterine in- 
cision to about two inches, and rendering a resort to the use of 
sutures in it seldom necessary, except for the arrest of hemorrhage 
where large vessels have been opened. 
" 5th. Two prominent causes of peritonitis, viz., the escape of 12 
the lochia, and effusion of blood into the abdominal cavity, are 
generally avoided by an early operation, as the uterine incision 
does not gape open, as in cases where muscular exhaustion has 
taken place." 
Craniotomy and Caesarean Section in Small Pelves.-Dr. John 
S. Parry read before the Obstetrical Society of Philadelphia a very 
able and suggestive paper on " The comparative merits of crani- 
otomy and the Caesarean section in pelves with a conjugate diameter 
of two and a half inches or less" (American Journal of Obstetrics, 
Feb. 1873). Both this paper and those of Dr. Harris, on which it 
is based, merit a careful study, and a more extended notice than 
we can give. 
After giving in detail the history of a successful case of embry- 
otomy by the crotchet and cranioclast, in a colored dwarf whose 
pelvis measured one inch and a half in the conjugate diameter, the 
author discusses the comparative merits, in badly deformed pelves, 
of craniotomy and cephalotripsy, and inclines to the former ope- 
ration. Having collected seventy cases of craniotomy in pelves 
with a conjugate diameter of two and a half inches or less, he shows 
that 61.43 per cent, recovered and 38.57 per cent. died. By com- 
paring these data with those of the American cases of Caesarean 
section tabulated by Dr. R. P. Harris, he proves a recovery of ten 
per cent, in favor of the Caesarean section, when it is properly per- 
formed and before the woman is exhausted. In conclusion the 
author sums up by the following propositions:- 
" 1st. If gestation has advanced to the full term, and the con- 
jugate diameter of the superior strait be two inches and a half, 
craniotomy affords the mother no better chance for recovery than 
Caesarean section; and that, if the diameter be two inches or less, 
exclusive of the soft parts, it is the duty of the accoucheur to per- 
form gastro-hysterotomy rather than craniotomy. 
" 2d. The recorded histories of cephalotripsy in such cases afford 
no evidence that it can compete with the Caesarean section in safety, 
while French and German experience seem to show that cranio- 
clasm is both more safe and more efficient. 
" 3d. English accoucheurs, who are the firmest supporters of 
cephalotripsy, have not recorded a sufficient number of facts to 
controvert this position." 
The Delivery of the Placenta by Supra-Pubic Pressure.- 
Judging from our own experience and from the number of lauda- 
tory papers on this subject, Crede's method of delivering the pla- 13 
centa, or some slight modification of it, bids fair to take the place 
of every other. The plan which we adopt is as follows: At the 
maximum of the first uterine contraction after the birth of the 
child, the fundus of the womb is grasped, through the abdominal 
wall, between the thumb in front and the fingers behind. It is then 
to be both forcibly squeezed and at the same time pressed down- 
ward and backward. By means of this uterine expression the 
placenta and membranes are usually at once detached and extruded. 
Sometimes, indeed, they will suddenly pop out of the vulva, just 
as the stone escapes when a cherry is compressed between the 
finger and thumb. Occasionally it will require two or more pains 
to effect this; but the sooner this plan is resorted to after the birth 
of the child, the more easy in execution will it be. Those who, 
like ourselves, practise this method, contend that it offers many 
advantages over any other. The risk of communicating any puer- 
peral disease is lessened. The expulsion of the placenta and mem- 
branes by a vis a tergo is more likely to be complete, than by 
traction on the cord. The cord cannot be broken, as no traction is 
made on it. Adherent placenta is less frequently met with. The 
introduction of the hand into the womb is avoided, and so also, as 
a consequence, is the ingress of air. Finally, the tonic and energetic 
contraction of the womb, following this manoeuvre, prevents the 
occurrence of hemorrhage or of unruly afterpains. 
Bibliography.-American Journal of Obstetrics, Aug. 1871, p. 
334; Transactions of the Indiana State Medical Society for 1871 ; 
Schroeder's Obstetrics, 1872 ; Med. Correspondenz-Blatt., 10, 1873; 
Lo Sperimentale, April, 1873. 
Version.-In neglected cases or in those of rigid contraction of 
the womb preventing version, Dr. Milne recommends (Lancet, Oct. 
15th, 1870, and Aug. 1872, p. 195) a draught containing one grain 
of tartar emetic and twenty-five minims of the tincture of lobelia 
inflata, followed in twenty minutes by anaesthesia. Under analo- 
gous circumstances Carl Braun of Vienna employs a hypodermic 
injection of from one-sixth to one-quarter of a grain of morphia. 
This he introduces under the skin in the linea alba below the um- 
bilicus (Medical and Surgical Reporter, Oct. 1871, p. 342). Fol- 
lowing Ramsbotham's advice, Dr. Milne recommends in version 
the use of the left hand-the woman's position on the left side 
being unchanged. The reasons he assigns are as follows: The 
left hand of a right-handed person is the smaller' one ; it adapts 
itself more readily to the curve of the obstetric canal, when the 
woman lies on her left side; and, finally, that the more powerful 14 
hand-viz., the right one-remains free to render assistance through 
the walls of the abdomen. Having repeatedly used this method of 
version, your reporter can heartily indorse all the advantages that 
Dr. Milne claims for it. 
With regard to version in contracted pelves-while the question 
yet remains an open one-we think that its adherents are steadily 
gaining ground in those countries in which the non-compressing 
forceps is in vogue. After careful consideration of the subject, it 
seems to us, that in practice, the question hinges very much upon 
the kind of forceps used, and upon the degree of manual dexterity 
which the physician possesses. He who knows how to use a com- 
pressing forceps such as Hodge's-by applying them to the sides 
of the child's head, or as near to them as possible-will mould 
a head, and safely draw it through a brim so contracted as to defy 
any amount of traction with a non-compressing instrument. Again : 
he who is habitually unlucky with his ordinary breech-cases would 
do well to trust to his forceps rather than to version. Further: 
the amount of traction-power exerted by the forceps is far greater 
than that which can be sustained by the neck of the child. On the 
other hand, there is no doubt that when a delivery can be effected 
by version, the operation will, as a rule, be shorter in duration than 
that by the forceps. At the same time it must be stated that, 
when the forceps are judiciously applied, the process of moulding 
the head may safely go on for one hour or more (we have known 
one instance of four hours); whereas no moulding can take place 
after version ; for, unless the after-coming head is delivered within 
five minutes, death from asphyxia is very likely to happen. 
Lacerations of the Perineum.-In the treatment of lacerations of 
the perineum, the utility of the immediate closure of the wound is 
becoming more and more appreciated by the profession. The loss 
of every fibre of muscle in the perineum entails a corresponding loss 
of power in the floor of the pelvis, and a consequent impairment of 
support to the reproductive organs. The sustaining power of the 
vaginal column depends upon the integrity of its perineal abut- 
ments. It is the tonicity of the vaginal walls, and the pelvic con- 
nections of the womb that mainly keep that organ in place. These, 
in a case of torn perineum, may not at once yield, but will sooner 
or later; for air gains access to the womb, irritating and congesting 
it to such a degree that it will ultimately prolapse from an acquired 
hypertrophy. Unless, therefore, the laceration is simply cutaneous 
or very slight indeed, it should not be left to nature. Further : it is 
far more rational to take advantage of the necessary confinement in 15 
bed after delivery, and to close the wound at once while its edges are 
fresh and the maternal soft parts are comparatively numb and in- 
sensible, than to postpone the operation to a time when the woman 
shall be nursing, when the cicatrized parts shall demand quite a 
formidable operation for their denudation, and when a special con- 
finement in bed for two or three weeks will be needed. 
Our own method is, immediately after the delivery of the pla- 
centa, to pass deeply two or more wire sutures, securing each one 
by merely twisting its ends together. In bad rents, the first 
stitch is entered half an inch below the lower angle of the wound. 
When the sphincter ani is torn, the cutaneous points of entrance 
and of exit of the needle should then be on a level with the lower 
margin of the anal orifice. This purses up the tissues from below 
upwards and secures complete coaptation. Enough opium must 
be daily given to keep the bowels bound for a week. 
On the eighth day, as recommended by Dr. D. H. Agnew, tea- 
spoonful doses of castor oil are given every four hours until an in- 
clination to go to stool is urgent; when an injection is given to 
liquefy the contents of the lower bowel. In severe lacerations the 
woman's knees must be kept bound for a week, and her urine 
drawn off for three or four days. On the third or fourth day-but 
not earlier, lest the process of immediate union should be inter- 
rupted-vaginal injections of weak solutions of carbolic acid or of 
the permanganate of potassa are made twice in the twenty-four 
hours. Our own rule, with regard to the sutures, is to remove 
each one as fast as it becomes loose without reference to any special 
time. This method of treatment both in the immediate operation, 
and in the secondary operation after the cicatrized parts are de- 
nuded, we can warmly recommend, as we cannot recall a case in 
which we failed to secure a very good union of the parts. It 
should, however, be stated, that in secondary operations, we always 
use superficial sutures between the deep ones, and clamp the latter 
with shot, following essentially the plan laid down by Dr. Agnew. 
From our own experience and from w'hat we have seen of the 
practice of others, we have long been convinced that the forceps is 
the common cause of most of the severe lacerations of the perineum. 
Even in comparatively easy cases, an instrumental delivery of the 
head will often occasion an unseen rent in the mucous surface of 
the vagina, which the passage of the shoulders extends through the 
perineum. In the American Journal of the Medical Sciences, Jan- 
uary 1871, p. IT, we used the following language: " Delivery by 
the forceps, even in skilful hands, will often produce laceration; 
for the head is liable to be brought down too quickly upon the 16 
unprepared soft parts, and it becomes a very nice point indeed to 
determine the exact moment when delivery may be ended with 
impunity. The most cautious physician is liable to be caught, 
as it were, 'on the centre.' He sees the perineum stretched out 
to a perilous thinness, and the fourchette almost cracking under 
the strain. In doubt whether the moment has arrived to raise the 
forceps-handles and turn out the head, or to depress them and thus 
restrain its advance, he wavers, and in a twinkling the fibres part. 
On the other hand, the impatient physician is tempted to turn out 
the head before the parts are sufficiently dilated. Finally, what is 
still more frequent, hinc mihi lachrymce, at the last moment the phy- 
sician's courage fails him, and he depresses the forceps-handles just 
as the head has begun to emerge; a course equally fatal to the in- 
tegrity of the perineum." More than two years has elapsed since 
the above was written, but this enlarged experience has served to 
confirm us in the opinion that, other things being equal, as soon as 
the perineum is well distended, the forceps should, as a rule, be re- 
moved, unless the withdrawal of the blades requires a force which 
might hasten the delivery. 
This opinion is, we are glad to find, entertained by Prof. Olshau- 
sen, who gives the same advice that we have given, and for the 
same reason (Sammlung Klinischer Vortrdge von Volkmann, No. 
44, 1872). Dr. T. Addis Emmett also contends that a bad lacera- 
tion of the perineum " is the result generally of instrumental de- 
livery;" whilst as early as the middle of the last century, Abra- 
ham Titsingh, of Amsterdam-acris homo el litigiosus, as Haller 
calls him-pointed out this tendency of the forceps to injure the 
perineum. As an additional warning, we may mention the fact that, 
not very long ago, a well-known accoucheur was dismissed from 
his attendance upon an imperial family, because such an injury 
had happened to one of its members, whom he delivered with the 
forceps. 
Bibliography.-Emmett, New York Medical Record, March 15, 
1872, p. 121; Bourgeot, Revues des Sciences M6dicales, April, 1873, 
p. 755 ; Madden, American Journal of Obstetrics, May, 1872, p. 50; 
Revue Medicale, vol. 72, p. 392; Glasgow Medical Journal, Nov. 
1869; Ewart, Indian Medical Gazette, Dec. 2, 1872; Hodgen, St. 
Louis Medical Archives, June, 1872; J. Matthews Duncan, Edin- 
burgh Medical Journal, Nov. 1871, p. 389; Theophilus Parvin, 
American Practitioner, Feb. 1873, p. 70; D. Hayes Agnew, Penn- 
sylvania Hospital Reports, 1867, and American Supplement to 
Obstetrical Journal of Great Britain, June 1873, p. 33 ; M. Boeckel, 17 
Gazette de Joulin, May, 1873, p. 252; Boston Gynaecological Jour- 
nal, May, 1871, p. 266. 
Puerperal Eclampsia.-By its property of diminishing the 
tension of the bloodvessels, and by thus relieving the intra-cerebral 
pressure, the nitrite of amyl bids fair to prove a valuable addition 
to our means for treating puerperal eclampsia. Dr. W. F. Jenks 
{Philadelphia Medical Times, August 1, 1872, p. 404) reports a 
case in which, after two violent convulsions, he, at the suggestion of 
Dr. S. Weir Mitchell, administered by inhalation two or three drops 
of this agent, "when the premonitory twitchings, the contracted 
pupils, and the convergent strabismus announced the return of a 
seizure. The effect was magical: the muscles relaxed, the strabis- 
mus disappeared, the face flushed, and the patient remained quiet 
for a longer or shorter time." Its use is, however, apparently 
attended by a partial paralysis of involuntary muscular fibre, for 
in the reported case a profuse post-partum hemorrhage took place, 
calling for a uterine injection of a weak solution of the subsulphate 
of iron. This tendency to post-partum hemorrhage we have, how- 
ever, repeatedly seen in eclampsia. In another case, treated by 
the same gentleman (American Supplement to the Obstetrical Jour- 
nal of Great Britain, April, 1873, p. 3), he hesitated, on account 
of this property, to resort to the nitrite of amyl. He was, however, 
successful by bleeding and by drastic cathartics. 
The treatment of puerperal eclampsia still remains unsettled. 
The profession is divided into those who deem this disease to be 
caused by serous apoplexy, and those who attribute it to uraemic 
poisoning or to nervous exhaustion-into those, consequently, who 
bleed and those who do not. The latter have, hitherto, had the 
large majority; but the signs of a reaction are manifest. There is, 
evidently, a growing tendency first to lessen provisionally the in- 
travascular pressure by an early and full bleeding, before resort- 
ing to anaesthesia, narcotics, and the drastic cathartics. Upon the 
great value of the hydrate of chloral in controlling the convulsive 
attacks we forbear to enlarge. This agent has so generally re- 
ceived the encomiums of the profession that it is needless for us 
to do more than to advert to its use, and we, therefore, subjoin but 
one reference (Lancet, April 12,1873). With this remedy we like to 
combine the bromide of potassium in full doses. In the treatment 
of this disease it often becomes a very nice point to determine 
whether or not labor should be either induced or urged on. To 
decide this grave question your reporter would diffidently suggest 
the following broad rules of guidance: If the convulsions are 18 
uncontrollable or the woman is near to term, if the os has begun to 
dilate, or the face is cedematous and the urine loaded with albumen, 
then, as the case may be, either induce labor or hasten it on. 
Should these conditions not be present, the indication will be to 
avoid exciting the uterus to premature action. Either in inducing 
a premature labor or in hastening on a labor already begun, your 
reporter has found nothing better than the hydrostatic bags of Dr. 
Barnes-the patient being kept profoundly anaesthetized. 
Bibliography.-Fordyce Barker, New York Medical Journal, 
January, 1871, p. 1 ; B. W. Richardson, London Practitioner, 
November, 1868, p. 274; W. F. Jenks, Philadelphia Medical Times, 
May 1, 1871, p. 285; A. W. Tupper, Transactions of the New York 
State Medical Society, 1872, p. 216; Joseph Carson, American 
Journal of the Medical Sciences, vol. Ixi. 1870, p. 433; A. B. Steele, 
Medical Times and Gazette, August 24, 1872; E. Montgomery, St. 
Louis Medical and Surgical Journal, September, 1872; R. Barnes, 
Lancet, April and May, 1873, pp. 516, 619. 
Post-Mortem Parturition.-Many cases of spontaneous post- 
mortem delivery have been collected. Among these your reporter 
wishes here to include a case which was noticed by the press after 
the explosion of the steamer Westfield's boiler, July 31, 1871. 
One of the passengers, quite uninjured, jumped overboard through 
fright, and was drowned. Although only a few minutes had elapsed 
before the body was recovered, a half-born infant was found pro- 
truding from the vulva. From a careful examination of forty-four 
cases, Dr. Jas. H. Aveling has deduced the following conclusions: 
"1. Expulsion of the contents of the uterus may take place after 
death without the aid of art; 2. This may occur in cases in which 
no symptom of natural parturition can be discovered before death; 
3. Many of the manoeuvres and accidents of a natural labor may 
occur in post-mortem parturition ; such, for example, as expulsion 
of the placenta, spontaneous evolution of the foetus, and the 
prolapse, inversion, and rupture of the uterus; 4. Expulsion of 
the uterine contents, and accidents which accompany labor, may 
be caused after death, either by the contracting power which per- 
sists in the uterus after the death of the rest of the body, or by the 
pressure exerted upon the uterus by the gases of decomposition 
which are pent up in the abdomen; 5. Of these causes, the latter 
is the most frequent; 6. After the death of its mother, a child 
may continue to live in the uterus for many hours; 7. After the 
death of a woman undelivered, no time should be lost in removing 
the foetus." 19 
From the Westfield case, and from some others enumerated in 
the journals and given below-in the bibliography-we should sug- 
gest the condition of asphyxia in articulo mortis as another factor 
in the production of post-mortem delivery. Blood charged with an 
excess of carbonic acid is, as Marshall Hall and Brown-Sequard 
have long ago pointed out, a direct stimulant to muscular contrac- 
tion. Hence it is, that uterine action is usually started up by 
eclamptic fits. Further: by numerous experiments upon pregnant 
rabbits, Drs. Aser and Schlesinger (Philadelphia Medical Times, 
August 1, 1872, p. 416) have shown that violent tetanic contrac- 
tions of the uterus will be excited whenever the blood circulating 
in the brain is made largely venous. This change in the character 
of the blood was effected, either directly by stopping the respira- 
tion, or indirectly, by the stagnation induced by tying the main 
arteries of the neck. So keenly, indeed, does the uterus itself 
resent the presence of venous blood, that tetanic contractions of 
that organ were invariably produced, when the aorta was com- 
pressed. By these experiments the cause of the arrest of post- 
partum hemorrhages, by means of the compression of the aorta, is 
made susceptible of a wider interpretation than the commonly 
accepted one of mechanical action. 
Bibliography.-Dr. Jam,es H. Aveling, London Obstetrical Trans- 
actions, vol. xiv. 1873, p. 240; Dr. Darby, Dublin Journal, Septem- 
ber, 1872; Drs. Swayne and Lanigan, Medical Press and Circular, 
April 3, 1872 ; M. Penard, Annal. d'Hygiene Publique et Medecine 
Legale, January, 1873; Dr. R. F. Hutchinson, Indian Medical 
Gazette, June, 1872 ; Dr. Rogers, Medical News and Library, April, 
1873, p. 58. 
Placenta Preevia.-In a case of central implantation of the pla- 
centa over the os uteri, Dr. W. 0. Baldwin (Richmond and Louis- 
ville Medical Journal, April, 1872) dilated the os with Barnes's 
dilators, and arrested the hemorrhage by injecting ice-watei' under 
the placenta while the fingers were peeling it from the womb. 
Both mother and child did well. An analogous case was success- 
fully treated by Dr. John Wallace (Edinburgh Medical Journal, 
November, 1872), by a solution of one part of the strong liquor 
ferri perchloridi to three of water. He applied it through the os 
uteri directly to the ruptured utero-placental vessels. The means 
employed were pledgets of cotton-wool, with a withdrawing thread 
attached, which were renewed at intervals of several hours. The 
astringency of the preparation both shrivels up the uterine and 
placental vessels, and also plugs them up by firm and elongated 20 
clots. In a case reported in the Transactions of the Obstetrical 
Society of Philadelphia (American Journal of Obstetrics, 1871, p. 
183), Dr. Wm. L. Knight attained the same end by throwing upon 
and under the placenta a solution of the sub-sulphate of iron. Dr. 
Wallace also proposes the diagnosis of this faulty position of the 
placenta by combined abdominal and vaginal stethoscopy. 
In order to save the woman from repeated hemorrhages, and 
from the dangers arising from the slow dilatation of the cervix 
during a natural labor, and in order also to have the physician at 
hand by the bedside of his patient, Drs. T. G. Thomas (American 
Journal of Obstetrics, 1869, p. 1) and W. S. Playfair (British 
Medical Journal, May, 1872, p. 463) advise the induction of labor 
in cases of placenta preevia. 
Post-Partum Hemorrhage.-Before the London Obstetrical So- 
ciety (Obstetrical Journal of Great Britain, April, 1873, p. 43), Dr. 
Heywood Smith related a case of secondary hemorrhage, in which 
a fatal peritonitis had been apparently set up by repeated intra- 
uterine injections of the liquor ferri perchloridi. The solutions 
used were of increasing strength, the first one being in the propor- 
tion of one part to eight of water, the last one being two drachms 
of the strong solution. From the post-mortem appearances it was 
evident that the sinuses had taken up the iron and carried it into 
the veins. The lesson he deduced was, that however suitable a 
remedy this may be in primary hemorrhage, it is not so in second- 
ary. For, after the process of involution and absorption had 
begun, it would be unwise to inject any substance which by absorp- 
tion might prove deleterious. 
In the discussion that ensued, almost all the speakers concurred 
in assigning great value to this powerful styptic, the use of which 
was revived by Dr. Barnes in 1869 (British Medical Journal, 1869, 
vol. i. pp. 327, 388, 504 ; vol. ii. p. 102). Several members, how- 
ever, testified to seeing death follow its use; but whether in any 
way from the action of the iron was uncertain, for flooding predis- 
poses to septicaemia. Drs. Hicks, Phillips, Playfair, and Holman 
had never seen any bad results whatever, although they had fre- 
quently used this remedy both in primary and secondary hemor- 
rhages. They generally resorted to a more or less diluted solution; 
but, in cases of emergency, had used the strong solution when 
weaker ones had failed. Dr. Sell said that his experience regard- 
ing the use of the perchloride was obtained at the University of 
Vienna, where from 7000 to 9000 deliveries annually take place. 
A weak solution of one drachm to the pint of water is always used 21 
after ergot and injections of cold water have failed. From this 
treatment he had never seen any bad results. 
In the May number of the same journal (p. 89), Dr. W. S. Play- 
fair reports a case of flooding in which, after ice had failed, he 
saved the life of his patient by injecting into the womb the strong 
solution of iron. Soon after she became very ill from absorption 
of septic matter induced by the decomposition of the hard clots 
retained in the womb. As, upon their removal, she began to mend, 
he recommends, when constitutional symptoms follow the use of 
this remedy, to break up these clots with the finger, and to wash 
out the womb by disinfectant injections. Both of these papers are 
very sharply criticized by M. Joulin (Gazette de Joulin, April, 1873, 
pp. 177 and 196), who objects to the deductions of the writers, and 
to the use of the intra-uterine injection of iron. He believes that 
the ordinary methods of treatment in vogue are quite sufficient to 
arrest post-partum hemorrhages, and yet he suggests the use of 
galvanism in desperate cases. But the battery is never at hand 
when most needed, and it can therefore be used in hospitals only, 
and not in private practice. 
In two cases only of post-partum hemorrhage have we used the 
perchloride of iron. In each a solution of one part to seven of 
water proved very efficacious. Several of our friends have resorted, 
with the happiest results, to the liquor ferri subsulphatis diluted 
with from four to eight parts of water. Since adopting the rule of 
invariably giving a teaspoonful of the fluid extract of ergot as soon 
as the head is born, and since practising the delivery of the placenta 
by uterine expression, we have met with very few cases of flooding, 
and not one that did not yield to kneading or to the introduction 
into the uterine cavity of a smooth lump of ice. 
The injection of a solution of one part of the tincture of iodine 
to two of water is lauded as a haemostatic by several French writers 
(L'Union Medicale, December, 1872, p. 976, and also in Archives 
of Scientific and Practical Medicine, March, 1873, p. 290). It has 
the great merit of not forming tenacious clots. 
When these or other measures fail, the subcutaneous injection of 
from four to six grains of ergotin, or of from twenty minims to a 
hypodermic syringeful of the fluid extract of ergot, has been found 
to act most promptly (Medical and Surgical Reporter, September, 
1871, p. 296 ; Dublin Medical Journal, April and June, 1872, pp. 
344, 346, 538; Transactions of the Ihdiana State Medical Society, 
1870, p. 37 ; Gazette de Joulin, March 15, 1873, p. 168 ; Nortlvwestern 
Medical and Surgical Journal, May, 1873, p. 424). 22 
Extra-uterine Fcetation.-Some light has, we believe, been thrown 
upon the diagnosis and treatment of extra-uterine pregnancy. In 
a discussion before the Obstetrical Society of Philadelphia (Ameri- 
can Journal of Obstetrics, May, 1872, p. 155), the following facts 
were shown: 1. The very striking resemblance of the fluctuating 
tumor in the recto-vaginal pouch to a retroversion of the gravid 
womb, so striking that many of the members present stated that 
they had attempted, in the cases they had seen, a reposition of the 
presumedly displaced organ. 2. That a decidual cast of the always 
enlarged womb is invariably formed, and, when expelled entire, is 
often mistaken for the blighted ovum of an abortion. 3. That par- 
oxysms of pelvic pain, resembling those of pelvic peritonitis, are a 
common accompaniment of this error of conception. 4. That in 
cases of ventral fcetation the beat of the foetal heart will be much 
louder and more distinct than in natural pregnancies. We would 
especially call attention t'o the first diagnostic sign, that of resem- 
blance to a retroversion of the gravid womb, as one which should in 
itself create a suspicion of this error loci. The taking of the one 
for the other is a trip in diagnosis which has been made by 
numerous observers, by such men as Carl Braun (Cincinnati Clinic, 
1872, p. 105), Robert Barnes (St. Thomas's Hospital Reports, vol. 
1, p. 367, case 8), and J. Hall Davis (London Obstetrical Transac- 
tions, vol. 12, 1871, p. 332). 
With regard to the treatment: in the above-named discussion, 
Dr. J. G. Allen related the history of two cases, in which he had 
successfully destroyed the life of the ovum by the galvanic current. 
" One pole of an ordinary electro-magnetic machine was passed 
through a common glass speculum, and applied to the vaginal 
portion of the tumor, behind the neck of the uterus. The other 
pole was placed upon and over the tumor, where it could now be felt 
in the abdomen ... A moderately strong current was applied every 
three days for a period of two weeks. On the third application a very 
powerful current was turned on." In each case the tumor first ceased 
to grow and then gradually diminished. Professor Burci, of Pisa 
(Bulletin General de Therapeutique, 1872, p. 276), also reports a 
successful case, in which the destruction of the ovum followed one 
application of electro-puncture to the sac. The tumor gradually 
diminished in size until it reached that of an egg, when it remained 
stationary. An incision through the vagina into the cyst wras 
unsuccessfully resorted to by Dr. Lawson Tait (British Medical 
Journal, August, 1872, p. 258). 
In these cases, Dr. Alfred Meadows (Lancet, November 23,1872) 
advocates a more frequent resort to gastrotomy in order to antici- 23 
pate, and so to avert, the almost inevitable fatal rupture of the 
cyst. Both the cyst and the placenta should be left in situ; special 
care being taken not to detach any portion of the latter. They will 
either break down and be discharged externally ; or else undergo 
the slow but sure process of atrophy and absorption. In a work 
upon the same subject {Des Grossesses Extra-uterines, Paris, 1872, 
quoted by the Half-Yearly Abstract, January, 1873, p. 230), M. T. 
Keller advocates, in the first half of the pregnancy, the induction of 
internal abortion by puncturing the ovum or by injecting poisonous 
substances. Each of these plans has been successfully employed 
by Dr. Greenhalgh, who tapped with a fine frrocar and injected a 
solution of morphia {Medical Times and Gazette, January 6, 1872, 
p. 24). When, as in cases of ventral foetation, the term of preg- 
nancy is reached with a living child, or is passed, the child being- 
dead, M. Keller insists upon gastrotomy-in the one to save mother 
and child ; in the other to save the mother. 
Two cases of gastrotomy for extra-uterine pregnancy, of which 
one was successful, although rupture of the cyst had taken place, are 
reported in the Obstetrical Journal of Great Britain, June, 1873, 
pp. 192, 194. 
An extra-uterine pregnancy almost always occurs in a multipara 
of mature age, but Mr. Lawson Tait, out of three cases that he had 
seen, reports two in primiparae {Medical Times and Gazette, May 
24, 1873, p. 561). 
In Gynaecology the past year has been fruitful of much that is 
noteworthy. 
Fibroid Tumors of the Womb-The therapeutic treatment of 
fibroid tumors of the womb has of late excited a great deal of at- 
tention. Very recently M. Gueiiiot {Medical Times and Gazette, 
March 23, 1872, p. 350) has proposed their absorption by such 
agents as tend to produce fatty transformation of tissue. Accord- 
ing to Claude Bernard, these steatogenetic substances are lead, 
arsenic, and phosphorus. In a prize essay ( Transactions American 
Medical Association, 1872, p. 652), Dr. Samuel R. Percy shows that 
phosphorus especially produces oily degeneration which " destroys 
structure, disintegrates cells, and, as a consequence, vital action is 
gradually but surely lost." Could the action of this drug be limited 
to the uterine region, there is little doubt that the absorption of 
these growths would result. But, unfortunately, its action, being 
diffused over the whole body, would tend to cause the same process 
of disintegration to take place in vital organs. 24 
A more feasible and rational method of treatment is proposed by 
Prof. Hildebrandt, of Kbnigsburg {Half-Yearly Abstract, January, 
1873, p. 248, from Berliner Klinische Wochenschrift, June 17, 
1872), which bids fair to prove of great value. He reports that he 
has successfully treated nine cases of fibroid tumors of the uterus 
by daily injections of the aqueous extract of ergot under the skin 
around the umbilicus. By this treatment one fibroid, reaching 
above the navel, entirely disappeared. Another, which so filled the 
entire abdominal cavity as to press upon the false ribs, was much 
reduced in size. In the other cases the tumors were greatly dimin- 
ished in volume ; and in each one all the alarming symptoms-such 
as menorrhagia, metrorrhagia, leucorrhoea, and uterine colics-dis- 
appeared. The duration of the treatment was from two to four 
months. In one case only did the toxic effects of the ergot compel 
a discontinuance of the treatment. For these injections Prof. H. 
uses an ordinary hypodermic syringeful of a solution containing 3 
parts of ergotin to 7.5 parts each of glycerin arid water. The mode 
of action of ergotin in these cases is, probably, its property of 
contracting the uterine walls, whereby the nutrition of the tumor is 
interfered with. It is, therefore, very questionable whether any 
but mural and submucoid tumors can be acted upon. 
With regard to this kind of treatment a number of physicians 
have reported very favorably. At a meeting of the College of 
Physicians of Philadelphia, held January 15th, 1873 (American 
Journal of the Medical Sciences, July, 1873, pp. 131, 138), Drs. W. 
V. Keating and John Ashhurst reported cases in which large fib- 
roids had rapidly diminished in size by one-third and one-half after 
sixteen injections made in nearly as many days. One of these 
cases was seen by your reporter, who can bear witness to the rapid 
diminution of the tumor, and to tfle very marked improvement in 
the health of the patient. Dr. Keating used a hypodermic syringe- 
ful, or about twenty drops, of the following solution : R. Ergotinae 
gr. xlv ; glycerince, aquae destil., aa Dr. Ashhurst employed 
the officinal fluid extract of ergot diluted according to the following 
formula: R. Ext. ergotae fluid, fjiss; glycerinae fjj; aquae fjij. 
Of this twenty minims, containing nearly seven minims of the fluid 
extract, were used at each injection. In each case the injections 
were made once daily, except when omitted from some special 
reason, and the point chosen for puncture was the sub-umbilical 
region. Abscesses were in each case avoided by making the in- 
jections as deep as possible, the nozzle of the syringe being car- 
ried fairly down to the level of the muscular parietes. A success- 
ful case is likewise reported by Dr. Wm. C. Wey, who, in a very 25 
impressible lady, had to abandon the hypodermic injections for vagi- 
nal and rectal suppositories containing eighty drops of the watery 
extract of ergot. Dr. B. F. Sherman also has treated a uterine 
fibroid by hypodermic injections, to the great improvement of all 
the symptoms. He used Squibb's extract, diluted with glycerine 
{American Practitioner, May, 1873, pp. 284, 285). Another suc- 
cessful case is reported by Dr. C. D. Palmer {Clinic, April 19, 1873, 
p. 183), and still another by Mr. John Clay {Lancet, May 10, 1873, 
p. 663), in which, after one hundred hypodermic injections, which 
were suspended during three menstrual periods, the tumor very 
sensibly diminished and the patient became " surprisingly im- 
proved." A concentrated solution of ergot was used, three minims 
of which were equal to four grains of ergot, and this quantity was 
daily injected in the hypogastric region. These injections caused 
at first great pain and redness of the skin ; but after a few days 
were well tolerated. Headache and severe pain in the back evinced 
the constitutional action of the ergot. 
From what we have gleaned from the various reports, and from 
our own personal observation, we are led to conclude that Prof. 
Hildebrandt's solution isopen to the objection of forming abscesses, 
giving great pain, and discoloring the skin at the seat of puncture. 
A further objection to it lies in the fact that there is no standard 
preparation of ergotin which is at all trustworthy. We should, 
therefore, recommend as a substitute either Mr. Clay's concentrated 
solution as given above, or the officinal fluid extract of ergot-say 
from ten to fifteen minims diluted with enough of water to fill the 
hypodermic syringe. If this cannot be borne, we should advise a 
rectal suppository, containing the equivalent of one or two flui- 
drachms of the same preparation, which can be made by inspissating 
the fluid extract by very moderate heat. Dr. Fordyce Barker pre- 
fers an enema of two drachms of Squibb's fluid extract with an 
ounce of thin starch {New York Medical Record, March 1, 1873, 
p. 118).1 
1 Since the above was written we have received the following note, which 
gives further information on the subject of ergot :- 
" The hypodermic solution of ergot of Dr. Squibb, as I make it, is an aqueous 
liquid of double the strength of the fluid extract made by the cold process. 
" One hundred drops of the solution measure one fluidrachm, which is 
equivalent to one hundred and twenty grains of ergot. 
" The fluid extract itself is inadmissible for hypodermic use, on account of 
the presence of a small proportion of alcohol and acetic acid, whereby the lia- 
bility to produce abscesses is greatly increased. 
" A very reliable ergotin is made from Dr. Squibb's fluid extract, by cautiously 
evaporating it at a very low temperature. It is about six times stronger, weight 26 
In cases of uterine fibroids not amenable to such a treatment 
there is a growing tendency to enucleate them. Dr. T. Gr. Thomas 
{American Journal of Obstetrics, 1872, pp. 104, 474, and 1873, p. 
688) reports six successful cases of enucleation by forcible traction 
and powerful supra-pubic expression, after the division of the cap- 
sule. He has not lost any patient after the operation; but two 
died from the effects of the preparatory treatment, viz., dilatation 
of the cervical canal by sponge-tents. Dr. Whitefield also reports 
a case treated successfully by a crucial incision of the capsule and 
by avulsion of the fibroid from its bed {Edinburgh Medical Journal, 
Feb. 1870, p. 697). In a series of clinical lectures on fibroid tumors 
of the womb {Philadelphia Medical- Times, May and June, 1872) 
we used the following language : " More in accordance with nature 
and less rude does the expectant plan of enucleation seem to me- 
viz., after the incision of the capsule, to depend for the further 
extrusion of the fibroid upon the expulsive property of ergot, and 
upon repeated attempts with the finger at enucleation-resorting to 
avulsion only after the lapse of weeks or even months." In cor- 
roboration of this opinion we are now able to state that Dr. J. H. 
Williams {Journal of the Gynaecological Society of Boston, Nov. 
1872, p. 347) reports a successful case of enucleation produced by 
the action of ergot after the division of the capsule. Dr. White- 
field {Glasgow Medical Journal, May, 1872, p. 321) reports one, 
and Dr. W. R. Jordan two successful cases. The latter cut into the 
most dependent portion of the tumor by an incision two inches 
long and half an inch deep, prolonging it by Lhe scissors through 
the cervix, the enucleation being effected by large doses of ergot 
(Zancetf, March, 1873, p. 442). 
For very large mural tumors, M. Pean {Gazette des Hbpitaux, 
November and December, 1871) has successfully removed the womb, 
or the greater portion of it, together with its appendages. He has 
also twice removed the whole uterus for fibro-cystic tumor, and in 
each case was rewarded by the recovery of his patient {American 
Journal of the Medical Sciences, October, 1872, p. 568). After a 
mortality of 12 out of 20 cases, M. Demarquay {British Medical 
Journal, January 4, 1873) rejects the operation of gastrotomy for 
the removal of fibro-cystic tumors. 
for weight, than the fluid, extract, and can be used in pilular form, or incorpo- 
rated with cacao butter into a suppository containing ten grains of the extract 
of ergotin. Very respectfully, 
JOSEPH P. REMINGTON, 
13th and Walnut. 
" Philadelphia, 6th mo. 9th, 1873." 27 
Cancer of the Uterus.-The subject of uterine carcinomata has, 
during the past year, received unusual attention. Drs. Paul Munde 
(American Journal of Obstetrics, August, 1872, p. 309), A. Wilt- 
shire and A. R. Simpson (British Medical Journal, vol. ii., 1872 
pp. 214, 437, and 489) report extremely interesting cases of re 
covery, or of prolonged reprieve from death, by scraping away 
the cancerous mass with sharply edged curettes and scoops. To 
Prof. G. Simon, of Heidelberg, is due the credit of devising this 
treatment, one which is undoubtedly the best whenever the can- 
cerous deposits have invaded tissues so deeply as to be beyond the 
control of caustics, or beyond the reach of the knife, or of the 
galvano-cautery. The hemorrhage attending this operation is free 
until healthy structures are reached ; but the pain and risk are 
very trifling indeed. A tampon of the perchloride, or of the sub- 
sulphate of iron, may afterwards be applied ; to be followed in a 
few days by vaginal injections of the chlorate of potash. When- 
ever the disease is beyond operative interference, Dr. A. Wiltshire 
stays the hemorrhage, and corrects the fetor, by a tampon of 
cotton-wool dipped into a solution of one drachm of chromic acid 
crystals to two ounces of water. The same end can be attained 
by vaginal injections of one drachm of the acid to ten or twenty 
ounces of water. 
In a very valuable contribution, Dr. J. Byrne (Medical Record, 
1872, pp. 529 and 553) reports several cases of malignant disease 
of the cervix cured by the galvano-cautery. He first slowly burns 
through the mucous coat with the heated loop, and then by, at the 
same time, making firm traction on the cervix with a volsella, burns 
off a cone-shaped piece. By this manoeuvre, and also by the use of 
curved knives heated by the battery, he claims to be able to remove 
the diseased portion of the cervix. 
In an essay read before the Obstetrical Society of Edinburgh, 
Dr. Alexander Milne related his experience in the treatment of 
uterine cancers by ergot and escharotics. He had cured two cases 
of cauliflower excrescence, and in three medullary ones had at least 
retarded the disease, and mitigated the severity of the symptoms. 
The ergot he gives by the mouth, for a protracted time, with a 
view to lessen the congestion of the womb, and to diminish the 
afflux of blood to the morbid mass. As regards the escharotic 
treatment, he first applies, for several days in succession, the dried 
sulphate of zinc freely through a cylindrical speculum to the cervix, 
and each time plugs the vagina with cotton-wool, whose uterine end 
is simply tipped with a little olive oil. W'hen the slough comes 
away, and a healthy-looking sore results, the substance of the cer- 28 
vix is injected at several points by a long hypodermic syringe, with 
a saturated solution of the nitrate of copper. This is done in order 
to attack any morbid cells lying beyond the sore from -which the 
slough has separated {Edinburgh Medical Journal, May, 1873, p. 
1043). 
Dr. Burow, of Kbnigsberg, claims to have cured cancer by the 
continuous application of the chlorate of potassa {Lancet, April 12, 
1873, p. 525). He sprinkles the sore with the chlorate, and then 
covers the whole by a wet compress. As the crystals exert a more 
powerful action than the powder, he first uses the latter, and re- 
places it by the crystals when sensibility has abated. Dr. Burow 
does not report any cases of uterine cancer thus treated ; but your 
reporter sees no reason why the chlorate of potassa should not be 
applied as well to the cervix uteri as to other parts of the body. 
Ovariotomy.-The past year has been signalized by the almost 
simultaneous appearance of three valuable works upon the diagnosis, 
or the treatment, of ovarian tumors. The first one comes from the 
pen of that distinguished member* of this association-Dr. Wash- 
ington L. Atlee. Its scope is limited to the diagnosis of these 
tumors, but it is to be followed by a second volume on their radical 
treatment. The next one, by Dr. E. R. Peaslee, is a treatise on the 
whole subject. The third is by T. Spencer Wells, who gives to the 
profession the results of his unrivalled experience. No member of 
the profession who operates or expects to operate for cystic dis- 
ease of the ovaries-no one, indeed, who wishes to keep abreast of 
the times, can afford to be without these three works. While these 
masterly treatises show some differences of opinion with regard to 
the minor details of the operation, they yet agree in recommending 
the extra-peritoneal treatment of the pedicle. They also show that 
success depends more upon the skill and boldness of the operator 
than upon any given method of treatment. 
Artificial Dilatation of the Anus and Rectum.-For diagnostic, 
as well as for operative, purposes, Prof. G. Simon, of Heidelberg 
{American Journal of Obstetrics, February, 1873, p. 568), recom- 
mends the artificial dilatation of the anus and rectum in adults, so 
as to admit the four fingers, or even the whole hand, if it is not 
too large. Anaesthesia is used, and the patient put in an exagge- 
rated lithotomy position, the thighs being strongly flexed upon the 
body. Usually, slow dilatation is alone necessary ; but sometimes 
an entrance can be gained only by nicking the sharp cutaneous 
border of the anus. Occasionally, Prof. S. has been obliged to cut 29 
through both sphincters posteriorly, before his hand could enter. 
When the hand has passed into the sacral portion of the rectum, 
" we can then," he remarks, " introduce three, and even four, fingers 
still further up, and a small distance into the sigmoid flexure, and 
reach above the umbilicus without in the least injuring the intes- 
tines, or the peritoneum • and, the upper portion of the rectum 
and the sigmoid flexure being extremely movable, can palpate the 
whole abdomen as far as the lower edge of the kidney." If the 
sphincter is so dilatable as to allow the passage of the hand with 
or without the superficial incisions of the cutaneous margin, no 
disturbance in its functions is produced. If, however, the sphincter 
is divided, fecal incontinence will last until the wound heals, that 
is, for ten or twelve days. 
By this extremely useful method, in conjunction with supra- 
pubic palpation, the nature of all tumors situated in the lower 
two-thirds of the abdomen can be determined. As the fingers are 
separated from the abdominal organs by the thin intestinal wall 
only, the physician can intelligently palpate the whole bladder, 
accurately and minutely examine the womb and each ovary, and 
determine the presence or absence of these organs. He can decide 
whether an ovarian cyst is bound down by'extensive adhesions, or 
whether' the pedicle is long or short. He can push up a fibroid 
tumor wedged firmly in the pelvic cavity, redress an inverted 
womb, liberate a gravid womb from a state of retroversion, or re- 
lease the lower bowels from the condition of invagination. In short 
the range of exploration thus gained offers to the general surgeon, 
as well as to the gynaecologist, a marvellous facility of diagnosis, 
and a wider field for operative inteference. So impressed is your 
reporter with the value of Prof. Simon's suggestion that he urges 
upon each member of this association a perusal of the original paper. 
Perforation of the Walls of the Womb by the Sound.-It has at 
last been definitely settled that the uterus can be perforated by the 
sound, not only when roughly handled-which will be readily con- 
ceded-but, under certain circumstances, even when great gentle- 
ness is used. It is well to remember that most of these accidents 
occurred within the six weeks following delivery-viz., at a time 
when the womb is softened by the normal process of fatty degene- 
ration, or by the after-effects of some puerperal disease. In all, 
the sound passed in without any appreciable resistance, to an un- 
usual depth, and its tip was distinctly felt directly under the abdo- 
minal wall. But in none of these reported cases did any serious 
symptoms occur. 30 
Prof. Schroeder, of Erlangen, gives two such examples. Prof. 
Martin, of Berlin, had one in a tuberculous patient, whose womb, 
after her death some months later, exhibited the cicatrix of the 
perforation (New York Medical Journal, January, 1871, p. 97, from 
Berliner Klinische Wbchenschrift, Oct. 1870). Drs. Hoenning 
(American Journal of the Medical Sciences, Oct. 1870, p. 571) and 
Noeggerath (American Journal of Obstetrics, Aug. 1871, p. 329) 
each report a case; while five, occurring within the month following 
delivery, are given in the Revue des Sciences Medicales, January, 
1873, p. 189. " 
Uterine Sound Penetrating the Fallopian Tubes.-After much 
discussion it is now regarded as a determined fact that the uterine 
sound will occasionally slip freely into a Fallopian tube, and give 
to the physician the impression that he has perforated the uterine 
wall. This can, however, rarely happen unless the tubes are dis- 
tended from a catarrhal inflammation, and from the consequent 
paralysis of their muscular walls. At a post-mortem examination 
of a woman, who died after ovariotomy, and whose womb had ap- 
parently measured seventeen centimetres, Prof. Bischoff (Revue 
des Sciences Medicales, April, 1873, p. 752) found that the sound 
had penetrated the left Fallopian tube, which was funnel-shaped, 
very much dilated, and lying in an almost vertical direction. Some 
physicians maintain, that by a little coaxing and by directing the 
tip of the sound to one or the other cornu, an entrance can be 
effected at will. This patency of the tubes in chronic cases of tubal 
catarrh explains the penetration of air or of fluids from the uterus 
into the cavity of the abdomen, and, consequently, the hazard 
attending the treatment of uterine disorders by intra-uterine injec- 
tions (British Medical Journal, January 11, 1873, p. 30). 
Bibliography.-Gazette Medicale, 1857, p. 13 ; American Journal 
of Obstetrics, 1869, p. 267, 1871, p. 329; National Medical Journal, 
Aug. 1871, p. 212; Boston Gynaecological Journal, April, 1871, p. 
231; Veit in Virchow's Handbuch der Speciellen Pathologic, 1867 ; 
J. Matthews Duncan, Edinburgh Medical Journal, 1856, p. 1063. 
In this relation it may be well to advert to three cases observed by 
Lawson Tait, in which the sound penetrated a long sinus formed 
by a utero-peritoneal fistula in the fundus of the womb-the result 
of pelvic abscess (Lancet, Oct. 19, 1872, p. 557). 
Prolapse of the Womb.-In two clinical lectures on prolapse of 
the womb delivered by your reporter (Philadelphia Medical Times, 
1872, pp. 97, 129, 145, 161, 177 ; 1873, p. 505), he has divided this 31 
disease into three varieties: (a) prolapse of the womb proper, viz., 
a substantial descent of the womb; (&) prolapse of the cervix from 
growth of its vaginal portion • (c) prolapse of the cervix from elon- 
gation of its supra-vaginal portion. In the first variety there is 
a descent of the whole womb, and but little, if any, increase in the 
length of the uterine cavity. In the other two, although not essen- 
tial, there commonly is a greater or less sinking down of the 
fundus, either from the weight of the cervix or from traction upon 
it, and there always is an increased length of the uterine cavity. 
The first variety will be found in old women whose vaginas have 
become relaxed by the absorption of the fat-packing of the pelvis. 
In young women, general uterine congestion, perineal laceration, 
and the prolonged use of the obstetric binder are common factors 
in the production of this kind of displacement. The obstetric 
binder is useful for the first twenty-four or forty-eight hours after 
labor. For it fills up the void left by the emptying of the womb; 
it gives a grateful support; it hinders the occurrence of a con- 
cealed hemorrhage, and presents a bar to the ingress of air into the 
uterine cavity. But when kept on for the purpose of preserving 
the shape, by paralyzing those abdominal muscles which it is in- 
tended to strengthen, it not only defeats this object, but crowds the 
womb down into the pelvic cavity, and, by impeding the freedom of 
the circulation, impairs the process of involution. In the treat- 
ment of this kind of prolapse there is no better pessary than 
Hodge's, or Smith's modification of it. It acts physiologically by 
restoring the posterior wall of the vagina. Whenever the relaxa- 
tion of the parts is great the physician may be driven to the ring 
pessary, but this should be deemed a misfortune, as it does not 
effect a cure; for by dilating the vagina it tends to confirm the 
cause of the displacement rather than to remove it. When, as in 
some old women, the vagina is much shortened, and the vaginal 
portion of the cervix has disappeared, Cutter's pessary answers an 
admirable purpose. When prolapsed, a congested womb should 
be restored by a pessary, and also be treated by scarifications, the 
hot douche, and the usual local remedies. 
The second variety of prolapse is rare, at least a very marked 
degree of elongation is uncommon. It sometimes results from the 
injuries which the cervix sustains in labor, or from irregular post- 
partum involution. It is, perhaps, more commonly a congenital 
affection. One of its modifications, the conical cervix, is often a 
cause of dysmenorrhoea and sterility. This form of prolapse needs 
no treatment unless it interferes with the comfort or the fecundity 
of the woman. Whenever the cervix is unduly long it may be 32 
amputated; but the conical cervix rarely demands the knife. Dila- 
tation by sponge-tents, just .before the catamenial flux, will usually 
be followed by conception-and parturition will then complete the 
cure. 
The third variety of prolapse is essentially a hernia of the 
bladder and vagina, acting upon a tensile womb. In other words, 
this condition is due to a primary prolapse of the bladder and 
vagina, which, by traction on the cervix of a congested or a sub- 
involuted womb, draws out the then ductile supra-vaginal portion- 
viz., that portion which lies between the uterine ligaments above, 
and the vesico-vaginal attachments below. By impeding the circu- 
lation of the vaginal portion it also begets "an eversion of the os 
and a circular hypertrophy of its lips. In this form of prolapse, 
the cervix, by eversion, often resembles the penis of a horse or the 
snout of a pig. Very commonly, from exposure to the air, from 
friction, and from the contact of urine, it is the seat of two or more 
true ulcers, always excavated, and sometimes covered by a diphthe- 
ritic exudation. The fundus may, or may not, descend very 
materially; and upon this circumstance will depend the kind of 
treatment. The sound usually passes in to a distance of at least 
five inches. The bladder will be found greatly prolapsed, and the 
vagina wholly inverted. 
In this form of displacement, pessaries are usually of no avail 
whatever. They cannot keep up the prolapsed cervix without 
forcibly bending the womb almost double, and the pain is, therefore, 
unbearable. Whenever the fundus uteri has barely sagged down, 
a radical cure is attainable by amputating the vaginal portion of 
the cervix. The suppuration from the open wound sets up the 
process of involution, and also such alterative changes in the womb 
as shall cause it, by virtue of its own stays, to sustain the bladder 
and vagina in situ. But if the fundus is low down or wholly 
extruded, as it sometimes will be when greatly retroflexed, then, in 
addition to the ablation of the vaginal cervix, must the vulvo- 
vaginal opening be contracted. This can be done by paring from 
the labia and vagina a horse-shoe strip of mucous membrane about 
an inch wide and extending to points a little below the level of the 
meatus urethrae; and by bringing together the raw surfaces by wire 
sutures. By combining these two operations your reporter has 
succeeded in curing two cases which every other method had failed 
even to relieve. The cure of the prolapse, in one of these women, 
was followed by the prompt disappearance of violent epileptic fits, 
which had, for many years, greatly afflicted her.