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that part which had been adherent within the cervical zone,and which had been consequently detached, infiltrated withcoagulated blood, its substance perhaps indurated, and alto-gether presenting an appearance quite different from that ofthe mass of the organ which had adhered within the meridionalzone, and which had only become detached after the expulsionof the child, through the general contraction of the womb.This part is usually so well defined as to admit of beingmeasured. It is usually found to vary from three to four inchesin length. This distance from the os will bring us again to theLower Polar Circle.

0

I believe, however, that the boundary-line of safety is oftenpractically reached before the expansion of the mouth of thewomb has reached the full diameter of the child’s head. Ihave observed that the heamorrhage has completely stoppedwhen the os uteri had opened to the size of the rim of a wine-glass, or even to a lesser size. In ordinary labour, when thebag of membranes or the child’s head is driven down upon theos by the pressure from behind—that is, when expulsive painssucceed to the preliminary dilating pains, the presenting partbecomes a mechanical distending or stretching power. The os,partly opened by the active shortening of the longitudinalmuscular fibres, is fully opened by the distending cone driventhrough it, as an indiarubber band is expanded. Thus it isthat a part of the opening of the os uteri is gained by a processthat does not involve detachment of placenta.

APPLICATIONS OF THE NEW PHYSIOLOGY OF PLA-CENTAL ATTACHMENT TO THE TREATMENT OFPLACENTA PRÆVIA.

The rules of treatment at present in force have all been dic-tated or influenced by theoretical doctrines essentially erroneous.One word in especial has exerted a most tyrannical and mis-chievous influence: the word " unavoidable haemorrhage," beingassumed to embody the whole theory of placenta prsevia, hascreated and maintained a blind and indiscriminating belief thatinterference, in the form of forced delivery, is imperatively calledfor. A striking word too often catches the assent by post-poning investigation, and, like the sword of Alexander, cutsthe knot it cannot unloose. The cases of placenta praevia, asthey are met with in practice, offer considerable varieties ofkind, of degree of danger; they cannot be treated on oneuniform plan. We are not in all cases of urgent haemorrhageto force the hand through the os uteri and extract the child;we are not in all cases to force the hand into the womb anddetach the whole placenta. There are cases in which either ofthese operations is more dangerous than the flooding itselfNor have I a panacea to offer in lieu of th<se operations.Although I believe that a full appreciation of the theory I haveenounced is essential to the intelligent conduct of any givencase of placenta prtevia, I do not pretend that the particularmode of treatment which is the more direct deduction fromthis theory is universally applicable; but it supplies a new,an additional remedy, often applicable precisely when theusual modes of treatment are either impracticable or dangerous.

1. I shall adduce evidence to prove that dangerous, and evenfatal, flooding may occur at so early a stage of labour that allmethods of forced delivery are absolutely excluded.

2. That in another class of cases, in which it has been pre-sumed that circumstances admitted of forced delivery, theoperation itself proved dangerous, and even fatal.The woman may die before delivery is practicable. Fatal

haemorrhage may occur from a very small detachment of pla-centa, and before the os uteri has undergone any materialdilatation. Thus, Professor Davis says " he had met withmany examples of even fatal results of profuse uterine hsemor-rhage unaccompanied by any amount of dilatation of the orificeof the womb." (" Principles and Practice of Obstetric Medi-cine," p. 1040.) Professor Hamilton says that " in the monthof September, 1816, he was called to two cases where the patientseemed to be in articulo mortis from the deluge of the dis-charge, and where nevertheless the os uteri was obstinatelyrigid. "

But, in the presence of even the most terrible flooding, weare warned in the most emphatic manner, even by thoseauthors who advocate forced delivery as the only hope, againstforcing the hand through the os before this structure is dilatedor dilatable. Dr. Edward Rigby says: "In no case is itproper or safe to force delivery by artificially dilating the osuteri where it is contracted and unyielding; but when the pla-centa is presenting it is peculiarly dangerous, for even slightlaceration of the os uteri will be followed by serious uonse-

, quences; ...... its vessels are immensely dilated, and large onesL are rupture<1 which cannot be closed by the firmest contraction, of the womb." Naegele has also proved that death has beencaused by the continued haemorrhage proceeding from an osuteri so injured.

Dr. Collins records the following history :-CASE 9.-" There being no chance of life without spood-y

delivery, we determined to make the attempt, tltottflh the partgwere badly prea&middot;ecl.. The hand was cautiously introduced:...... great debility succeeded the operation, with a slight dis-charge of blood at intervals....... On examining an hour after,a laceration of the neck of the uterus was discovered, com-mencing at it junction with the vagina....... Dissection verifiedthe result of the vaginal examination." "

Taught, no doubt, by such instances, this excellent authoremphatically says: " I know of no operation more truly dan-gerous both to mother and child than the artificial dilatationof the os uteri and turning the child."

Cases such as I have cited are by no means exceptional.Our clinical records teem with instances of resolute, I might,say desperate, turning, with the view of saving the patient,where the operation, not the flooding, was shown to- havecaused her death. Let me quote one more, out of several,from that rich storehouse, the "Clinical Midwifery of Dr.Robert Lee (p. 158) :-CASE 10.-" On the 22nd February, 1840, I examined the

body of Mrs. C--. A great uterine haemorrhage had takenplace spontaneously six weeks before, when she was sevenmonths pregnant. Another took place on the 19th February,which continued till the evening of the 21st, when her medicalattendant, with some difficulty, introduced the hand into theuterus, perforated a portion of the placenta, and turned thechild. The head was extracted with difficulty. The placentasoon followed, but she soon after began to sink, and died in anhour and a half. There was an extensive laceration in themucous and muscular coats of the cervix uteri, on the left side,and a smaller and more superficial rent on the right side. The

placenta had adhered to the whole circumference of the cervix.’The following case, also from Dr. Lee, exemplifies in the

strongest manner the proposition before us :-CASE 11.&mdash;A lady in the eighth-and-a-half month had been

attacked with uterine haemorrhage a month before. Two otherattacks, at intervals of several days followed. " At one o’clock,Jan. 12th, 1839, the haemorrhage was renewed to an alarmingextent, without any pain ; about a quart of blood was suddenlylost, and she became extremely faint. At four A.M. the dis-charge still continued......The placenta was felt adhering allround to the neck of the uterus, which was thick and rigid andvery little diiated. The effect produced by the haemorrhagewas so great that it was evident death would soon take place iftlte delivery were not speedl1y completed; and the state of theorifice was such that it was certain the hand could not bepassed but with the greatest difficulty. At eight P.M., Dr.Merriman saw her with us, and agreed that immediate deliverywas necessary. I passed the right hand into the vagina, andinsinuated my fingers between the uterus and placenta at theback part, and reached the membranes. But the rigidity ofthe orifice was so great that, though I employed great forcefor a considerable time, I could not succeed in getting thehand into the uterus. Dr. Merriman recommended rupturingthe membranes, and I was proceeding to do this with thefingers, when I felt one of the feet of the child, which I grasped,and brought down into the vagina, enveloped in the mem-branes, which then gave way. Nearly half an hour elapsedbefore the version could be completed, and when it was effected,the neck of the uterus grasped the neck of the child so firmlythat I experienced the greatest difficulty in extracting thehead. A great discharge of blood instantly followed. Theplacenta was removed, and every means employed to stop thehaemorrhage; but the breathing became hurried, the extre-mities cold, and she died in less than an hour after delivery.Dr. Merriman informed me that a patient of his had actuallydied under similar circumstances before the head could be ex-tracted. "-(p. 156.), If such are the lamentable results of forced delivery underdesperate circumstances, what are the results of forced deliveryunder circumstances presumed to be favourable ? The situa-tion is still full of danger.At p. 118 of Dr. Collins’ book we find the following case:-CASE 12.-" D. C-, at her full time, was brought to hospital

with profuse haemorrhage, the blood literally flowing awayfrom her. Finding the pulse almost imperceptible, the os uteribeing partially dilated and in a relaxed state, the hand waspassed, and the child delivered by the feet. The hand was

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introduced immediately afterwards for the removal of the

placenta; the uterus acted well, and expelled both. From themoment of her admission, cordials and stimulants were freelygiven, which, after delivery, were occasionally combined withopiates; notwithstanding which, as also the sedulous applica-

cold, pressure, 8cc., a slight discharge of blood con-tion of cold, pressure, &c., a. slight discharge of Mood con-tinued and she died in two hours. On dissection, the intes-tines were found completely blanched; the uterus was contractedto the ordinary size. On making a section of it, a rent wasdiscovered in its mouth, which was evidently the cause of thecontinued draining. This injury, no doubt, occurred in thedelivery of the child’, although it was effected with great, care,with no difficulty, and very little exertion."

I have no desire to pass over the fact, that in many cases theos uteri, undilated at the time, yields with tolerable facilitybefore the hand, and admits of turning with safety; or anotherfact-one of great importance-that occasionally, through ahappy coincidence of skill and chance, the feet of the childmay be seized by two fingers, and turning performed withoutthe necessity of passing the hand into the uterus at all.Neither of these fortunate occurrences can be counted upon.The voice of experience is loud as to the dangers of turningeven where there is no placental presentation. It is decisivein the cases we are now considering.We have, then, three formidable facts before us :-1. The woman may die from flooding so early, before the

dilatation of the os uteri, that forced delivery is out of the iquestion

I

2. If forced delivery be attempted before the os uteri isdilated, a fatal result is eminently threatening.

3. If forced delivery be performed when the os uteri isdilated, it may contract around the neck of the child; andeven if it do not, such injury may be done to the womb in theextraction, that death may follow.A remedy then is urgently required, to replace in certain

ases, at least, forced delivery.(To be co2zeluded.)

Clinical LectureON

A CASE OF FRACTURED RIBS,WITH

WOUNDED LUNG AND EMPHYSEMA, FOL-LOWED BY DELIRIUM TREMENS, ANDCOMPLETE RECOVERY.

BY SAMUEL SOLLY, ESQ., F.R.S.,SURGEON TO ST. THOMAS’S HOSPITAL.

JoBEN B-, aged forty-seven, was admitted into Abraham’s&deg;&deg;ward about half-past six A.M., June llth, 1857, suffering fromthe effects of a fall from a ladder on a place covered with roughstones. It was stated by those who brought him to the hos-pital, that whilst on the top of the ladder, it slipped, precipi-tating him from a height of between twenty to thirty feet, andthey considered that he received some of his injuries by pullingdown the ladder on him, as he kept hold of it during his fall.He was perfectly sober, though wearied from extra work at thetime. When taken up he was insensible, but when he arrivedat the hospital he was conscious, and answered questionsrationally, but was not disposed to speak. These details re-

garding the accident, and. his mental condition at the timeof his admission, are very important in connexion with hismental condition after he had been in the hospital somedays. The fact of his being insensible immediately afterthe accident shows that there must have been some con-

cussion; but that it was very slight is clear from the factof his answering questions rationally when admitted, thedistance of the hospital from the site of the accident beingvery small. His disinclination to speak you can well under-stand when you learn that his lung was wounded by thefractured rib; so that we must not look to the brain for anexplanation of his torpor. He complained of great pain in his

left side, and on examination three or four ribs were foundfractured on that side. The exact number were not ascertainedfrom the pain the examination occasioned him. On the rightside no ribs were broken. There was a severe bruise at thelower part of his back; a slight scalp wound ou the occiput, andalso slight wounds on the nose and lower lip.From his previous history it appears that about twenty years

ago he was a sailor, but quitted the sea when he married; sincethat time he has worked in the Docks, and for the last fourteenyears in the service of Alderman Humphrey. His wife statesthat about fifteen years ago he had an attack of brain fever,and afterwards had four or five fits, the last of which occurredabout twelve years ago, since which he has never been at allaffected in his head, and has generally enjoyed good health.His fellow workmen say that he is a civil, well-conducted man,that he is accustomed to drink a considerable quantity of beerduring the day, sometimes as much as seven or eight pints, butthat he never gets actually drunk. He has also been in thehabit of chewing a quarter of an ounce of tobacco daily for someyears, but lie does not smoke. He has had two or three slightaccidents before this one.The previous history in a case of this kind is of the greatest im-

portance ; and though there is often some difficulty in procuringaccurate information, you should always take great pains toobtain all that is possible. Only a short time since, youwatched with me a case of considerable interest, where a manwas brought into the hospital having received a violent blow onthe back of the head, causing severe concussion of the brain,followed by epilepsy and delirium tremens, cured by tonicsand stimulants. In that case, a knowledge of the previoushabits of the man guided us to a correct diagnosis of the truepathology of the case. In this you will find that the deliriumand general aberration of intellect which followed were alsoexplained bya knowledge of his habits of life. It is seldom thatyou can obtain a correct account from the wife of the patient;she will generally speak of her husband as sober if he does notcome home drunk every night; whereas a man who drinks hissix, seven, or eight pints of beer every day, though withoutbeing drunk, is a bad subject for an accident. The suddenremoval of this amount of stimulus, which is necessary in theearly stages of the treatment of such an injury is very likelyto induce delirium tremens. There was another habit. in whichhe indulged which would tend to the same point-viz., chew-ing tobacco. I am not now going to dwell on the injuries in-flicted on the human race by this weed. I am thankful to saythat the observations which I made in this theatre some monthsago, and the correspondence to which those observations gaverise in THE LANCET, have already produced a great abatementof the evil. I would, however, here remark, by the bye, thatthe information regarding the extent to which tobacco smokingwas productive of insanity, which our own lunacy doctors havebeen unable to supply, has been given us from America. Ihave been told by some of those medical men who have hadthe charge of lunatics in this country, and, not being smokersthemselves, can take a candid view of it, that it is very diffi-cult here to separate the effect of tobacco from the effect pro-duced by the intemperate use of intoxicating drinks, the habitsbeing so generally associated amongst the lower classes of thiscountry. The following passage occurs in the report of Dr. Kirk-bride, of the Hospital of the Insane, Pennsylvania :-" Fivecases were clearly attributable to tobacco. Common as is the useof tobacco in some of its various forms, its injurious influenceon many constitutions is much more serious than is commonly

supposed, and not unfrequently the cause of exceedinglytroublesome and obscure nervous affections, which cannot be

! cured while its use is persisted in. The effect on many insane. patients is so striking that an intelligent attendant is often

I able to say without difficulty when it has been used to anyextent. When occasionally gratified, the craving for it is verystrong, but an entire disuse of it for a week will commonly

! obviate all serious annoyance from abandoning the habit, and, I have never known any injury to result from its sudden dis-

continuance. I have no doubt that much advantage is gained. from its use being strictly interdicted within the walls of an _

’

institution for the insane."&mdash;p. 24.To return to my own patient: I have said that in addition

j to his habit of drinking every day six or seven pints of porter,that he chewed tobacco. I advert to the fact now to impress

r upon you the importance of gaining a knowledge of every: habit to which your patients have been addicted, if you wish.,

to treat successfully the disturbed functions of the brain. I, have often pointed out to you the difference between the deli-Lriuni ebriosorum-that is, the delirium of the duaka)d&mdash;and c

! the delirium e potu. In the f rmer, the disease is ansemic; iit